Hewitt Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Hewitt, Texas.
- Location
- 8836 Mars Dr, Hewitt, Texas 76643
- CMS Provider Number
- 676213
- Inspections on file
- 44
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hewitt Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was left with a soiled washcloth and a full urinal on the bedside table for several hours after requesting assistance. The responsible CNA failed to return to remove the items, and interviews with staff confirmed this was not in line with facility infection control policies, resulting in a lapse in maintaining a safe and sanitary environment.
A resident with multiple medical conditions and an NPO order did not have required documentation completed in the MAR by an LVN during overnight shifts. The DON and ADM confirmed that the lack of signature indicated the task was not performed, and facility policy requires all care and treatments to be documented with staff signatures.
A resident with multiple medical conditions did not receive timely physical and occupational therapy services due to the facility's failure to submit a completed and accurate PASARR specialized services request in the LTC Online Portal within the required timeframe. Errors and late submissions by the MDS-RN led to repeated rejections and a delay in the resident accessing Medicaid Entitled Services as recommended by the PASARR evaluation.
Two residents with severe cognitive impairment and high dependence on staff were found with their call lights out of reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed awareness of the need for call lights to be within reach, but observations showed that both residents could not access their call lights and had to call out for assistance instead.
A resident with diabetes was inaccurately coded on the MDS as receiving insulin and injections, despite no physician orders or evidence of such treatment. The resident, who was cognitively intact and managed her diabetes without insulin, confirmed she had never received insulin. Staff interviews revealed uncertainty about the resident's treatment history, and the error led to an inaccurate assessment that could affect facility reimbursement.
A resident with a history of thyroid cancer and hypothyroidism did not receive her prescribed Levothyroxine for an unknown period, leading to elevated TSH levels and symptoms such as fatigue, dizziness, and depression. The facility failed to administer the medication as ordered, resulting in a significant change in the resident's condition. Staff interviews revealed a lack of awareness about the missed doses, and the resident expressed a loss of trust in the nursing staff.
A resident with hypothyroidism did not receive her prescribed Levothyroxine medication for an unspecified period, leading to elevated TSH levels and symptoms such as fatigue, dizziness, and depression. The facility's failure to administer the medication as ordered was identified as an Immediate Jeopardy situation. Interviews and record reviews revealed discrepancies in the medication administration records, and the resident's NP confirmed the correlation between missed medication and the resident's deteriorating condition.
A facility failed to provide appropriate care for residents with incontinence and indwelling catheters, leading to deficiencies in preventing UTIs. A resident's Foley catheter was not changed promptly after a UTI diagnosis, and her drainage bag was found on the ground. Two residents did not receive proper incontinent care, with staff failing to clean or change gloves. Another resident's catheter care lacked infection control practices, with staff reusing wipes and not donning PPE. These actions violated the facility's infection control policies.
A resident with increased confusion and altered mental status experienced a delay in urine analysis collection due to a shortage of specimen cups at the facility. The STAT UA ordered by the physician was not collected until several days later, leading to a late diagnosis of a UTI. Interviews revealed a lack of communication among staff regarding the shortage, and the facility's policy for timely test processing was not followed.
A resident with cerebral palsy and quadriplegia developed red areas on the buttocks, with one area opening and causing pain. The facility failed to obtain timely wound care orders, delaying communication with the wound care nurse and physician. This inaction risked improper wound management and potential complications, as staff did not adhere to the facility's skin management policy.
A facility failed to maintain proper infection control during peri care for a resident with severe cognitive impairment and a history of UTIs. Two CNAs did not follow hand hygiene protocols, reused wipes, and failed to change gloves between tasks, contrary to the facility's Perineal Care Policy. This placed residents at risk for cross-contamination and infection spread.
Two residents requiring BiPAP and CPAP therapy did not receive proper respiratory care, as their equipment was not cleaned or maintained according to professional standards. One resident experienced multiple hospitalizations due to respiratory distress, with observations revealing dirty filters and incorrect machine settings. The facility lacked replacement filters, and staff inaccurately documented equipment maintenance, placing residents at risk for infection and respiratory issues.
The facility's dietary services failed to properly reseal, label, and date food items in the walk-in refrigerator and freezer, as observed during a survey. Bags of ravioli and hamburger patties in the freezer lacked dates, while shredded and mozzarella cheese in the refrigerator were improperly labeled or exposed. Staff interviews confirmed that opened items should be discarded within three days if not labeled with received, opened, and used-by dates, as per facility policy and FDA guidelines.
Two residents in an LTC facility did not receive necessary nail care, leading to hygiene issues and potential risks. One resident, not cognitively impaired, had nails protruding past fingertips with dirt and debris, while another, with severe cognitive impairment, had long, curling toenails and dirty fingernails. Despite care plans and policies, staff failed to follow through with interventions, highlighting a breakdown in communication and documentation.
The facility failed to ensure that call light pull strings in the bathrooms of three residents were free from entanglements and extended to their intended length, making them unreachable from the floor. This deficiency was observed in the bathrooms of a resident with moderate cognitive impairment and mobility issues, a resident with severe cognitive impairment and a history of falls, and a resident without cognitive impairments but with a high risk for falls. The call light pull strings were knotted multiple times, reducing their length and making them inaccessible, potentially placing residents at risk of being unable to call for assistance in case of a fall.
A facility failed to document a resident's tobacco use in the MDS assessment, despite the resident being identified as a safe smoker and observed smoking. This omission was confirmed by interviews with the MDS nurse, DON, and ADM, who stated that tobacco use should be reflected in the MDS and care plan to ensure accurate care planning. The resident's medical history included partial intestinal obstruction, pulmonary embolism, muscle weakness, and cardiac murmur.
A facility failed to conduct proper PASRR screening for a resident with schizophrenia, resulting in the resident not being referred for a necessary Level 2 evaluation. The MDS nurse, unaware of the resident's diagnosis, did not ensure accurate PASRR Level 1 information, leading to a lack of appropriate services. Interviews with staff revealed a lack of responsibility for ensuring correct screenings.
A facility failed to develop a baseline care plan within 48 hours for a resident with complex medical needs, including hemiplegia and diabetes, upon admission. Interviews with staff revealed that the admitting nurse was responsible for completing the care plan, but it was found blank and unsigned. This oversight could lead to unmet care needs and communication issues, contrary to the facility's policy requiring timely care plan development.
Two residents' care plans lacked critical information, with one missing details on a fentanyl patch and the other on smoking habits. Both residents were cognitively intact, yet their care plans did not reflect these important aspects, potentially affecting their care. Interviews with staff highlighted the importance of accurate MDS assessments for comprehensive care planning.
A resident admitted with a Foley catheter experienced discomfort and irritation, yet the facility failed to evaluate the necessity of the catheter or consult with a physician for its removal. Despite the resident's cognitive intactness and reported issues, staff did not adhere to the policy requiring assessment of catheter use, risking infection and urinary dependence.
A resident with a history of depression and cognitive impairment was given an incorrect dosage of Amitriptyline due to a transcription error at an LTC facility. The resident received 300 mg instead of the intended 10 mg, resulting in an acute drug overdose and hospitalization. The error was identified after the resident showed increased lethargy and family concerns about over-sedation.
A resident was prescribed Bupropion, an antidepressant, without a documented diagnosis or consent, contrary to facility policy. Interviews with the ADON and DON revealed that the expected process of obtaining consent and diagnosis upon admission was not followed, leading to the administration of the medication without proper documentation.
Failure to Remove Soiled Items and Maintain Infection Control
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for one resident who required assistance with activities of daily living. On the specified date, a soiled washcloth used by the resident was left on the bedside table, and a urinal bottle filled to the top was also left on the bedside table. The resident, who had diagnoses including congestive heart failure, type 2 diabetes, and hypertensive heart disease, reported using the call light early in the morning to request assistance from a CNA to remove the soiled items. The CNA responded initially but did not return to complete the tasks, leaving the soiled washcloth and full urinal unattended for several hours. Interviews with the CNA, DON, and ADM confirmed that it was the expectation for staff to remove soiled washcloths and empty urinals promptly to maintain infection control and prevent potential hazards. The CNA acknowledged forgetting to return to the resident after being called away to assist others. Facility policy required maintaining a safe and sanitary environment to prevent the transmission of infections, but these procedures were not followed in this instance, resulting in a failure to meet infection control standards.
Incomplete NPO Documentation in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who required nothing by mouth (NPO) status and tube feeding. Specifically, the resident's Medication Administration Record (MAR) did not have the required NPO documentation signed off by the assigned LVN during the overnight shift on two consecutive days. This omission was confirmed through record review, which showed that the NPO order, in place since early March, was not documented as completed on the specified dates and shift. The facility's policy requires all services and treatments provided to residents to be documented in the medical record, including the date, time, and signature of the staff member providing care. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that it was expected for the LVN to sign off on the MAR to ensure documentation was complete. Both acknowledged that the absence of a signature would indicate the task was not performed. Attempts to interview the responsible LVN and the resident's representative were unsuccessful. The resident involved had significant medical conditions, including type 2 diabetes, heart failure, dysphagia, and hypertension, and was unable to participate in interviews due to cognitive impairment.
Delayed Submission of PASARR Specialized Services Request
Penalty
Summary
The facility failed to submit a completed and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days from the Interdisciplinary Team (IDT) meeting for a resident with mild intellectual disabilities, diabetes, hypertension, chronic kidney disease stage 5, and a history of stroke. The resident was admitted with a care plan that included interventions such as physical therapy due to poor balance and an unrealistic sense of physical abilities. Despite recommendations from the PASARR evaluation for physical and occupational therapy, the required NFSS forms were submitted late and contained errors, resulting in repeated rejections and a final submission marked as late according to PASARR timelines. Interviews with facility staff, including the MDS-RN, DON, and ADM, confirmed that the MDS-RN was responsible for handling the PASARR process and that the failure to submit accurate and timely forms led to a delay in the resident receiving Medicaid Entitled Services, specifically physical and occupational therapy. Record review showed that the NFSS form was denied due to an incorrectly completed signature page, and the facility's policy did not specify a timeline for submission from the IDT meeting. This deficiency resulted in the resident not receiving the recommended specialized services in a timely manner.
Failure to Ensure Call Lights Were Accessible to Residents
Penalty
Summary
The facility failed to ensure that two residents received services with reasonable accommodations for their needs and preferences, specifically regarding the accessibility of their call lights. For one resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, observations revealed that her call light was on the floor and out of reach. The resident confirmed she could not access the call light and would have to yell for assistance if needed. Staff interviews acknowledged awareness of the importance of call light placement and that the call light was not within reach at the time of observation. Another resident, also severely cognitively impaired and dependent on staff, was observed with her call light placed on top of an oxygen concentrator approximately 2.5 feet from her bed, making it inaccessible. The resident stated she could not reach the call light and instead called out for help due to pain. A CNA responded to her calls and confirmed the call light should have been clipped to the bed sheet. Staff interviews indicated knowledge of the expectation for call lights to be within reach, and that the resident sometimes threw the call light away due to her cognitive impairment. Record reviews for both residents showed care plans that included interventions to ensure call lights were within reach, and facility policy required call lights to be easily accessible for residents in bed or confined to a chair. Despite these documented expectations and staff training, observations and interviews confirmed that the call lights were not within reach for these two residents at the time of the survey.
Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to conduct an accurate and comprehensive assessment for one resident, as required by federal regulations. Specifically, the Minimum Data Set (MDS) assessment for the resident incorrectly indicated that she was receiving insulin and injections, despite no physician's orders for such treatments and the resident's own statement that she had never received insulin. The resident's diagnoses included acute respiratory failure with hypoxia, diabetes, depression, and white matter disease, but her diabetes was managed without insulin, and she was reportedly doing well at the time of the assessment. Interviews with facility staff revealed that the LVN responsible for completing the MDS assessments was unsure whether the resident had received insulin or injections during the relevant period and acknowledged that if a resident was not receiving these treatments, the MDS should not reflect otherwise. The administrator and DON both stated their expectation that MDS assessments be completed accurately and confirmed that the RUG score, which is influenced by the MDS, determines facility reimbursement. Both also acknowledged that an inaccurate MDS could result in incorrect billing. A review of the facility's policy confirmed that comprehensive assessments must be completed within specified timeframes and must accurately reflect the resident's functional capacity and care needs. In this case, the inaccurate coding on the MDS assessment did not align with the resident's actual care and treatment, as documented in her records and confirmed by interviews, resulting in a deficiency related to the accuracy of resident assessments.
Failure to Administer Thyroid Medication Leads to Resident Neglect
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, specifically in the administration of her prescribed medication, Levothyroxine, which is used to treat hypothyroidism. The resident, who had a history of thyroid cancer and a thyroidectomy, did not receive her medication for an unknown period at the end of June and beginning of July 2024. This lapse in medication administration led to a significant elevation in her TSH levels, resulting in symptoms such as fatigue, dizziness, and depression. The resident's medical records indicated that she was cognitively intact and had been stable until the medication error occurred. Despite having a physician's order for daily Levothyroxine, the medication was not administered as prescribed. The resident experienced a noticeable change in her condition, including mental health deterioration, which she reported to the nursing staff. Lab results confirmed the elevated TSH levels, and the resident's NP noted the absence of medication administration, which was corroborated by the discovery of a nearly full blister pack of the medication. Interviews with facility staff revealed a lack of awareness regarding the missed medication doses. The ADON and DON acknowledged the oversight, with the ADON finding only a few pills missing from the blister pack and the previous month's pack unaccounted for. The resident expressed a loss of trust in the nursing staff due to this incident, and the NP confirmed that the resident's symptoms were consistent with not receiving her thyroid medication. The facility's policies on medication administration and abuse and neglect were not adhered to, leading to this deficiency.
Failure to Administer Thyroid Medication Leads to Resident's Health Decline
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident diagnosed with hypothyroidism. The resident did not receive her prescribed Levothyroxine medication for an unspecified period at the end of June and beginning of July 2024. This lapse in medication administration led to a significant elevation in her TSH levels, resulting in symptoms such as fatigue, dizziness, and depression. The resident's condition deteriorated to the point where she withdrew from therapy services and expressed a desire to give up. Interviews and record reviews revealed that the resident's thyroid medication was not administered as prescribed, with discrepancies noted in the medication administration records (MAR). The ADON discovered that only a few pills were missing from the blister pack, indicating that the medication had not been given consistently. The resident's NP confirmed that the resident had been stable until her depression worsened, correlating with the period she missed her thyroid medication. The NP noted that the resident's TSH levels were extremely high, confirming the lack of medication administration. The facility's failure to administer the medication as ordered was identified as an Immediate Jeopardy situation, highlighting the risk of not receiving the intended therapeutic benefits of medications. Interviews with staff indicated a lack of awareness and oversight regarding the medication administration process. The DON and ADON acknowledged the oversight, with the ADON noting that the nurse responsible for the lapse no longer worked at the facility. The facility's medication administration policy was not followed, leading to the resident's adverse health outcomes.
Deficiencies in Incontinent Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for residents who are incontinent of bladder, leading to deficiencies in preventing urinary tract infections (UTIs). Resident #1, who had an indwelling catheter, was diagnosed with a UTI, but her Foley catheter was not changed until six days later, despite the presence of sediment and cloudy urine. Observations revealed that her catheter drainage bag was repeatedly found lying on the ground, which is against the facility's catheter care policy. The resident's responsible party, who is a nurse, expressed concerns about the unchanged catheter and the risk of bacteria remaining in the system. Resident #2, who was severely cognitively impaired and dependent on staff for toileting, did not receive proper incontinent care. Video footage showed that CNAs E and F removed her dirty brief and replaced it with a clean one without providing any cleaning or using wipes. The CNAs also failed to change gloves during the process, which could lead to contamination and infection. The facility's infection control policy emphasizes the importance of thorough cleaning to prevent infections. Resident #3, who had an indwelling catheter, did not receive proper infection control practices during peri and catheter care. CNA G did not follow enhanced barrier precautions (EBP) by failing to don a gown or mask and reused wipes multiple times during the cleaning process. The facility's policies require the use of PPE and single-use wipes to prevent infection. Interviews with staff indicated a lack of understanding and adherence to infection control protocols, which could increase the risk of UTIs and other infections.
Delayed Urine Analysis Collection Due to Supply Shortage
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who required a urine analysis (UA) due to increased confusion and altered mental status. The physician ordered a STAT UA on 07/19/24, but the specimen was not collected until 07/24/24 because the facility was out of UA specimen collection cups. This delay in collecting the urine sample resulted in a late diagnosis of a urinary tract infection (UTI) on 07/28/24, which required antibiotic treatment. Interviews with facility staff revealed a lack of communication and awareness regarding the shortage of specimen cups. The Assistant Director of Nursing (ADON) was not informed of the shortage until 07/22/24 and had to search for additional supplies. The Director of Nursing (DON) was unaware of the shortage and believed that specimen cups were available. The Physician Assistant (PA) and Nurse Practitioner (NP) were also not informed of the delay in collecting the specimen, which was against their expectations for timely testing. The facility's policy required staff to process test requisitions and arrange for tests, which was not adhered to in this case.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, a male with cerebral palsy, spinal fusion, knee contractures, muscle weakness, and quadriplegia, was at risk of developing pressure ulcers. On June 30, 2024, several round red areas were identified on the resident's upper bilateral buttocks, with one area opening and causing pain and a burning sensation by July 3, 2024. Despite the identification of these skin issues, the facility did not obtain orders for wound care in a timely manner. The wound care nurse was not informed until July 2, 2024, and medical orders for treatment were not obtained until July 3, 2024. This delay in communication and action placed the resident at risk of improper wound management and potential complications. The resident expressed that he had not been seen by the wound care nurse recently and was unsure of the frequency of treatment, indicating a lack of adequate care. Interviews with staff revealed a breakdown in communication and adherence to the facility's skin management policy. The charge nurse was expected to document skin integrity issues and notify the wound care nurse and physician immediately, especially if an open area or pressure injury was present. However, the initial nurse who identified the issue did not notify the appropriate personnel, leaving the matter unresolved in shift reports. The Director of Nursing acknowledged that this practice did not meet expectations and could lead to worsening conditions if not addressed promptly.
Infection Control Deficiency During Peri Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during peri care for a resident. The CNAs did not adhere to proper infection control practices, which included failing to perform hand hygiene before donning gloves, reusing wipes during cleaning, and not changing gloves between dirty and clean tasks. These actions were observed during the care of a resident with severe cognitive impairment and a history of urinary tract infections, who required assistance with toileting due to incontinence. The CNAs' failure to follow the facility's Perineal Care Policy, which outlines the necessity of hand hygiene, single-use of wipes, and changing gloves between tasks, placed residents at risk for cross-contamination and the spread of infection. The Director of Nursing confirmed that the expected procedures were not followed, and one of the CNAs acknowledged the mistake, understanding that such practices could lead to infection.
Inadequate Respiratory Care for Residents Using BiPAP/CPAP
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required BiPAP and CPAP therapy, leading to potential health risks. Resident #1, a female with acute and chronic respiratory failure and obstructive sleep apnea, did not receive weekly filter cleanings for her BiPAP machine as per professional standards. Her medical records indicated multiple hospitalizations due to respiratory distress, with allegations that the facility did not ensure proper BiPAP mask placement. Observations revealed that her BiPAP machine's filter was dirty, and the settings did not match the physician's orders. Resident #2, diagnosed with COPD and obstructive sleep apnea, also did not receive the necessary weekly filter cleanings for her CPAP machine. During an observation, it was found that her CPAP machine lacked a filter entirely. Despite not experiencing exacerbations of her conditions, the absence of a filter posed a risk of infection and compromised respiratory care. The facility's policy required regular cleaning and maintenance of BiPAP/CPAP equipment, which was not adhered to. Interviews with staff and record reviews confirmed that the facility did not have replacement filters available, and staff were inaccurately documenting that the equipment was cleaned and maintained. The facility's failure to follow physician orders and maintain respiratory equipment placed residents at risk for infection and respiratory distress, as evidenced by Resident #1's repeated hospitalizations.
Improper Food Storage and Labeling in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its dietary services, as observed during a survey. Specifically, the dietary staff did not properly reseal, label, and date food items in the walk-in refrigerator and freezer. During an initial tour of the kitchen, it was noted that the walk-in freezer contained bags of ravioli and hamburger patties without any documented dates. Similarly, the walk-in refrigerator had a bag of shredded cheese with a prepared date but no use-by date, and a bag of mozzarella cheese that was loosely opened and exposed to air. These lapses in food storage practices could potentially lead to food contamination and foodborne illness among residents. Interviews with the Dietary Manager and other staff members revealed that there was an expectation for opened food items to be discarded within three days if not properly labeled with received, opened, and used-by dates. The Dietary Manager acknowledged that improperly labeled food could become old, moldy, or develop an odor, posing a risk to residents if consumed. The facility's policy, as well as the FDA's 2022 Food Code, requires that all time/temperature control for safety foods be stored in a manner that prevents cross-contamination and includes clear date marking for items held for more than 24 hours. The failure to comply with these standards was confirmed by the ADM, who stated that improperly labeled food could result in serving spoiled food to residents.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary nail care for two residents, leading to issues with personal hygiene and potential risks to their well-being. Resident #7, who was not cognitively impaired and required substantial assistance for personal hygiene, was observed with nails protruding past the fingertips, some nails gagged, and dirt or debris under the nails. Despite having care plans in place to maintain personal hygiene and prevent skin integrity issues, the nursing staff did not follow through with the interventions to check, trim, and clean the resident's nails as necessary. Resident #40, who had severe cognitive impairment and required maximum assistance with personal hygiene, was also neglected in terms of nail care. Her fingernails were long and dirty, and her toenails were excessively long, curling, and splitting. Despite multiple records indicating the need for toenail care, the facility staff failed to address these needs. Observations revealed that the resident had accidentally scratched herself due to the long nails, and she expressed a desire for better care. Interviews with staff, including CNAs and LVNs, highlighted a breakdown in communication and follow-through regarding the residents' nail care needs. The facility's policy required daily cleaning and regular trimming of nails, but this was not adhered to, as evidenced by the observations and interviews. The ADON and ADM acknowledged the failure in communication and documentation, which resulted in the residents not receiving the necessary nail care, as outlined in their care plans.
Inaccessible Call Light Pull Strings in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the call light pull strings in the bathrooms of three residents were free from entanglements and extended to their intended length, making them reachable from the floor. This deficiency was observed in the bathrooms of Resident #41, Resident #10, and Resident #51. The call light pull strings were found to be knotted multiple times, which reduced their length and made them inaccessible from the floor, potentially placing residents at risk of being unable to call for assistance in case of a fall. Resident #41, a female with moderate cognitive impairment and mobility issues, was observed to have a call light pull string knotted four times, reducing its length to 25 inches from the floor. Despite multiple observations over consecutive days, the string remained knotted and inaccessible. Resident #10, a male with severe cognitive impairment and a history of falls, had a call light pull string wrapped and knotted around a support bar, rendering it inoperable and only 23 inches from the floor. Similarly, Resident #51, a female without cognitive impairments but with a high risk for falls, had a call light pull string knotted ten times, reducing its length to 27.5 inches from the floor. Interviews with staff and residents revealed a lack of awareness and understanding of the importance of the call light system's accessibility. Staff were trained to ensure the call light strings were in their intended position, but the failure to recognize and correct the strings' placement was evident. The facility's policy required staff to explain and demonstrate the call light system to residents, but the deficiency indicated a lapse in adherence to this policy, leading to the inaccessibility of the call light pull strings in the residents' bathrooms.
Failure to Document Tobacco Use in Resident's MDS Assessment
Penalty
Summary
The facility failed to complete an accurate assessment for a resident, specifically regarding tobacco use, which was not reflected in the resident's Admission MDS assessment. The resident, a male with a history of partial intestinal obstruction, pulmonary embolism, muscle weakness, and cardiac murmur, was admitted to the facility and assessed with a BIMS score indicating cognitive intactness. Despite being identified as a safe smoker in a smoking risk assessment and being observed smoking, the resident's tobacco use was not documented in the MDS or care plan. Interviews with the MDS nurse, DON, and ADM confirmed that tobacco use should have been documented in both the MDS and care plan to ensure accurate care planning and prevent potential negative outcomes. The facility's policy on Care Area Assessments emphasizes the importance of accurate MDS assessments to develop individualized care plans. The failure to document the resident's tobacco use in the MDS and care plan placed the resident at risk of not receiving appropriate care and services.
Failure to Conduct Proper PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with mental illness was properly screened and evaluated prior to admission, as required by the PASRR process. Specifically, the facility did not refer a resident with a diagnosis of schizophrenia to the appropriate state-designated mental health authority for evaluation. This oversight was identified during a review of the resident's records, which showed conflicting information regarding the presence of mental illness. The PASRR Level 1 screening form initially indicated evidence of mental illness, but a subsequent form did not, leading to a failure in obtaining the necessary PASRR Level 2 evaluation. Interviews with facility staff, including the MDS nurse, DON, and Administrator, revealed a lack of awareness and responsibility for ensuring accurate PASRR Level 1 screenings. The MDS nurse, who was new to the facility, was unaware of the resident's schizophrenia diagnosis and the implications for PASRR screening. Both the DON and Administrator acknowledged that an inaccurate PASRR Level 1 screening would prevent the resident from receiving appropriate services and care. The facility's PASRR Clinical Policy outlines the requirement for a PASRR Level 2 evaluation when mental illness is indicated, but this was not followed in this case.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a female with a history of hemiplegia and hemiparesis following a cerebral infarction, hypothyroidism, weakness, type 2 diabetes mellitus, and heart failure, was admitted from a rehab hospital. She required extensive assistance with mobility and daily activities, was alert and oriented, and had a Foley catheter upon admission. Despite these needs, the baseline care plan for the resident was found to be blank and unsigned, indicating that it was not completed as per the facility's policy. Interviews with facility staff, including a registered nurse, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the baseline care plan should have been completed at the time of admission by the admitting nurse. The ADON and DON both acknowledged that the lack of a completed baseline care plan could lead to a lack of communication and unmet care needs for the resident. The facility's policy, dated December 2016, mandates that a baseline care plan be developed within 48 hours of admission to ensure residents' immediate care needs are met, but this was not adhered to in this case.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which resulted in deficiencies in addressing their specific needs. Resident #35, a cognitively intact male with a history of cerebral infarction, type 1 diabetes mellitus with ketoacidosis, and chronic pain, had a care plan dated 02/20/2024 that did not include the management of his fentanyl patch, which was prescribed for pain management. Despite having a physician's order for the fentanyl patch since 05/17/23, this critical aspect of his care was omitted from the care plan. Similarly, Resident #44, also cognitively intact, was admitted with diagnoses including partial intestinal obstruction and pulmonary embolism. His care plan dated 01/26/24 failed to address his tobacco use, despite observations and interviews confirming that he smoked regularly at the facility. The facility's smoking list included him as a smoker, yet this information was not reflected in his care plan or MDS assessment, potentially leading to safety risks. Interviews with the MDS nurse, DON, and ADM revealed a consensus that the care plans should accurately reflect all aspects of a resident's care, including opioid use and smoking habits. The failure to include these elements in the care plans was attributed to inaccuracies in the MDS assessments, which are crucial for developing comprehensive care plans. The facility's policy mandates that care plans include measurable objectives and timetables, and be updated with any significant changes in a resident's condition, which was not adhered to in these cases.
Failure to Evaluate and Justify Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident who was incontinent of bladder, specifically in preventing urinary tract infections and evaluating the need for an indwelling catheter. The resident, a cognitively intact female with a history of hemiplegia, hypothyroidism, diabetes, and heart failure, was admitted with a Foley catheter from a rehab hospital. Despite the resident's report of irritation and discomfort from the catheter, there was no documented evaluation or justification for its continued use upon admission. Interviews with facility staff, including an RN, ADON, and DON, revealed a lack of adherence to the facility's policy requiring evaluation of the necessity of a Foley catheter for newly admitted residents. The staff acknowledged the risks associated with prolonged catheter use, such as infection and urinary dependence, but failed to initiate a voiding trial or consult with a physician or urologist to assess the resident's condition. The facility's policy mandates that the attending physician and staff evaluate the potential for catheter removal, which was not followed in this case.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide medically-related social services to help a resident achieve the highest possible quality of life. Specifically, the facility did not provide appropriate behavioral health services and interventions to prevent or improve the depressive behaviors of a resident. The resident, a male with a history of heart attack, metabolic encephalopathy, anemia, dementia, and type 2 diabetes, was admitted to the facility and was cognitively impaired with a BIMS score of 8. Despite being on an antidepressant medication with a goal to remain free from signs and symptoms of depression, the facility's care plan only included administering medications as ordered and arranging psychiatric consults as needed. A significant error occurred when a family member requested the continuation of the resident's home medication, Amitriptyline. The facility received an order for 300 mg of Amitriptyline to be administered twice daily, which was a transcription error. The resident received a dose of 300 mg, leading to an acute drug overdose and subsequent hospitalization. The nurse practitioner (NP) identified the error after being notified of the resident's increased lethargy and family concerns about over-sedation. The NP confirmed that the order should have been for 10 mg at bedtime, not 300 mg twice daily, resulting in the resident being sent to the hospital for evaluation of adverse effects related to the medication error.
Failure to Document Justification for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, Resident #230 was prescribed Bupropion, an antidepressant, without a documented diagnosis to justify its use. The resident's care plan did not include any antidepressant medications, and there was no medication consent on file for Bupropion. This oversight could lead to adverse consequences for the resident, such as impairment or decline in mental or physical condition. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's expectation was to obtain consent and a diagnosis for any psychotropic medication upon admission. However, this process was not followed for Resident #230. The facility's policy on medication utilization and prescribing requires that medications be prescribed in response to an identified problem or condition, considering the resident's age, condition, risks, health status, and existing medications. The failure to adhere to these procedures resulted in the administration of Bupropion without proper documentation or consent.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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