Huebner Creek Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 8306 Huebner Rd, San Antonio, Texas 78240
- CMS Provider Number
- 676136
- Inspections on file
- 50
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Huebner Creek Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure three diabetic residents received scheduled podiatry foot care to maintain proper toenail length, despite care plans directing referral to a podiatrist or foot care nurse and a contracted podiatry group visiting the facility. All three residents were on the podiatry list but were not seen during the most recent visit, and their last documented podiatry care had occurred several months earlier. One resident, cognitively intact and dependent for footwear, reported needing help with toenail cutting and had toenails extending beyond the toe with some curving toward the skin. Another cognitively intact resident who required substantial assistance with footwear stated he had not seen the podiatrist in a long time. A third resident with moderate cognitive impairment, who ambulated with a walker, reported asking staff about nail care, said her toenails were last cut the prior year, and described pain with wearing shoes and embarrassment; her toenails were visibly long. Staff interviews confirmed that the podiatry company did not see all residents on the last visit, could not return for several weeks, and that only the podiatrist trims toenails for residents with diabetes, consistent with facility policy. Leadership acknowledged that some residents did not receive foot care and that this placed them at risk for injury or infection and that long toenails can cause pain and be a fall hazard.
Two residents with intact cognition and documented needs for assistance with showering had incomplete ADL-bathing entries in the EMR, with multiple scheduled bath days lacking any recorded bath or refusal despite stated bathing preferences and observed clean, groomed appearances. CNAs reported that showers are required to be documented in the plan of care software but acknowledged that documentation is sometimes not completed when workloads are heavy, and one CNA suggested a resident likely refused showers without this being recorded. The DON confirmed that both showers and refusals must be documented and outlined a process for handling refusals that was not reflected in the residents’ records.
A resident with severe cognitive impairment, upper and lower extremity limitations, bowel incontinence, and a Foley catheter, and identified as high fall risk, experienced an unwitnessed fall next to her bed while her call light was in reach but not activated. The resident had been changed from a regular call light to a pressure bulb call light, yet observations and interviews showed she could not locate or trigger the device due to weakness, impaired upper body function, and cognitive decline, and she spoke in a faint voice from a room several doors away from the nurse station. Staff accounts conflicted on whether the resident could use the call light, and the Rehab Director acknowledged that no alternative adaptive call light devices or training had been implemented despite the resident’s decline. The facility’s fall and resident rights policies referenced call bells being within reach and supporting communication, but there was no specific policy governing the call light system.
An LPN failed to disinfect a shared blood pressure cuff between two residents during routine blood pressure checks associated with medication administration. The LPN used the same cuff on two male residents with cardiovascular and other medical conditions, placing the cuff back on the medication cart after each use without wiping it with disinfectant wipes, despite existing infection control training and a facility policy requiring an infection prevention and control program to prevent the development and transmission of infections.
The facility failed to post required current daily nurse staffing and census information for an extended period, instead displaying an outdated staffing sheet in the lobby. The ADON, who was responsible for posting the information, acknowledged that although the daily postings were prepared and kept in a book, they were not actually posted and that there was no facility policy governing this process. The DON and ADMIN both stated their expectation that the daily staffing and census information be posted, while the ADMIN noted that some families accessed a staffing binder at the nursing station, which listed scheduled staff and assignments but did not replace the required public posting.
Surveyors found multiple dietary service deficiencies, including opened ham and cheese in the walk-in refrigerator without discard dates, boxes stored too close to the ceiling in the walk-in refrigerator and freezer, and bacon that was not fully covered. The CDM and a cook acknowledged that food items should be dated, properly wrapped, and stored at an appropriate distance from sprinkler heads for ventilation. A cook was also observed preparing a meal without a required beard restraint, despite prior training and facility policy mandating hair restraints for dietary staff with facial hair.
Surveyors found that MDS assessments did not accurately reflect the clinical status of two residents. One resident’s admission MDS incorrectly indicated no unhealed pressure ulcers, despite documentation of a pressure ulcer to the right buttock, a care plan addressing the ulcer, and physician orders and weekly wound assessments describing ongoing treatment. Another resident’s Medicare 5-day MDS incorrectly coded bladder status as having none of the listed devices, even though the care plan and physician orders documented an indwelling Foley catheter with shift-by-shift monitoring. The MDS nurse acknowledged both errors as coding mistakes, and the DON affirmed that MDS assessments are required by facility policy to accurately reflect each resident’s condition.
A resident with dementia, bowel and bladder incontinence, and multiple comorbidities did not receive complete perineal care during an observed incontinence episode. A CNA removed a soiled brief, cleaned only the groin, buttock, and rectal areas, but did not clean the suprapubic area or open the labia while cleansing the genital area, contrary to the facility’s perineal care policy requiring wiping across the pubis and proper cleansing of the labia majora from front to back. The CNA later stated she was nervous and forgot these steps, despite prior peri-care training, and the DON confirmed these actions should have been performed to prevent possible infection.
The facility did not provide individualized activities according to residents' care plans, particularly by restricting access to the activities room to limited weekday hours. Several residents with depression, PTSD, and intact cognition reported that they were unable to engage in preferred activities such as complex puzzles and art during nights and weekends, leading to complaints and feelings of isolation. Staff confirmed the restricted access and acknowledged its negative impact, while no activities policy was provided when requested.
A resident with quadriplegia and no cognitive impairment was found without access to a call light, as it had been left inside a nightstand by staff after care. The resident reported this was a recurring issue, and staff interviews confirmed the oversight. The care plan required encouragement to use the call bell, but the failure to ensure accessibility resulted in the resident being unable to independently request assistance.
A resident with dementia and depression was not provided adequate support to practice his Muslim faith, as his care plan lacked religious accommodations and staff were unaware of his preferences. The resident felt excluded from religious activities, was unable to watch religious programs due to a non-functioning TV, and did not receive meal accommodations for fasting, despite informing staff of his needs.
Two residents did not have their care plans updated to reflect important aspects of their care needs, including religious preferences and a PTSD diagnosis. One resident's care plan lacked documentation of his religion, resulting in missed opportunities for religious practice and staff being unaware of his needs. Another resident's care plan did not address his PTSD, despite staff knowing he was sensitive to noise and required specific accommodations. Staff interviews revealed confusion about responsibility for care planning and a lack of awareness of residents' individualized needs.
A resident with moisture associated skin damage did not have three scheduled wound care treatments properly documented in the electronic record. Nursing staff reported providing the care but failed to record it, especially during weekend shifts when the wound care nurse was absent. The lack of documentation was confirmed by review of the administration records and staff interviews, resulting in incomplete clinical records.
A CNA failed to sanitize hands after touching her face and eyeglasses and before assisting a resident with their meal, including handling utensils and cutting food. The CNA had not attended a recent in-service training on meal tray pass, and interviews confirmed she was unclear about hand hygiene procedures after touching personal items. Facility leadership stated their expectation for hand hygiene between each resident's tray delivery, and relevant policies emphasized its importance, but the meal service policy lacked specific guidance.
The facility did not post required contact information for State agencies and advocacy groups, including the LTC Ombudsman, in a manner accessible to residents and their representatives. Over several days, surveyors observed the absence of this information, and the DON confirmed both the missing posting and the lack of a facility policy or designated staff responsible for maintaining required postings.
The facility did not post required daily nurse staffing and census information for three days. Observations and interviews with the DON and ADON confirmed the postings were missing, and neither could determine how long this had been the case. The display case for the postings could not be found, and there was no facility policy regarding the required postings.
A CNA failed to perform hand hygiene between glove changes while providing peri-care to a resident who was fully dependent on staff for toileting and had multiple chronic conditions. After removing soiled gloves contaminated with stool, the CNA immediately donned clean gloves without using hand sanitizer or washing hands, contrary to facility policy and infection control standards. Interviews confirmed staff were aware of the required procedures, and records showed the CNA had been previously assessed as proficient in infection control.
The facility failed to provide a safe and clean environment for two residents. One resident with dementia was found in a room with a strong urine odor and soiled sheets, while another resident with mobility issues reported a wobbly toilet that was not fixed despite multiple complaints. Staffing shortages and inadequate communication regarding maintenance needs contributed to these deficiencies.
The facility failed to develop baseline care plans within 48 hours for two residents, one with dementia and other health issues, and another with severe cognitive impairment and multiple diagnoses. This oversight was confirmed by staff interviews, highlighting the importance of timely care plans for adequate resident care.
A facility failed to include a resident's mental health diagnoses and medication orders in her comprehensive care plan, despite her conditions of Depression, Generalized Anxiety Disorder, and Dementia. The MDS nurse acknowledged the oversight, and the DON confirmed that care plans should address all resident needs. The facility's policy emphasizes person-centered care plans to meet medical, physical, mental, and psychosocial needs.
A resident with dementia and unsteadiness experienced three falls in a short period, but the facility failed to update the care plan with new interventions. Despite discussions among staff and a hospital visit, the care plan remained unchanged, contrary to facility policy requiring updates after significant changes.
A resident with multiple health conditions did not receive consistent wound care and leg wrapping as per physician orders and care plan. Observations showed missing treatments on specific dates, and staff interviews revealed time constraints and workload issues as reasons for the lapses. The DON acknowledged the importance of following orders to prevent complications.
The facility failed to store medications securely, as observed in the medication room and on a nurse medication cart. Controlled substances were found unlocked in a refrigerator, and medications for a resident with diabetes were left unattended on a cart. The DON acknowledged the risk of drug diversion and confirmed that all medications should be locked according to facility policy.
The facility failed to maintain an effective training program for staff, with missing annual training in key areas for five employees. The HR Manager cited recent administrative changes as a reason for the oversight.
A resident with a history of Alzheimer's and suicidal ideation was found lethargic with an empty Tylenol bottle at their bedside, resulting in a 12,000mg overdose. The facility failed to monitor medications at the bedside and did not provide in-service training or assess other residents for safety following the incident.
A resident with a history of Alzheimer's and depression was found lethargic with an empty Tylenol bottle, leading to a 12,000mg overdose. Despite the seriousness of the incident, the facility failed to report the event to the state agency as required. Interviews revealed that the previous and current leadership were unaware if the incident had been reported, highlighting a lapse in following the facility's policy for reporting suspected neglect.
A resident with a history of suicidal ideation was found lethargic with an empty Tylenol bottle, leading to a 12,000mg overdose. The facility failed to investigate or report the incident to the state agency, as required by law. Staff interviews revealed a lack of awareness and action regarding the incident, and no documentation was provided to support that the facility had taken appropriate steps to address the situation.
An LVN failed to document a skin assessment and treatment for a resident with a rash, leading to incomplete medical records. The resident, with cognitive impairments and behavioral issues, was prescribed a steroid cream by a physician, but the order lacked specific application instructions. The facility's documentation policy was not followed, as confirmed by interviews with the LVN and DON.
The facility failed to provide privacy for three residents during care, as observed during a survey. A resident with a pressure ulcer did not receive privacy during wound care, as the LVN did not close the door or curtain. Another resident with a pressure ulcer was not provided privacy during wound care, with the LVN leaving the door, curtain, and blinds open. A third resident, requiring assistance with ADLs, was not given privacy during perineal care and dressing, as the CNA did not close the curtain or blinds. Staff interviews highlighted the importance of ensuring privacy to maintain resident dignity.
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks of improper care. A resident's records lacked documentation of wound care treatments on specific dates, despite confirmation of receipt. Interviews revealed inconsistencies in responsibility for documentation, with some staff unaware of who was responsible when the treatment nurse was unavailable. Another resident's records showed missing documentation for wound care treatments across several months, with staff admitting to not documenting treatments even if provided. Similarly, a third resident's records were incomplete, with missing documentation for wound care treatments. The DON was unaware of the missing documentation, assuming treatments were completed but not documented.
The facility failed to maintain effective infection control practices, as staff did not perform adequate hand hygiene, sanitize surfaces, or use PPE during wound care and personal hygiene for multiple residents. This included improper glove changes and neglecting Enhanced Barrier Precautions, increasing the risk of cross-contamination and infection.
The facility failed to ensure residents' rights to communication and visitor access due to a malfunctioning phone system at the nurse station, which did not alert staff to incoming calls. This issue, coupled with the absence of a weekend receptionist, potentially denied residents access to visitors, including family and physicians. The deficiency was observed when the surveyor found the main entrance secured without a doorbell and the phone system unresponsive.
Two residents in an LTC facility experienced issues with the call light system, leading to delays in receiving assistance. One resident was admitted without a call light, while another faced a malfunctioning system, resulting in a 36-minute wait for help with a burst colostomy bag. Staff failed to notice the alert due to a malfunctioning illuminator, causing prolonged discomfort for the resident.
Failure to Provide Timely Podiatry Foot Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide podiatry foot care and treatment in accordance with professional standards of practice for three residents with diabetes who were care planned to receive podiatry services. All three residents had care plans indicating diabetes mellitus with an intervention to refer to a podiatrist or foot care nurse to monitor and document foot care needs and to cut long nails. A local podiatry group was scheduled to provide services on 3/4/26, and all three residents were listed to be seen, but they did not receive foot care during that visit. Record review showed that the last podiatry service date for each of these residents was 10/28/2025, despite their insurance allowing 4–6 podiatry visits per year. Resident #1 was an 82-year-old female with unspecified dementia, type 2 diabetes mellitus, and a need for assistance with personal care, who was dependent on staff for putting on and taking off footwear and had no cognitive impairment per a BIMS score of 15. During observation and interview, she reported needing help cutting her toenails, stated she could not do it herself, and that nurses did not cut her nails because she had diabetes and the podiatrist had to do it. She reported her last toenail trimming was about five months prior. Her toenails were observed to extend up to 1/4 inch beyond the flesh of the toes, with some nails curving toward the skin. Resident #2 was a male with spinal stenosis with neurogenic claudication, type 2 diabetes mellitus, and a need for assistance with personal care, who required substantial to maximum assistance with footwear and had a BIMS score of 15. He stated that a podiatrist usually cut his toenails but that he had not seen her in quite a while. Resident #3 was a female with unspecified dementia, type 2 diabetes mellitus, a need for assistance with personal care, and moderate cognitive impairment with a BIMS score of 7, who ambulated with a walker. She reported asking staff about getting her toenails cut and being told it would occur when the podiatrist came, stated her toenails were last cut the previous year, and reported pain with wearing shoes and embarrassment. Her toenails were observed to be 1/2 to 1 inch beyond the flesh of the toe. A family member reported that a hospital had noted her need for nail care and that the podiatrist had left before seeing her at the last visit. The SW confirmed the podiatry company could not see everyone on the March visit, could not return until late April, and that only the podiatrist provided toenail care for residents with diabetes, consistent with the facility’s nail care policy stating that nail care, especially trimming, is performed by a podiatrist in those with diabetes and peripheral vascular disease. The DON and ADON acknowledged that some residents did not receive foot care and that this put them at risk for injury or infections, and that long toenails can be a fall hazard and cause pain.
Incomplete ADL-Bathing Documentation for Two Residents
Penalty
Summary
Surveyors identified that the facility failed to maintain complete and accurate ADL-bathing documentation in the electronic medical record for two residents. For an 82-year-old female resident with dementia, type 2 diabetes, and a need for assistance with personal care, review of her quarterly MDS showed she had a BIMS score of 15/15 and was dependent on staff for showering/bathing. Her 30‑day task record reflected a preference for bathing on Tuesdays, Thursdays, and Saturdays, but there were no bath or refusal entries documented for multiple specified dates over February and March, despite her admission date of 1/1/2026. During observation, she appeared clean and groomed and reported that she was able to take showers on scheduled days but sometimes refused when offered early in the morning, preferring showers after dinner. A male resident with spinal stenosis, type 2 diabetes, and a need for assistance with personal care also had incomplete ADL-bathing documentation. His quarterly MDS showed a BIMS score of 15/15 and a need for substantial to maximum assistance with showering/bathing, with a documented preference for bathing on Tuesdays, Thursdays, and Saturdays. However, his 30‑day task record lacked bath or refusal entries for the same series of dates, despite a readmission date of 8/9/2025. During observation, he was in his room with clean clothes and a groomed appearance and stated he required help with showers. CNA A reported that showers were required to be documented in the plan of care but admitted that when work was very busy, she did not chart, even though she stated she always offered showers. CNA B stated that shower documentation was in the system and must be completed, and suggested the male resident probably refused scheduled showers. The DON stated that showers and refusals were required to be documented and described a process in which CNAs notify the nurse of refusals and attempts are made and documented, but the records for these residents did not reflect such documentation.
Failure to Provide Effective Call Light Access for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences regarding access to and use of the call light system. The resident was an 80-year-old female with sepsis, diabetes, dementia, hypertension, cognitive deficits, bowel incontinence, and a Foley catheter. Her MDS reflected a BIMS score of 02, indicating severe cognitive impairment, and she was dependent for transfers and mobility with impaired upper and lower range of motion. She had a history of falls and a fall risk score of 11, categorized as high risk. Her care plan included interventions such as a low bed, call light in reach, clutter-free room, and monitoring for risk of falls. On the date of the incident, the resident experienced an unwitnessed fall in her room, landing on the left side of the bed near the wall and sustaining scratches to the right side of her face. The fall assessment documented that the resident was disoriented and that neurological checks were initiated. A nurse note indicated that shortly before the fall, the resident had been given a pain medication, and when the LVN returned to administer night medications, the resident was found on the floor with the bed in a low position and the call light in reach but not activated. The resident was unable to provide a clear explanation for the fall. The resident’s room was located three rooms away from the nurse station, and she spoke in a faint voice, making it difficult for staff to hear her if she called out verbally. Observations and interviews showed that the resident could not effectively use the assigned pressure bulb call light due to upper body impairment and cognitive decline. The call light was tied to the left side of her nightgown, but her arms were crossed away from it, and she stated she could not reach or push the call light. The Rehab Director reported that the resident had previously used a regular call light effectively but had declined and was switched to a pressure call light; however, the Rehab Director was not aware that the resident could not use the squeeze pad requiring palm or pressure dexterity and acknowledged that no other adaptive devices or training had been tried. During direct observation, the resident was unable to locate or trigger the call light even when it was placed in her hand. Staff interviews were inconsistent: some staff stated the resident could not push the call light, while another LVN stated the resident was able to trigger it and that no further accommodations were needed. The DON stated that depending on the day and time, the resident could or could not activate the call light and that the resident’s door should have been open unless care was being given. The facility’s fall policy required call bells to be positioned within reach and responded to timely, and the resident rights policy addressed the right to communication and access to services, but the facility had no specific policy on the call light system.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program by not disinfecting shared blood pressure equipment between residents. On 02/13/2026 at 07:40 a.m., an LPN was observed taking one resident’s blood pressure prior to administering medications. After completing the blood pressure check, the LPN returned to the medication cart and placed the blood pressure cuff on the cart without sanitizing it. The LPN then administered medications to that resident. At 07:58 a.m. the same day, the LPN used the same blood pressure cuff to take another resident’s blood pressure, again returning the cuff to the top of the medication cart without disinfecting it. During a later interview, the LPN stated she forgot to wipe the blood pressure cuff between residents because she was nervous and acknowledged that failing to wipe the cuff with disinfectant wipes between residents was an infection control concern. She also stated that nursing staff received frequent training on hand hygiene and infection control. The first resident involved was an adult male with diagnoses including metabolic encephalopathy, essential hypertension, and paroxysmal atrial fibrillation, who was cognitively intact with no infections or antibiotic use noted in the seven days prior to the assessment. The second resident was an adult male with anemia, atherosclerotic heart disease, and essential hypertension, who was moderately cognitively impaired and also had no infections or antibiotic use in the seven days prior to the assessment. Facility leadership, including the ADON, DON, and Administrator, each stated in interviews that staff were expected to disinfect blood pressure cuffs between residents using disinfectant wipes and acknowledged that failure to do so was an infection control concern. The facility’s Infection Control Plan policy stated that the facility would establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing and census information for a continuous period of 20 days. Surveyors observed on multiple occasions that the only staffing document displayed in the front lobby was dated several weeks earlier and labeled for a prior day, even though it contained census and scheduled staffing information for various shifts. The required current daily posting, which must include the facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, and CNAs directly responsible for resident care per shift, as well as the resident census, was not posted for any of the days reviewed. During interviews, the ADON stated he was responsible for posting the daily census and nurse staffing information and acknowledged that he had not been posting it, despite having the prepared postings kept in a book. He explained that he had “just not put them out” and had “forgot” to post them, and also reported that the facility did not have a policy on posting the daily census and nurse staffing. The DON stated her expectation was that the information be posted daily and confirmed the ADON was responsible for this task, but she was unsure why it was not posted on one of the observed days. The Administrator also stated his expectation that the posting be done daily, acknowledged it was a requirement, and noted that some families were aware they could review a nurse staffing binder at the nursing station, which contained staffing schedules and assignments, but this binder was separate from the required public posting.
Food Storage, Labeling, and Hair Restraint Lapses in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper food storage, labeling, and staff attire in the kitchen. During observation of the walk-in refrigerator, they found an opened package of ham and an opened package of cheese without discard dates. The Certified Dietary Manager (CDM) stated that once opened, these items should be discarded after 14 days and acknowledged responsibility for ensuring proper labeling. Surveyors also observed boxes stored in both the walk-in refrigerator and freezer less than 18 inches from the ceiling, contrary to facility policy requiring storage 18 inches or more from sprinkler heads to allow appropriate ventilation and air flow. The CDM confirmed she was responsible for putting boxes away and agreed the boxes were too close to the ceiling. Additional observations showed bacon in the walk-in refrigerator that was not fully covered, which the CDM stated should have been properly covered by another staff member earlier that day to prevent contamination. During meal preparation, a cook was observed working without a beard restraint while cooking dinner, despite acknowledging he had been trained to wear one and understood its importance in preventing hair from getting into food. Another cook later confirmed that boxes should be kept a certain distance from the ceiling for proper circulation, that discard dates are important for prepared foods, and that bacon must be fully wrapped so it does not go bad. Review of facility policies on food storage and dress code showed requirements for food and supplies to be stored six inches above the floor and 18 inches or more from sprinkler heads, and for dietary staff with facial hair to wear hair restraints or nets.
Inaccurate MDS Coding for Pressure Ulcer and Indwelling Catheter
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents’ clinical status for two residents reviewed. For one resident, the admission MDS coded Section M (Skin Conditions) as “No” to the question of whether the resident had one or more unhealed pressure ulcers/injuries. However, the resident’s comprehensive care plan documented an actual unstageable pressure ulcer to the right buttock, and a Weekly-Ulcer Assessment described a Stage II pressure ulcer in the right buttock area near the sacrum, with corresponding physician orders for daily wound care using normal saline and triad. The MDS nurse later acknowledged that, because the resident had a pressure ulcer in the sacral area during the assessment period, Section M should have been coded “Yes” and stated that the inaccurate coding was a mistake by a former MDS nurse. For a second resident, the Medicare 5-day MDS coded Section H (Bladder and Bowel) as “None of the above” for urinary elimination status, despite facility records showing the resident had an indwelling urinary catheter at readmission. The resident’s comprehensive care plan identified the presence of an indwelling urinary catheter with an intervention for catheter care as ordered, and physician orders directed staff to monitor the Foley catheter every shift for leakage, blockage, sediment buildup, or low output. The MDS nurse confirmed that “Indwelling catheter” should have been selected instead of “None of the above” and described this as a coding mistake. The DON stated that all MDS assessments should be coded accurately to provide appropriate care, and the facility’s MDS policy requires that assessments accurately reflect the resident’s status.
Inadequate Perineal Care for Incontinent Resident
Penalty
Summary
The facility failed to provide appropriate incontinence and perineal care to a female resident who was frequently incontinent of bladder and bowel and had multiple comorbidities, including a hip fracture, type 2 diabetes mellitus, dementia with moderate cognitive impairment (BIMS score 8/15), and chronic kidney disease. Her comprehensive care plan documented bowel and bladder incontinence related to dementia, hospice status, weakness, impaired mobility, and pain, with interventions to check her every two hours, assist with toileting as needed, and provide peri care after each incontinent episode. During an observation, CNA-B removed the resident’s soiled brief and cleaned only the right and left groin areas, then turned the resident to her right side and cleaned the buttock and rectal area before applying a clean brief. The observation further showed that CNA-B did not clean the resident’s suprapubic area and did not open the labia while cleaning the genital area, contrary to the facility’s perineal care policy, which directs staff to wipe across the pubis area and, for female residents, to wipe one side of the labia majora from front to back to avoid contaminating the urethral area. In a subsequent interview, CNA-B acknowledged she did not clean the suprapubic area or open the labia, stating she was nervous and forgot, and confirmed she had received peri-care training in the prior year. The DON also stated that CNA-B should have cleaned the suprapubic area and opened the labia area to prevent possible infection and confirmed responsibility for providing peri-care training and monitoring skill checkoffs.
Failure to Provide Individualized Activities and Access to Activities Room
Penalty
Summary
The facility failed to provide individualized activities based on comprehensive assessments and care plans for three residents, particularly during nights and weekends. Observations and interviews revealed that the activities room was only open for limited hours on weekdays, restricting access to preferred activities such as complex puzzles, drawing, and painting. Residents expressed that the closure of the activities room outside of these hours prevented them from engaging in meaningful activities, which they found stimulating and comforting, especially during the evening and night. Residents with intact cognition and diagnoses including depression and PTSD reported that access to the activities room was important for their mental well-being. One resident with PTSD and a traumatic brain injury stated that working on puzzles at night in the activities room helped him cope with his trauma. Another resident described feeling lost and depressed when unable to access the room after hours, as she did not enjoy alternative activities like watching TV and found it difficult to transport her complex puzzles. Staff interviews confirmed that residents had complained about the restricted access to the activities room, and the Activities Director acknowledged the negative impact of the limited hours. The facility did not provide a policy for activities when requested, and the care plans for the affected residents included interventions that could not be implemented due to the restricted access. The lack of individualized activities and limited access to the activities room led to unmet physical, mental, and psychosocial needs for the residents involved.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, muscle wasting and atrophy, and acute respiratory failure was found without access to their call light. The resident, who was cognitively intact and required full assistance from two staff members, had a care plan intervention to encourage use of the call bell for assistance. During an observation, the call light was discovered inside the nightstand, out of the resident's reach. The resident reported that staff frequently left the call light inaccessible, causing distress and forcing him to call the facility's phone number for help. Interviews with staff confirmed the call light was not accessible to the resident. The assigned CNA admitted to forgetting to place the call light within reach after returning the resident to bed following a shower. The LVN acknowledged that the call light was not accessible and stated this was not good nursing practice, as the resident would be unable to call for help. The DON and ADON both emphasized the importance of call light accessibility and stated that staff are trained on this procedure, but there was no formal policy addressing the issue.
Failure to Support Resident's Religious Practices and Self-Determination
Penalty
Summary
The facility failed to ensure that a resident's right to self-determination and religious practice was honored. The resident, a male with dementia and depression, had informed staff of his Muslim faith and expressed a desire to practice his religion within the facility. Despite this, his care plan did not include any mention of his religious preferences or related activities, except for a selective menu for certain meals. The resident reported feeling excluded because he could not participate in religious activities relevant to his faith, while other residents could attend Bible study. He also stated that he was unable to watch religious programs on his TV due to it not working, an issue the facility was aware of but had not resolved. Interviews with staff, including an LVN, the Activities Director, and the DON, revealed a lack of awareness or effective support for the resident's religious needs. The Activities Director acknowledged attempts to support the resident's religion, but these efforts did not meet his expectations. The resident also noted that he did not receive food before fasting periods and felt unable to request accommodations due to the facility's set meal times. The facility's policy requires respect for resident rights and individuality, but documentation and staff actions did not reflect adequate support for this resident's religious practices.
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 two residents, as required by regulation. For one resident with dementia and depression, the care plan did not include any mention of his religious preferences or needs, despite the resident being Muslim and having communicated this to staff. The only reference to his religion was a dietary note about a selective menu, but there was no documentation regarding his desire to practice his religion or participate in religious activities. Interviews revealed that the resident felt excluded from religious activities and was not provided alternatives to practice his faith, and several staff members were unaware of his religious background or how to accommodate his needs. For another resident with a diagnosis of PTSD and a history of traumatic brain injury, the care plan did not address his PTSD diagnosis or related care needs. The resident reported that engaging in puzzles at night helped him cope with his trauma, and staff interviews confirmed that he was sensitive to loud noises and required accommodations to avoid being triggered. However, this information was not reflected in his care plan, and some staff were unaware of his PTSD diagnosis or how to support him appropriately. Record reviews and staff interviews indicated a lack of communication and clarity regarding responsibility for updating care plans to reflect residents' religious and psychosocial needs. The facility's policy required person-centered care plans that addressed each resident's preferences and needs, but in these cases, the care plans were incomplete and did not provide measurable objectives or time frames for addressing the identified needs. This failure was confirmed through interviews with residents and staff, as well as review of facility documentation.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for one resident reviewed for clinical records. Specifically, wound care treatments for a resident with moisture associated skin damage (MASD) to the sacral area were not properly documented on the Wound Administration Record (WAR) for three scheduled treatments out of thirty-nine reviewed. The treatment order required cleansing the sacral area and applying Triad cream every day and evening shift, but the WAR showed blanks for three specific shifts, indicating missing documentation. Interviews with nursing staff revealed that the wound care nurse was not present on weekends, and direct care nurses were expected to provide and document wound care in her absence. One LPN recalled providing the treatment but admitted she did not document it, while another LPN, new to the facility, stated she may not have noticed the order in the electronic record and therefore did not mark it as completed. The Director of Nursing confirmed that a blank in the administration record typically indicates a missed administration or lack of documentation, which impacts the ability to monitor whether orders are being followed. The resident involved was cognitively intact, dependent for all self-care and mobility, and at risk for pressure ulcers, with a history of MASD. The resident could not recall if wound care was provided on the dates in question. Facility policy required that the person administering a treatment document it at the time of administration, but this was not consistently followed, resulting in incomplete clinical records for the resident.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
A certified nursing assistant (CNA) failed to perform proper hand hygiene while serving and assisting residents with their meals. During observation, the CNA was seen leaving a resident's room after delivering a meal tray, adjusting her eyeglasses, and then proceeding to handle another resident's meal tray and utensils without sanitizing her hands. The CNA touched her face and personal glasses multiple times before assisting a resident with their meal, including cutting up the resident's food, without performing hand hygiene in between these actions. Record review showed that the CNA did not attend a recent in-service training on meal tray pass, which included hand hygiene expectations. Interviews with the CNA revealed she was aware of the need for hand hygiene between serving residents but was unclear about the procedure after touching her glasses. Both the Director of Nursing (DON) and the Administrator confirmed their expectations for staff to use hand sanitizer before and between each resident's tray delivery, including after touching their face or glasses. Facility policies emphasized hand hygiene as a primary means of infection prevention, but the policy on nursing responsibilities at meal service did not address hand hygiene during meal service.
Failure to Post Required State Agency and Ombudsman Contact Information
Penalty
Summary
The facility failed to post, in an accessible and understandable manner, the required list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the Office of the State Long-Term Care Ombudsman program. This deficiency was observed over a three-day period, during which surveyors noted the absence of the required information in public postings on multiple occasions. The lack of posting was confirmed during interviews and observations, with no information available for residents or their representatives to access. During interviews, the DON acknowledged the missing ombudsman contact information and was unable to provide a timeline for how long the posting had been absent. The DON also stated that there was no facility policy regarding required postings and was unable to identify any staff responsible for ensuring the postings were maintained. The absence of this information could impact residents' ability to contact advocacy resources and exercise their rights, as noted by the DON during the interview.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post daily nurse staffing and census information for three consecutive days, as required. Observations on multiple occasions revealed that the information regarding the facility name, current date, total number and actual hours worked by RNs, LPNs, and CNAs per shift, as well as the resident census, was not publicly posted. Interviews with the DON and ADON confirmed that the postings were missing and that neither could determine how long the information had not been posted. The DON stated that the responsibility for posting was assigned to the ADON and the weekend supervisor, but the display case used for posting could not be located. Both the DON and ADON indicated they were unaware of any inquiries from residents or families regarding the posting and did not believe the absence of the posting had an impact. Further, the DON revealed that the facility did not have a policy regarding the required postings. The ADON confirmed that while the facility maintained the procedure of creating, updating, and preserving the daily census and nurse staffing documents, the actual public posting had not occurred for an undetermined period. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Perform Hand Hygiene Between Glove Changes During Peri-Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform proper hand hygiene during peri-care for a female resident who was totally dependent on staff for toileting and incontinent. The resident, who had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, congestive heart failure, and generalized muscle weakness, required total assistance for toilet hygiene. During an observed episode of peri-care, the CNA removed soiled gloves after handling a large volume of stool and immediately donned clean gloves without performing hand hygiene in between, despite her gloves being visibly contaminated. Interviews with the CNA, the Assistant Director of Nursing (ADON) who also served as the facility's Infection Preventionist, and the Director of Nursing (DON) confirmed that the facility's expectation and policy required staff to perform hand hygiene after removing gloves and before putting on new gloves, especially during peri-care. The CNA acknowledged awareness of the correct procedure but failed to follow it during the observed care. Facility records indicated the CNA had previously been assessed as proficient in both peri-care and infection control awareness. Facility policies reviewed also specified the necessity of hand hygiene before and after glove use, particularly when gloves are visibly soiled.
Failure to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents. One resident, who had dementia and was frequently incontinent, was found in a room with a strong urine odor and soiled sheets containing urine and feces. Despite having a care plan that included regular incontinent care, the resident's needs were not met due to staffing shortages, as only one CNA was available during the shift. The maintenance supervisor noted that the urine odor persisted due to absorption into the flooring, and the housekeeping supervisor identified stains on the walls, indicating inadequate cleaning. Another resident, who was legally blind and had difficulty walking, reported a wobbly toilet in her restroom that had been loose since her admission. Despite informing several staff members, the issue was not addressed, and the toilet remained unstable, posing a safety risk. The maintenance supervisor was unaware of the problem due to a lack of work orders from staff, although the resident had previously reported an overflowing toilet, which was fixed. The facility had a system for maintenance requests, but it was not utilized effectively by the staff. The facility's policies on resident rights, linens, and housekeeping emphasize the importance of maintaining a clean and safe environment. However, these policies were not followed, leading to deficiencies in the care provided to the residents. The lack of adequate staffing and communication regarding maintenance needs contributed to the failure to address the residents' environmental concerns.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure proper care and continuity of services. Resident #12, a woman with dementia, dehydration, chronic respiratory failure with hypoxia, and generalized anxiety disorder, was admitted on 12/12/2024. Her baseline care plan was not completed until 18 days after her admission, on 12/30/2024. She was assessed with a BIMS score of 13, indicating intact cognition, and required assistance with mobility and toileting hygiene. Similarly, Resident #29, a woman with dementia, type 2 diabetes, depression, and anxiety disorder, was admitted on 11/21/2024, but her baseline care plan was not completed until 11 days later, on 12/02/2024. She had a BIMS score of 5, indicating severe cognitive impairment, and was dependent on assistance for personal hygiene and bathing. Interviews with facility staff, including the MDS-A and the DON, confirmed the oversight and acknowledged the importance of completing baseline care plans within the required timeframe to provide adequate care for newly admitted residents.
Failure to Address Mental Health Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is consistent with resident rights and includes measurable objectives and time frames to meet the resident's mental, nursing, and psychosocial needs. Specifically, the care plan for a resident with diagnoses of Depression, Generalized Anxiety Disorder, and Dementia did not address these conditions or the active orders for anti-anxiety and anti-psychotic medications. This oversight was identified during a record review and interview, where it was noted that these diagnoses and medications should have automatically triggered a Care Area Assessment (CAA) but were missed. The resident's comprehensive care plan, initiated on a specific date, lacked focus areas addressing her mental health diagnoses and medication orders. The MDS nurse acknowledged the omission and stated that these should have been included in the care plan. The facility's Director of Nursing (DON) and other staff confirmed that comprehensive care plans should address all nursing, mental, and psychosocial needs, including necessary interventions and services. The facility's policy on comprehensive care planning emphasizes the development and implementation of person-centered care plans to meet residents' medical, physical, mental, and psychosocial needs.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident after experiencing three falls within a four-hour period. The resident, who has a history of dementia, overactive bladder, hearing loss, and unsteadiness on feet, was admitted to the facility with a moderate cognitive impairment. Despite the falls being unusual for the resident, the care plan, which had not been updated since July 2024, was not revised to include new interventions or assessments following the incidents. The falls resulted in a skin tear and a hospital visit, but no new medical orders were issued upon the resident's return. Interviews with facility staff revealed that the falls were discussed in a morning meeting, and it was agreed that the resident should receive an Occupational Therapy evaluation in addition to ongoing physical therapy. However, these interventions were not documented in the resident's care plan, which is a requirement according to the facility's policy. The Director of Nursing, who was responsible for updating the care plan, was no longer with the facility, and the new Director of Nursing acknowledged the oversight. The facility's policy mandates that care plans be reviewed and revised after significant changes, such as falls, to ensure all staff are informed of the resident's needs.
Failure to Provide Consistent Wound Care and Leg Wrapping
Penalty
Summary
The facility failed to provide appropriate wound care and leg wrapping for a resident, as per the physician's orders and the resident's care plan. The resident, an elderly woman with intact cognition, was admitted with conditions including Lichen Simplex Chronicus, obesity, and mobility issues. She was dependent on assistance for personal care and had moisture-associated skin damage. The care plan included daily wound dressing and leg wrapping to manage her conditions. However, observations revealed that these treatments were not consistently applied, with specific dates noted where the treatments were not documented as completed. Interviews with facility staff, including the Treatment Nurse and the Director of Nursing (DON), confirmed the lapses in care. The Treatment Nurse admitted to not completing the treatments due to time constraints and workload, and there was no coverage in her absence. The DON acknowledged the issue and emphasized the importance of adhering to physician orders to prevent slow healing and infection. The facility's policy on skin integrity management required wound care to be performed as ordered, highlighting a failure to comply with established protocols.
Failure to Secure Medications in Locked Compartments
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed in the medication room and on a nurse medication cart. During an observation, it was found that the compartment inside the refrigerator designated for controlled substances was unlocked and contained lorazepam, a controlled medication. The Director of Nursing (DON) acknowledged that this oversight could lead to drug diversion and confirmed that the bin should have been locked. The facility's policy mandates that all controlled medications be stored under double lock and checked for accountability at each shift change. Additionally, medications for a resident with a history of hemiplegia, hemiparesis, and Type 2 Diabetes Mellitus were found unattended on top of a medication cart outside the nurse's station. The medications included Tradjenta, Metformin, and Potassium Chloride. A Licensed Vocational Nurse (LVN) admitted to being distracted and forgetting to secure the medications back into the cart, which should have been locked at all times. The DON confirmed that leaving medications unsecured could result in them being taken by anyone, including residents, staff, or visitors. The facility's policy requires medication carts to be locked when not in use or under direct supervision.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members, as evidenced by the lack of required annual training for five employees: CNA G, LVN H, LVN I, LVN J, and PT. The personnel records for these staff members showed missing documentation of annual training in critical areas such as Resident Rights, Dementia, Behavioral Health, HIV, Falls, Restraints, and Emergency Preparedness, among others. The HR Manager, during an interview, acknowledged the oversight in training due to recent changes in administration and staffing. The deficiency was identified through a review of personnel records and interviews, revealing that the facility relied on an online system, RELIAS, for training, which was not effectively utilized to ensure compliance with training requirements. The Nursing Policy and Procedure Manual indicated that the facility was supposed to provide ongoing in-services on issues related to abuse/neglect prohibition practices, but this was not adhered to, leading to the deficiency.
Failure to Monitor Resident Medications Leads to Overdose
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents. This deficiency was identified when a resident was found lethargic and difficult to arouse with an empty Tylenol bottle at the bedside. The resident was assessed with a 12,000mg Tylenol overdose, significantly exceeding the harm threshold of 4,000mg over 24 hours. The resident was transported to the emergency room for evaluation and treatment, where they were stabilized and later discharged back to the facility. The resident involved had a history of Alzheimer's disease, depression, and encephalopathy, and was assessed with a BIMS score indicating no cognitive impairment. Despite this, the resident's care plan noted suicidal ideation, and the resident had recently returned from a hospital stay after a suicide attempt involving an overdose of over-the-counter Tylenol provided by family. The facility failed to monitor the resident for medications at the bedside, which contributed to the overdose incident. Interviews with facility staff, including the previous Director of Nursing (DON) and Registered Nurse (RN) involved, revealed that there was no in-service training provided to staff regarding the incident or the presence of medications at the bedside. Additionally, there was no evidence that the facility assessed other residents for safety or conducted a sweep for medications at the bedside following the incident. The current Administrator and DON, who were not in leadership at the time of the incident, acknowledged the lack of in-service training and safety assessments for peer residents.
Failure to Report Resident's Overdose Incident
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency in a timely manner, as required by regulations. On February 24, 2024, a resident was found lethargic and difficult to arouse with an empty Tylenol bottle at their bedside. The resident was transported to the emergency room and diagnosed with a 12,000mg Tylenol overdose, which significantly exceeded the harm threshold of 4,000mg over 24 hours. Despite the seriousness of the incident, there was no evidence that the facility reported the suicide attempt or the presence of medications at the bedside to the state agency. The resident involved had a history of Alzheimer's disease, depression, and encephalopathy, and was assessed with a BIMS score indicating no cognitive impairment. The resident's care plan noted suicidal ideation, and the resident had recently returned from a hospital stay after taking over-the-counter Tylenol provided by family. The resident's representative and family had been present at the hospital, and it was noted that the resident felt more depressed after their visit. Interviews with facility staff revealed that the previous Director of Nursing (DON) and the current Administrator and DON were not aware if the incident had been reported to the state agency. The previous DON recalled the incident but did not remember if it was reported. The current Administrator and DON, who began their roles in April 2024, stated they had minimal knowledge of the incident and acknowledged that it should have been reported. The facility's policy required immediate reporting of suspected abuse, neglect, or exploitation, but there was no documentation to support that this was done in this case.
Failure to Investigate and Report Tylenol Overdose Incident
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and reported in accordance with state law. This deficiency was identified in the case of a resident who was found lethargic and difficult to arouse with an empty Tylenol bottle at their bedside. The resident was subsequently diagnosed with a 12,000mg Tylenol overdose, which significantly exceeded the harm threshold of 4,000mg over 24 hours. Despite the severity of the incident, there was no evidence that the facility investigated or reported the incident to the state agency within the required timeframe. The resident involved in the incident had a medical history that included Alzheimer's disease, depression, and encephalopathy, and was assessed with a BIMS score indicating no cognitive impairment. The resident was admitted for long-term care and was generally independent in daily activities. However, the resident's care plan noted a history of suicidal ideation. On the day of the incident, the resident was found with an empty bottle of Tylenol, which had been provided by family members, and was transported to the emergency room for treatment. Interviews with facility staff revealed a lack of awareness and action regarding the investigation and reporting of the incident. The previous Director of Nursing (DON) and the current Administrator and DON were unable to confirm whether the incident had been reported to the state agency. Additionally, there was no documentation to support that the facility had taken steps to investigate the incident or assess the safety of other residents. This lack of action and documentation highlights a significant deficiency in the facility's handling of the incident.
Failure to Document Skin Assessment and Treatment
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding a skin assessment and subsequent treatment. An LVN assessed a resident with a rash on their forearms but did not document the assessment, the communication with the physician, or the detailed physician's order. The physician prescribed a steroid skin cream, but the order lacked specific instructions on where to apply the medication. This lack of documentation could lead to inaccurate medical records. The resident involved was admitted for long-term care with diagnoses including hemiplegia, hemiparesis following cerebral infarction, restlessness, agitation, and cognitive communication deficit. The resident's care plan included the use of antipsychotic medications for behavior management. The facility's documentation policy requires accurate and complete recording of all information related to resident care, but this was not adhered to in this instance, as confirmed by interviews with the LVN and the DON.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to provide personal privacy for three residents during care, which was observed during a survey. Resident #2, who had a pressure ulcer on the left hip, did not receive privacy during wound care as the Licensed Vocational Nurse (LVN) did not completely close the door or the privacy curtain. This lack of privacy was acknowledged by the LVN during an interview, where she stated the importance of ensuring the resident was covered and the door and curtain were closed. Similarly, Resident #4, who had a pressure ulcer on the left buttock, was not provided privacy during wound care. The LVN did not close the door, privacy curtain, or blinds while performing the procedure. In an interview, the LVN admitted she had not noticed the door was open and emphasized the importance of closing the door, curtain, and blinds to maintain resident dignity and privacy. Resident #6, who required assistance with activities of daily living (ADLs) due to severe cognitive impairment, was also not provided privacy during perineal care and dressing. The Certified Nursing Assistant (CNA) closed the door but failed to close the privacy curtain or blinds. Interviews with the CNA, Registered Nurse (RN), and other staff members highlighted the importance of ensuring privacy by closing the door, blinds, and curtains during care to protect the residents' dignity and prevent embarrassment.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks of improper care. Resident #1's medical records lacked documentation of wound care treatments on specific dates, despite the resident confirming receipt of the treatments. Interviews with staff revealed inconsistencies in the responsibility for wound care documentation, with some staff unaware of who was responsible when the treatment nurse was unavailable. Resident #3's records also showed missing documentation for wound care treatments on multiple occasions across several months. Interviews with staff indicated a lack of clarity regarding who was responsible for wound care on weekends, with some nurses admitting to not documenting treatments even if they were provided. The facility's procedure required documentation of treatments, but this was not consistently followed, leading to gaps in the resident's medical records. Similarly, Resident #4's records were incomplete, with missing documentation for wound care treatments on specific dates. The Director of Nursing (DON) was unaware of the missing documentation and assumed treatments were completed but not documented. Interviews with staff highlighted a lack of clear responsibility for ensuring documentation was completed, with some staff indicating that the weekend supervisor or assigned nurse was responsible for wound care. The facility's administrator acknowledged the need for a system to monitor documentation but was unsure of the current arrangements.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper infection control practices during wound care and personal hygiene for multiple residents. For instance, during wound care for a resident with a pressure ulcer, a registered nurse (RN) did not perform adequate hand hygiene, failed to sanitize surfaces before placing treatment supplies, and did not change gloves appropriately. The RN also neglected to clean the resident's genital area thoroughly during perineal care, which left the resident feeling unclean and uncomfortable. Another resident with a pressure ulcer received wound care from a licensed vocational nurse (LVN) who did not don personal protective equipment (PPE) and failed to perform hand hygiene between glove changes. The LVN also placed treatment supplies on unsanitized surfaces, increasing the risk of cross-contamination. Similarly, during toileting assistance for a resident, a certified nursing assistant (CNA) did not perform hand hygiene between glove changes and failed to assist the resident with hand hygiene after using the restroom. The facility also did not ensure compliance with Enhanced Barrier Precautions (EBP) for residents requiring such measures. Staff members, including an RN and LVNs, did not wear the necessary PPE when providing care to residents on EBP, which included those with wounds and other conditions requiring additional precautions. Interviews with staff revealed a lack of adherence to proper infection control protocols, such as hand hygiene, glove changes, and the use of PPE, which could lead to cross-contamination and increased infection risk among residents.
Failure to Facilitate Resident Communication and Visitor Access
Penalty
Summary
The facility failed to protect and facilitate the residents' right to communicate with individuals and entities both within and external to the facility. This deficiency was identified during an observation where the facility's main entrance was found to be secured without a doorbell, and a sign was posted with the facility's phone number for assistance. However, the phone at the nurse station did not ring to alert staff of incoming calls, which could potentially deny access to visitors, including family members and physicians. The surveyor observed that pulling on the door for an extended period triggered an automatic release mechanism, allowing entry and sounding an alarm. Further investigation revealed that the facility did not have a weekend receptionist, and staff were expected to answer calls to allow entry for visitors and care providers. During a tour, the surveyor demonstrated the issue to the Manager on Duty (MOD), who confirmed that the phone was not alerting staff to incoming calls. The Administrator and the Director of Nursing (DON) were unaware of the phone issue and acknowledged the lack of a weekend receptionist. The facility's policy on resident rights emphasized the residents' right to receive visitors and have reasonable access to communication, which was not upheld due to the phone system failure.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that a working call system was available for residents to alert staff for assistance, which was observed in two cases. Resident #4 was admitted without a call light system in place, leaving him unable to alert staff for help or emergencies. This resident, who had severe cognitive impairment and was assessed as a high fall risk, was found in his room calling out for help without a functioning call light system. Resident #2 experienced a malfunctioning call light system, which resulted in a significant delay in receiving assistance. Despite using his call light to request help with a burst colostomy bag, the call was not recognized by staff due to a malfunctioning illuminator outside his room. This resident, who required total assistance with personal hygiene, was left in a soiled state for 36 minutes until a surveyor intervened. The facility's call light system was not adequately monitored, as evidenced by staff failing to notice the alert for Resident #2. The call light system box at the nurse's station was visually and audibly alerting a call for assistance, but staff did not recognize it. This oversight led to prolonged wait times for Resident #2, who reported frequent delays in receiving colostomy care, causing discomfort and feelings of neglect.
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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