Huntington Health Care & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington, Texas.
- Location
- 220 E Ash Street, Huntington, Texas 75949
- CMS Provider Number
- 676183
- Inspections on file
- 23
- Latest survey
- July 16, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Huntington Health Care & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified that food items in the kitchen, including opened containers of thickened lemon water, pies, French fries, and crispy onions, were stored without proper labeling or dating, and frozen egg products were stored below meat products. The Dietary Manager, who had recently started, acknowledged responsibility for checking expired foods but noted staff had not been fully trained on labeling and dating procedures, leading to these deficiencies.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Surveyors observed soiled and sticky floors with black residue in multiple resident rooms, a hallway, and the main dining room. Housekeeping staff and the supervisor reported that the facility lacked a floor technician to deep clean, strip, and wax the floors, and current cleaning methods were ineffective. The administrator confirmed the absence of a floor technician and acknowledged the responsibility for maintaining a clean environment.
A resident with multiple medical conditions experienced a significant weight loss over 30 days, but the physician was not notified as required. The facility's process for monitoring and reporting weight changes was not followed, and documentation of physician notification was absent in the clinical record.
A resident with severe cognitive impairment and a diagnosis of senile degeneration of the brain was admitted to hospice care, but the facility did not complete a required significant change MDS assessment within 14 days or update the care plan to address hospice services, as required by facility policy.
A resident with a primary diagnosis of senile degeneration of the brain was not referred for a required Level II PASRR after new diagnoses of psychotic disorder with delusions and major depressive disorder were added. The MDS coordinator did not complete a new Level I PASRR, and staff interviews revealed a lack of awareness regarding the requirement to reassess after significant changes in condition.
A resident with a documented diagnosis of bipolar disorder was admitted, but the PASRR Level I screening was incorrectly marked as negative for mental illness, despite clear evidence in the medical record and care plan. Staff interviews confirmed the error and lack of a related facility policy.
A resident with severe cognitive impairment and a diagnosis of senile degeneration of the brain was admitted to hospice services, but her care plan was not updated to reflect her hospice status after a comprehensive MDS assessment. Staff interviews and record review confirmed the oversight, which was not in accordance with facility policy requiring timely care plan revisions for residents receiving hospice care.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with obstructive sleep apnea used a Bipap machine nightly as part of their care plan, but the facility failed to obtain and document physician orders specifying the required Bipap settings. Staff interviews revealed that neither the charge nurse nor the DON knew the correct settings, and the facility's policy requiring a respiratory therapist setup with a physician's order was not followed.
The facility did not ensure that a licensed pharmacist and two staff witnesses signed the drug destruction log during a medication destruction event, as required by policy. The destruction record for controlled substances was only initialed by the consultant pharmacist, with no witness signatures present.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident's personal refrigerator was found to contain expired milk and whipped cream, with food items not labeled or dated, and the refrigerator was not clean. Staff interviews revealed inconsistent practices and confusion about responsibilities for checking and cleaning personal refrigerators, resulting in missed removal of expired items.
A resident with dementia and behavioral issues was transferred to a behavioral hospital after multiple incidents of aggression and attempts to elope. The facility did not provide the required physician documentation detailing the reason for discharge, unmet needs, or efforts to address those needs, nor did it issue a 30-day notice to the resident or their representative. Staff interviews confirmed the lack of proper notification and documentation as required by federal regulations.
The facility's arbitration agreement lacked required elements, failing to grant residents the right to rescind within 30 days and restricting communication with officials. The Administrator was unaware of these requirements and relied on corporate-provided paperwork, with no specific policy in place.
The facility's Arbitration Agreement failed to include a neutral arbitrator and a convenient venue, as required. This was discovered during a review of the Admission Agreement, which lacked these provisions. The administrator, responsible for the agreements, was unaware of these requirements and relied on corporate-supplied paperwork. No residents had entered binding arbitration, and the facility lacked a specific policy on binding arbitrations.
The facility did not follow its smoking policy, leading to an unsafe smoking area with overflowing ash trays and burn-marked paper towels. Staff interviews revealed confusion over maintenance responsibilities, and the administrator admitted that training on this issue had not been recent. The facility's policy requires regular checks to prevent fire hazards.
The facility failed to remove worn and damaged mechanical lift slings from service, posing a risk of falls and injuries to residents requiring mechanical lifts for transfers. Observations showed slings with faded colors, loose strings, and missing labels. Interviews confirmed that CNAs were responsible for inspecting slings, but the facility did not ensure proper maintenance, leading to the deficiency.
The facility failed to maintain clean oxygen concentrator filters for three residents requiring respiratory care. Observations showed significant dust buildup on the filters, contrary to professional standards. Residents with conditions like COPD and respiratory failure were affected. Staff interviews revealed that night shift nurses were responsible for cleaning the filters weekly, but this was not consistently done, leading to the deficiency.
The facility failed to maintain sanitary conditions in its kitchen due to missing temperature logs for dishwashers, refrigerators, and freezers, potentially exposing residents to foodborne illnesses. Despite expectations for daily log completion, staff sometimes forgot to record temperatures, as admitted by the dietary manager. The administrator confirmed the dietary manager's responsibility for compliance, but the facility's policies requiring frequent monitoring were not followed.
A facility failed to maintain an effective infection prevention and control program, with lapses in hand hygiene by an MDS nurse during meal service and improper use of enhanced barrier precautions by two CNAs during foley catheter care. A resident with a foley catheter and dementia was involved, and staff were not adequately trained on new EBP guidelines, posing a risk for infection spread.
A resident with severe cognitive impairment was assisted with eating by an LVN who stood beside her wheelchair, contrary to the facility's policy of sitting at eye level to ensure dignity. The resident had multiple health conditions and required moderate assistance with meals. The DON and administrator confirmed that standing over residents during meals is a dignity issue.
A resident with severe cognitive impairment was subjected to a position change alarm without a physician's order or informed consent. Facility staff, including a CNA and LVN, confirmed the absence of necessary documentation, violating the facility's policy that requires a physician's order and informed consent for restraint use.
A facility failed to refer a resident with new diagnoses of PTSD and major depressive disorder for a Level II PASSAR evaluation. The DON, responsible for PASSAR assessments, was unaware of the resident's mental health conditions until questioned by surveyors. The facility's policy mandates referrals for new or changed diagnoses indicating serious mental disorders, which was not initially followed.
The facility failed to complete baseline care plans within 48 hours for two residents, one with end-stage heart failure and another with multiple diagnoses including dementia. Staff interviews revealed a lack of awareness about the requirement to complete and provide a summary of the care plan to residents or their representatives. This oversight could lead to residents not receiving necessary care.
The facility failed to dispose of expired medications, specifically two bottles of enteric-coated aspirin, found in the medication room. Staff interviews revealed that while the responsibility for checking expired medications was shared, the DON was ultimately accountable but unaware of the expired items. The facility's policy requires immediate removal of outdated medications, which was not followed.
A resident complained about receiving cold and unappetizing food. Observations confirmed that meals served to residents dining in their rooms were not at a safe and appetizing temperature. The dietary manager and administrator acknowledged the availability of heated carts and plate warmers, but these were not being used, leading to the deficiency.
The facility failed to ensure that emergency call lights in the bathrooms of two residents were reachable, potentially preventing them from calling for help. One resident with dementia had a call light tied and inaccessible, while another with Alzheimer's had a call light wrapped around a grab bar. Staff interviews revealed a lack of adherence to the facility's policy requiring call lights to be within reach.
Deficient Food Storage and Labeling Practices in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices during a kitchen review. Opened containers of thickened lemon water in one refrigerator were found undated, and two pies with unknown white filling in another refrigerator were also opened, unlabeled, and undated. In the freezer, five bags of French fries were found without labels or dates, and cases of frozen egg products were stored below meat products, contrary to safe food storage protocols. In the dry storage area, several bags of crispy onions lacked received dates. These observations were confirmed through interviews and record reviews. The Dietary Manager (DM) stated she had been employed for about one and a half months and was responsible for checking for expired foods, as there was no reliable staff member for this task at the time. She acknowledged that cooks were aware of the requirement to label and date opened foods but admitted to overlooking certain items and noted that some foods had been present since before her employment. The DM also indicated that an untrained employee failed to label and date the pies. The facility's policy requires all foods in refrigerators or freezers to be covered, labeled, and dated, and for raw animal products to be stored separately and below ready-to-eat foods, which was not consistently followed.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Maintain Clean and Sanitary Resident Areas and Dining Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in one of four resident hallways (Hallway 100) and the main dining room. Observations on two consecutive days revealed that rooms 101, 103, 106, and 107, as well as the 100 hallway and main dining room, had soiled floors with black residue on the floor tiles, sticky surfaces, and a buildup of thick black residue at the baseboards and around furniture. These conditions were directly observed by surveyors during specified timeframes. Interviews with housekeeping staff and the housekeeping supervisor confirmed that while routine sweeping and mopping were performed, the facility no longer employed a floor technician capable of deep cleaning, stripping, and waxing the tiles. The cleaning solutions used were ineffective against the buildup, and attempts to buff the floors did not resolve the issue. The administrator acknowledged the lack of a floor technician and stated that the housekeeping supervisor was responsible for maintaining the environment. Facility policy reviewed indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to immediately notify a resident's physician of a significant change in the resident's physical status, specifically a substantial weight loss of 25.8 pounds within 30 days. The resident in question had multiple diagnoses, including cerebral palsy, dysphagia, and lack of coordination, and was assessed as being moderately impaired for daily decision making and rarely or never understood. Despite the significant weight fluctuation documented in the electronic medical record, there was no evidence in the progress notes that the primary care physician was informed of these changes. Interviews with facility staff revealed that the process for monitoring and reporting weight variances involved several steps, including weighing by CNAs, data entry by charge nurses, and review by the ADON, who was responsible for notifying the physician, responsible party, and dietician. However, the ADON had recently been relieved of duties, and the DON, who had just assumed responsibility, was unaware of the resident's weight variance until the survey. The facility's policy required timely notification and documentation of significant weight changes, but this was not followed in this instance.
Failure to Complete Timely MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days following a significant change in condition for one resident who was admitted to hospice care. Record review showed that the resident, an elderly female with a primary diagnosis of senile degeneration of the brain and severely impaired cognition, was admitted to hospice services, but no significant change MDS assessment was completed within the required timeframe. The resident's care plan also did not address hospice services after her admission to hospice. Interviews with facility staff, including the MDS coordinator, DON, and Administrator, confirmed that the significant change MDS assessment was overlooked after the resident's hospice admission. The facility's policy requires a significant change in status assessment to be completed within 14 days when a resident enrolls in a hospice program, but this was not followed in this case.
Failure to Refer Resident for PASRR Level II Review After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to refer a resident with newly identified serious mental disorders for a required Level II PASRR (Preadmission Screening and Resident Review) evaluation following a significant change in condition. Specifically, a female resident with a primary diagnosis of senile degeneration of the brain was admitted and initially screened negative for mental illness on her Level I PASRR. However, subsequent diagnoses of psychotic disorder with delusions and major depressive disorder were added to her record. Despite these new diagnoses, no new Level I PASRR was completed, and the resident was not referred for a Level II review as required. Interviews with facility staff revealed that the MDS coordinator, who was responsible for PASRR, was unaware of the need to complete a new Level I PASRR when new psychiatric diagnoses were made. The DON confirmed oversight responsibility but did not ensure the process was followed. The administrator acknowledged that failure to complete appropriate PASRR evaluations could result in residents not receiving necessary services. Additionally, the facility was unable to provide a PASRR policy when requested.
Inaccurate PASRR Level I Screening for Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-admission Screening and Resident Review (PASRR) Level I assessment for one resident. Upon admission, the resident had a documented diagnosis of bipolar disorder, which is a mental illness. However, the PASRR Level I screening completed after admission was marked as negative for mental illness, despite the presence of this diagnosis in the resident's medical records, physician orders, and care plan. The resident's records also indicated active management of mood problems related to bipolar disorder, including medication interventions. Interviews with facility staff confirmed that the MDS Coordinator, who was responsible for PASRR screenings, entered the incorrect information on the PASRR Level I assessment. The Director of Nursing and the Administrator both acknowledged that the MDS Coordinator was responsible for ensuring the accuracy of PASRR screenings and that the screening should have reflected the resident's mental health diagnosis. The facility did not have a policy related to PASRR at the time of the deficiency.
Failure to Update Care Plan for Hospice Status
Penalty
Summary
The facility failed to review and revise the comprehensive care plan after each assessment for one resident who was receiving hospice services. Specifically, the care plan for a female resident with a primary diagnosis of senile degeneration of the brain and severely impaired cognition was not updated to reflect her hospice status after a comprehensive MDS assessment. The resident had a physician's order for hospice services, but the care plan, last updated prior to the hospice order, did not address this change in her care needs. Interviews with facility staff, including the MDS coordinator, DON, and Administrator, confirmed that the care plan update was overlooked and that care plans should be updated after each MDS assessment. Facility policy also required that care plans for residents receiving hospice services be developed in conjunction with hospice organizations and reviewed at least every 90 days. The failure to update the care plan as required was identified through record review and staff interviews.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Obtain and Document Physician Orders for Bipap Settings
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care, specifically the use of a Bipap machine for obstructive sleep apnea, received care consistent with professional standards and the resident's care plan. Upon admission, the resident brought his own Bipap machine and used it nightly, as indicated in his care plan and physician's order. However, the physician's order did not specify the required Bipap settings, and this omission persisted from admission through the time of the survey. The resident was cognitively intact, able to communicate his needs, and independently used the Bipap machine at night, but was unaware of the correct settings. Interviews with facility staff, including the charge nurse and DON, revealed that neither the Bipap settings nor the process for verifying them were documented or known. The charge nurse was unable to locate the settings in the electronic medical record, and the DON acknowledged that a physician's order specifying the settings was necessary but had not been obtained. The facility's policy required Bipap setup by a respiratory therapist with a physician's order, but this was not followed. This deficiency was identified through observation, interviews, and record review, and involved a resident with multiple diagnoses including obstructive sleep apnea and mitral valve insufficiency.
Failure to Ensure Proper Witnessing During Drug Destruction
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident during May 2025. Specifically, on May 22, 2025, the facility did not have a licensed pharmacist and two facility staff witnesses sign the drug destruction log during a drug destruction event. Record review showed that the controlled substances destruction record was initialed only by the consultant pharmacist, with no witness signatures present. The facility's policy required the consultant pharmacist to arrange for proper witnesses to be present for the destruction and to destroy the medications in accordance with federal regulations. This failure was confirmed during an interview with the DON, who acknowledged the lack of required witness signatures.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions and inactions resulted in a failure to meet regulatory requirements for the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Ensure Safe Storage and Monitoring of Resident's Personal Refrigerator
Penalty
Summary
The facility failed to have an adequate policy regarding the use and storage of foods brought in by family and visitors, and did not ensure safe and sanitary storage, handling, and consumption of these foods for a resident with a personal refrigerator. Observation and interviews revealed that the resident's refrigerator contained expired milk and whipped cream, and food items were not labeled or dated. The refrigerator was not clean, and there was no consistent process for checking and removing expired food items. Staff interviews indicated confusion about responsibilities, with some staff believing they were not allowed to touch food in residents' refrigerators, while others stated it was their duty to clean and check for expired items. The facility's policy only required weekly checks, but staff practices varied, and expired items were missed. The resident involved was a cognitively intact male with diagnoses including cellulitis, obstructive sleep apnea, and nonrheumatic mitral valve insufficiency. He was able to ambulate independently and required some assistance with activities of daily living. The resident was unaware that expired food was present in his refrigerator. Staff interviews confirmed that checks for expired food were not performed as required, and there was a lack of clarity regarding who was responsible for cleaning and monitoring the contents of personal refrigerators.
Failure to Provide Required Documentation and Notification for Resident Discharge
Penalty
Summary
The facility failed to provide required documentation for the transfer or discharge of a resident, specifically lacking documentation from the resident's physician regarding the reason for discharge, the specific needs of the resident that could not be met, the facility's efforts to meet those needs, and the services the receiving facility would provide. The deficiency was identified through interviews and record reviews, which revealed that the discharge summary signed by the Medical Director did not include these required elements. Additionally, there was no evidence that a 30-day notice was provided to the resident or their representative prior to the discharge. The resident involved was an elderly male with a history of Hodgkin lymphoma, diabetes, dementia, and anxiety disorder. Upon admission, he exhibited significant cognitive impairment, communication difficulties, and behavioral symptoms such as wandering, agitation, and aggression. Progress notes documented multiple incidents of physical and verbal aggression, attempts to elope, and threats toward staff and other residents. These behaviors escalated to the point where the resident attempted to exit the facility through windows and physically threatened and endangered others, resulting in his transfer to a behavioral hospital. Despite the severity of the resident's behaviors and the subsequent transfer, the facility did not document the specific unmet needs or the steps taken to address them, nor did it provide the required notification and explanation to the resident, their representative, or the ombudsman. Interviews with staff, including the DON and Administrator, confirmed that a 30-day notice was not issued and that the discharge documentation lacked the necessary details as outlined in federal regulations. The absence of these required actions and documentation constituted the deficiency cited by surveyors.
Deficient Arbitration Agreement Elements
Penalty
Summary
The facility failed to ensure that its arbitration agreement contained all the required elements, specifically for one facility reviewed for Arbitration Agreements. The arbitration agreement did not grant the resident or their representative the right to rescind the agreement within 30 calendar days of signing. Additionally, the agreement did not allow the resident or their representative to communicate with federal, state, or local officials, including federal and state surveyors, health department employees, and representatives of the Office of the State Long Term Care Ombudsman. During an interview, the Administrator admitted responsibility for the admission agreements and was unaware of the specific requirements for arbitration agreements. He stated that no resident had entered into a binding arbitration and that he was using paperwork provided by the corporate office. The Administrator acknowledged that if the arbitration agreement did not comply with regulations, it could affect resolution outcomes. Furthermore, the facility lacked a policy regarding binding arbitrations and relied solely on the admission agreement.
Arbitration Agreement Lacks Required Elements
Penalty
Summary
The facility failed to ensure that its Arbitration Agreement included all required elements, specifically the provision of a neutral arbitrator and a section indicating a convenient venue. This deficiency was identified during a record review of an undated Admission Agreement, which included sections titled 'Arbitration' and 'Dispute Resolution Plan.' These sections did not guarantee the provision of a neutral arbitrator or a convenient venue for arbitration. During an interview, the facility administrator acknowledged responsibility for the admission agreements and admitted to being unaware of the specific requirements for arbitration agreements. He stated that no resident had entered into a binding arbitration and that he relied on paperwork supplied by the corporate office. The administrator also noted that the facility lacked a policy regarding binding arbitrations and followed the admission agreement as provided.
Failure to Maintain Safe Smoking Area
Penalty
Summary
The facility failed to adhere to its established smoking policy, which resulted in an unsafe smoking environment. During an observation, it was noted that the designated smoking area contained two ash trays, one of which was overflowing with cigarette butts, while the other contained a paper towel with burn marks. This situation was observed on the morning of May 29, 2024. Interviews with staff revealed a lack of clarity regarding the responsibility for maintaining the smoking area. The housekeeping staff member indicated that the maintenance director was responsible for the area, while the maintenance supervisor stated that the housekeeping department and staff supervising smokers were responsible for ensuring the area was safe. The facility's administrator confirmed that the housekeeping department was tasked with maintaining the smoking area and that staff assisting smokers were trained to ensure ash trays were emptied and free of trash. However, the administrator acknowledged that the training had occurred some time ago. The facility's smoking policy, dated November 2022, required staff monitoring smoke breaks to regularly check ashtrays and trash to ensure compliance with regulations, prohibiting trash or foreign debris in ash trays. The failure to follow this policy could potentially lead to a fire hazard, as noted by the staff interviewed.
Failure to Remove Worn Mechanical Lift Slings
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not removing worn and damaged mechanical lift slings from service. This deficiency was observed in three residents who required mechanical lifts for transfers due to their medical conditions, including dysphagia, muscle weakness, dementia, hypertension, hyperlipidemia, Alzheimer's disease, pneumonia, and asthma. Observations revealed that the slings used for these residents had faded colors, loose strings, and in some cases, missing or illegible labels, indicating wear and potential safety risks. Interviews with the Director of Nursing (DON) and the Administrator confirmed that Certified Nursing Assistants (CNAs) were responsible for inspecting the lift pads before use. Both acknowledged that using worn pads could pose a risk of falls and injuries to residents. The facility's policy and manufacturer guidelines emphasized the importance of inspecting slings for signs of wear, such as rips, tears, frays, color fading, and illegible labels, and removing them from use if any of these signs were present. Despite these guidelines, the facility did not ensure that the slings were adequately inspected and maintained, leading to the deficiency.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen therapy. Observations revealed that the external filters of the oxygen concentrators for these residents had significant dust buildup, which was not consistent with professional standards of practice. This deficiency was noted during a survey conducted on May 28, 2024, where the oxygen concentrators for Residents #15, #29, and #1 were found with large amounts of white dust on their external filters. Resident #15, who had a history of acute respiratory failure, Parkinson's disease, COPD, and Type 2 diabetes, was observed to have an oxygen concentrator with a dusty filter. Similarly, Resident #29, diagnosed with schizoaffective disorder, COPD, and hypertension, was found with a dusty filter on his oxygen concentrator. He was unable to recall the last time the filter was cleaned. Resident #1, with a history of pneumonia, acute and chronic respiratory failure, and COPD, also had a dusty filter on her oxygen concentrator. She too could not remember when the filter was last cleaned. Interviews with staff, including LVN B and the DON, indicated that the responsibility for cleaning the filters lay with the night shift nurses on Sundays. However, there was a lack of adherence to this protocol, as evidenced by the dusty filters. The facility's policy required that filters be washed every seven days, but this was not consistently followed, leading to the observed deficiencies.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as evidenced by missing temperature logs for critical equipment such as dishwashers, refrigerators, and freezers. During an observation, it was noted that temperature checks were not recorded for several days in May 2024. Specifically, the dishwasher had missing temperature logs from May 20 to May 27, while the freezers and refrigerators had missing logs from mid-May to late May. This lapse in documentation could potentially expose residents to foodborne illnesses due to improper food storage and preparation. Interviews with the dietary manager and the administrator revealed that the morning shift was responsible for checking temperatures, and the dietary aide was tasked with filling out the logs. Despite the expectation that logs be completed daily, the dietary manager admitted that staff sometimes forgot to record temperatures, although no mechanical issues with the equipment were reported. The administrator confirmed that the dietary manager was responsible for ensuring compliance with temperature monitoring. The facility's policies from the Dietary Services Policy and Procedure Manual 2006 require frequent monitoring and recording of temperatures, which was not adhered to, leading to the deficiency.
Infection Control Lapses in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene and the use of enhanced barrier precautions (EBP). During a meal service, the MDS nurse did not perform hand hygiene between handling resident wheelchairs and serving meal trays, despite having been trained on the importance of hand hygiene. This oversight was acknowledged by the MDS nurse, who admitted that failing to sanitize hands could lead to the spread of bacteria and infections. Additionally, two CNAs, CNA E and CNA F, did not adhere to EBP while providing foley catheter and incontinent care to a resident. They only wore gloves and did not use gowns, which is contrary to the guidelines for residents with indwelling catheters. The resident in question had a history of urinary retention, acute kidney failure, and dementia, and was dependent on staff for activities of daily living. The facility's ADON and LVN were unaware of the requirement to use gowns and gloves for residents with indwelling catheters until an in-service training was conducted. The Director of Nursing (DON), who also served as the infection prevention nurse, admitted to not thoroughly reviewing the CMS memo regarding EBP, which led to a lack of staff training on the new guidelines. The facility administrator confirmed that the DON was responsible for staff training on infection control and acknowledged that the staff had not been informed about the EBP requirements prior to the in-service training. This lack of awareness and training posed a risk for the spread of infections within the facility.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity during meal service, as observed by surveyors. A Licensed Vocational Nurse (LVN) assisted a resident with eating while standing beside her wheelchair, rather than sitting at eye level. This action was contrary to the facility's policy and the expectations set by the Director of Nursing (DON) and the administrator, who both emphasized the importance of providing meal assistance with dignity and respect. The resident involved was an elderly female with severe cognitive impairment, requiring moderate assistance with meals. The resident had multiple diagnoses, including hyperthyroidism, Alzheimer's disease, anxiety disorder, chronic kidney disease, and hypertension. During the observation, the LVN intermittently left the resident to check on others, returning to feed her while standing. This approach was acknowledged by the LVN as potentially making the resident feel rushed and uncomfortable, which was confirmed by the DON and the administrator as a dignity issue. The facility's policy on dignity, revised in February 2021, mandates a dignified dining experience for residents, which was not adhered to in this instance.
Inappropriate Use of Restraint Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required for medical treatment. Specifically, a position change alarm was used on a resident without obtaining a physician's order or informed consent. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including hypertension, dementia, and kidney failure, was observed with a chair alarm in place, despite the absence of documentation indicating its necessity or approval. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that there was no physician order for the chair alarm, and the staff acknowledged the requirement for such an order. The facility's policy mandates that restraints should only be used with a physician's written order and informed consent from the resident or their representative. The lack of adherence to this policy resulted in the inappropriate use of a restraint device on the resident.
Failure to Refer Resident for PASSAR Evaluation
Penalty
Summary
The facility failed to refer a resident with newly evident mental health conditions for a Level II Preadmission Screening and Resident Review (PASSAR) upon a significant change in condition. Specifically, Resident #32, who was diagnosed with Post-Traumatic Stress Disorder (PTSD) and major depressive disorder, did not have a new Level 1 PASSAR completed in a timely manner. The resident's face sheet indicated these diagnoses, but no referral was made to the Local Contact Agency for further evaluation, and the care plan did not reflect a PASSAR positive status. Interviews with the Director of Nursing (DON) and the Administrator revealed that the DON was responsible for completing PASSAR assessments but was unaware of the resident's mental health diagnoses until questioned by surveyors. The DON acknowledged the oversight and completed a new Level 1 PASSAR after the surveyor's inquiry. The facility's policy requires that new or changed diagnoses indicating serious mental disorders be referred for a PASSAR Level 2 evaluation, which was not initially done for Resident #32.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. Resident #48, a male with end-stage heart failure, was admitted without a baseline care plan being completed, and he did not recall any discussion about his care plan upon admission. Similarly, Resident #64, a female with diagnoses including macular degeneration, dementia, and cerebral infarction, did not have a baseline care plan initiated before her passing in the facility. The absence of these care plans could lead to residents not receiving the necessary care or treatment. Interviews with facility staff revealed a lack of awareness and adherence to the requirement of completing baseline care plans within 48 hours and providing a summary to the resident or their representative. The LVN and MDS nurse both indicated they were unaware of the 48-hour requirement and the need to provide a care plan summary. The Director of Nursing and the Administrator acknowledged the oversight and emphasized the importance of following regulations to prevent negative outcomes. The facility's policy and admission tool indicated that the baseline care plan should be completed on admission, but this was not followed in these cases.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not disposing of expired medications in the medication storage room. During an observation, two bottles of enteric-coated aspirin with an expiration date of April 2024 were found in the medication room. Interviews with staff, including a medication aide (MA C) and the Director of Nursing (DON), revealed that the responsibility for checking and removing expired medications was shared among nursing staff and medication aides. However, the DON acknowledged that she was ultimately responsible for ensuring expired medications were removed, but was unaware of the expired aspirin bottles. The facility's policy on medication storage, dated September 2022, mandates that outdated or deteriorated medications be immediately removed from stock and disposed of according to procedures. Despite this policy, the expired medications were not removed, indicating a lapse in adherence to the facility's procedures. The Administrator confirmed that the DON was responsible for ensuring the medication room was free of expired medications, emphasizing the importance of not administering out-of-date medications to residents.
Failure to Serve Hot and Palatable Food
Penalty
Summary
The facility failed to provide food that was palatable and at a safe and appetizing temperature for residents, specifically affecting a resident who complained about the food being served cold and unappetizing. During an observation, it was noted that the meal cart for residents dining in their rooms left the kitchen at 12:55 PM, and the test tray was served at 1:01 PM. The meal, which included fettuccine alfredo with chicken, green beans, and mashed potatoes with gravy, was found to be bland and cool. The dietary manager, upon sampling the test tray, confirmed that the food was cold. Interviews with the dietary manager and the administrator revealed that there were heated carts and plate warmers available, but they were not being utilized. The dietary manager was unsure if the heated carts were operational and admitted that the plate warmers were not in use. The administrator was unaware of the issue and stated that he expected the dietary staff to use the available equipment to ensure meals were delivered hot. The failure to serve hot and palatable food could potentially lead to residents not consuming their meals adequately, resulting in weight loss and altered nutritional status.
Inaccessible Call Lights in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the emergency call lights in the bathrooms of two residents were reachable from the floor, which could prevent residents from calling for help when needed. Resident #44, a female with dementia and a history of falling, was observed with a call light in her bathroom that was tied and approximately 3 to 4 inches from the white panel box, making it inaccessible. Her comprehensive care plan indicated she was at risk of falls, and interventions included keeping the call light within reach. Similarly, Resident #55, a female with Alzheimer's disease, had her bathroom call light wrapped around the grab bar, making it unreachable. Her care plan also noted a risk for falls with the same intervention to keep the call light accessible. During interviews, the facility's Administrator and Director of Nursing (DON) acknowledged the responsibility of staff to ensure call lights are in place and functioning. The Administrator noted that CNAs were responsible for ensuring call lights were in working order, while the DON emphasized that all staff members were responsible for checking call lights every shift to prevent them from being tied up. The facility's policy, dated August 2022, stated that residents should have a call light within reach and be instructed on its use, which was not adhered to in these cases.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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