Kemp Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kemp, Texas.
- Location
- 1351 South Elm Street, Kemp, Texas 75143
- CMS Provider Number
- 675802
- Inspections on file
- 26
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Kemp Care Center during CMS and state inspections, most recent first.
Three residents with varying levels of cognitive and physical impairment did not receive scheduled showers or assistance with personal hygiene as outlined in their care plans. Documentation and interviews revealed that showers were frequently missed or delayed, with residents and staff citing time constraints and staffing shortages as contributing factors. Residents expressed dissatisfaction with their hygiene care, and observations confirmed instances of soiled clothing and infrequent bathing.
Several residents reported that meals were frequently served cold, unseasoned, or inconsistently heated, with observations confirming lukewarm food and red-tinged meat during a lunch service. Despite these complaints, dietary staff and management did not acknowledge issues, and facility policy lacked guidance on food palatability or temperature.
Surveyors found that kitchen staff failed to discard ham past its use by date and did not ensure potatoes were properly labeled and dated, as required by facility policy. The Dietary Manager and staff confirmed responsibility for daily checks and proper labeling, but expired and unlabeled food was still present in the fridge.
A CNA failed to change gloves or perform hand hygiene while providing incontinent care to a resident with impaired cognition and multiple health conditions. The CNA handled clean items after contact with soiled areas, only washing hands after leaving the room. Interviews confirmed staff expectations for proper infection control, and facility policies required hand hygiene and glove changes between dirty and clean tasks, which were not followed during this incident.
A resident reported a potential theft involving a PASRR representative, prompting an internal investigation that ultimately found the allegation unconfirmed. However, the facility did not submit the required provider investigation report to the state survey agency within the mandated 5 working days, and leadership could not provide proof of submission or contact the responsible former administrator.
A resident with severe malnutrition and a feeding tube was administered enteral nutrition at a rate higher than the physician-ordered 53 ml/hr, with the pump set at 55 ml/hr on multiple occasions. Nursing staff and leadership confirmed the discrepancy, despite protocols requiring verification of orders and adherence to prescribed feeding rates.
A resident with COPD who required a CPAP device had her mask left exposed on her nightstand rather than stored in a bag as required. Staff interviews confirmed the mask should have been bagged when not in use, but this was not done, and the facility's policy did not address CPAP mask storage.
A nurse administered the wrong magnesium supplement to a resident with dementia and other chronic conditions, failing to follow the physician's order and facility policy. The error was due to reliance on a handwritten note and lack of order clarification, resulting in the resident receiving an incorrect medication and dosage.
A resident with heart failure, who was not assessed or authorized for self-administration, was found with Ayr Nasal Solution and biotene spray left unsecured on his bedside table. Facility staff, including the DON and ADON, confirmed that no residents were permitted to self-medicate and that medications should be stored in locked carts, in accordance with facility policy.
Residents did not consistently receive nourishing, palatable, and well-balanced meals that met their daily nutritional and special dietary needs, resulting in a deficiency related to dietary services.
A resident with chronic combined heart failure was incorrectly coded on the discharge MDS assessment as 'return not anticipated' instead of 'return anticipated' after a hospital stay. The MDS Coordinator and other staff confirmed the error, noting that the correct assessment was not completed, and there was no specific policy in place for MDS assessment accuracy.
The facility did not coordinate assessments with the PASRR program and failed to refer a resident for necessary services, resulting in noncompliance with assessment and referral requirements.
A resident with multiple medical conditions and a physician's order for oxygen therapy did not have an oxygen care plan developed or implemented. Despite documentation and observation of oxygen use needs, the care plan lacked any mention of oxygen therapy, and staff interviews confirmed the oversight. The facility's policy requires comprehensive care planning for all identified needs, but this was not followed for the resident's oxygen therapy.
A facility failed to implement its policies to prevent abuse and misappropriation of resident property, as a resident reported that a Community Support Advocate used his money for personal purchases. Despite the resident's cognitive intactness and clear allegations, the incident was not reported to the administrator or state authorities as required. Interviews revealed a breakdown in communication and adherence to the facility's abuse prevention policy, placing the resident at risk for exploitation.
A facility failed to report an alleged misappropriation of a resident's property within the required 24-hour timeframe. The incident involved a community support advocate allegedly using the resident's money for personal purchases. The resident, who was cognitively intact, reported the misuse of funds, but the facility did not investigate or report the allegation due to a lack of communication among staff. This failure to adhere to reporting procedures could place residents at risk for abuse.
A facility failed to investigate and report an allegation of misappropriation of a resident's property involving a Community Support Advocate. The resident, who was cognitively intact, reported that the advocate used his money for personal purchases and exerted undue influence during shopping trips. The facility's LVN did not report the incident to the administrator, and the administrator was unaware of the incident, resulting in a failure to comply with reporting requirements.
The facility failed to ensure residents with pressure ulcers received necessary treatment and services, including performing weekly ulcer assessments, obtaining measurements, and following treatment orders. The facility also lacked a system to ensure skin assessments and treatments were completed as ordered, leading to worsening of wounds and an Immediate Jeopardy situation.
The facility failed to maintain a safe environment, leading to incidents where a resident was burned by hot coffee, another smoked unsupervised, and two others kept cigarettes and lighters against policy. Staff were unaware of proper procedures, and care plans were not updated promptly.
The facility failed to provide sufficient staff to ensure proper incontinent care for two residents, leading to inadequate hygiene practices and potential infection risks. Observations and interviews confirmed that the CNAs did not follow proper care protocols due to understaffing and being sidetracked by other duties.
The facility failed to maintain an effective infection prevention and control program, with staff not following proper hand hygiene, glove-changing protocols, and enhanced barrier precautions. Additionally, medical equipment was not cleaned between residents, and clean linen carts were left uncovered, increasing the risk of cross-contamination and infection spread.
The facility failed to address and document the concerns raised by the resident council regarding call lights not being answered timely. Despite repeated complaints over several months, no grievances were filed, and no actions were documented to resolve the issues. Interviews with staff confirmed the lack of follow-up and proper grievance handling.
The facility failed to ensure necessary services to maintain grooming and personal hygiene for three residents, leading to missed showers, unchanged clothes, and untrimmed, dirty nails. Observations and interviews revealed confusion and lack of communication among staff regarding responsibilities, resulting in poor hygiene and potential health risks.
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. A resident was found with unauthorized medications at her bedside, and two medication carts were left unlocked and unattended. The DON and Administrator confirmed that these actions violated facility policies and posed potential hazards.
The facility failed to ensure timely administration of medications for five residents, including delays in anxiety, pain, depression, and blood pressure medications. The care plans and medication orders were not followed, and staff reported challenges in meeting medication administration timeframes. The DON was unaware of the late medications, and the facility's procedures were not adhered to.
A resident with vascular dementia was administered Seroquel without an appropriate diagnosis to support its use. Facility staff, including an LVN and the DON, acknowledged the improper use and potential risks, while the Administrator admitted to a lack of familiarity with antipsychotic medications.
The facility had a medication error rate of 10.0%, involving two residents who received incorrect doses or types of medication. The errors were observed during medication administration by an RN, and the DON attributed the issues to staffing problems.
The facility failed to provide prompt and proper incontinent care for two residents, leading to potential risks of infections and decreased quality of life. Observations revealed lapses in hygiene practices, such as not changing gloves and using clean wipes, and inadequate oversight by the staff.
The facility failed to ensure proper respiratory care for two residents. One resident's handheld nebulizer was not stored in a bag, and another resident's nasal cannula was found on the floor with a dirty oxygen concentrator filter. Interviews with staff confirmed the importance of proper storage and cleaning to prevent infection, but these actions were not taken, leading to the deficiency.
The facility failed to maintain a safe, clean, and homelike environment for a resident with incontinence issues, resulting in persistent urine and bowel odors in the room despite regular cleaning efforts.
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with multiple diagnoses, including the use of Trazodone for insomnia. The omission was confirmed by the MDS nurse, DON, and Administrator, and the care plan was updated only after state surveyor intervention.
A resident with a history of cerebral infarction, type 2 diabetes, and vascular dementia was found in a room with a strong urine odor and wet, brown stains on her sheets and mattress. The resident had not been changed since around 12:30 PM, despite the requirement for checks every two hours. Staff admitted to not checking on the resident as frequently as needed, and the incident was confirmed as neglect by the facility's administration.
The facility failed to implement their abuse prevention policies, as a Social Worker did not immediately report a resident's allegation of verbal abuse, and an LVN did not complete abuse training upon hire. These lapses could place residents at risk of abuse and neglect.
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately. A Social Worker did not report a resident's allegation of verbal abuse and a death threat by her roommate to the Administrator immediately, as required by the facility's policy. The Social Worker, who had been employed for only three months, did not believe the threat was credible and decided to wait until the next morning meeting to report it.
Failure to Provide Scheduled Showers and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, for three residents who were unable to perform these tasks independently. For one resident with moderate cognitive impairment and multiple diagnoses, documentation showed missed scheduled showers, with the resident and staff interviews confirming that showers were often delayed or not provided as scheduled. The care plan for this resident included specific interventions for negotiating ADL times and reattempting care after refusals, but these were not consistently followed, and the resident reported only receiving a shower about once a week despite being scheduled for three times weekly. Another resident, who was cognitively intact but required moderate assistance with showering, also did not receive scheduled showers or bed baths on several occasions. This resident expressed feeling unclean and dissatisfied with the infrequency of bathing, stating a desire to receive showers at least three times a week as scheduled. Documentation confirmed multiple missed showers, and the care plan required staff assistance with personal hygiene and bathing, which was not consistently provided. A third resident with moderate cognitive impairment and significant physical limitations received only one documented bath in a month, despite being scheduled for multiple showers per week. Observations noted the resident wearing soiled clothing, and both the resident and staff interviews indicated that showers were frequently missed due to time constraints and staffing issues. Staff reported that missed showers were communicated to supervisors, but no changes were made, and there was a lack of clarity and follow-through regarding responsibility for completing showers on different shifts. The facility's policy required bathing according to the resident-centered plan of care, but this was not adhered to for these residents.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
Surveyors identified that the facility failed to provide food that was palatable and served at an appetizing temperature for several residents. Multiple residents reported that their food was often cold, not seasoned, or, at times, too hot to eat. Resident grievances and council meeting minutes documented complaints about cold food and beverages. During interviews, residents consistently described dissatisfaction with the temperature and taste of their meals, with some stating the food was lukewarm, unseasoned, or had an unappealing texture. A sampled lunch tray reviewed by the Dietary Manager, Area Director of Operations, and surveyors revealed that the meatloaf had red-tinged areas and the potato wedges were lukewarm, further supporting resident complaints. Despite these findings, facility staff, including the Dietary Manager and Area Director of Operations, maintained that there were no issues with the food, citing proper cooking temperatures and a lack of direct complaints to them. The facility's policy on menu approval and honoring resident preferences did not address requirements for food palatability or serving temperature. The deficiency was substantiated through resident interviews, review of grievances and council minutes, and direct observation of meal service.
Failure to Properly Store and Label Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen. During an initial kitchen tour, ham was found in the refrigerator past its use by date, and potatoes were stored in a container without a label or date. The Dietary Manager confirmed that the ham was one day out of date and acknowledged that it should have been discarded on the expiration date. She also explained that the potatoes had been labeled and dated, but the label became unreadable due to moisture and was not replaced. The Dietary Manager stated that both she and the cooks were responsible for ensuring proper labeling and removal of expired food, and that daily checks of the fridge were conducted, but she was unsure how the expired ham was missed. Further interviews with dietary staff confirmed that the fridges were checked daily for expired food and that all food items should be labeled and dated when prepared. The Administrator stated that all food items were expected to be labeled, dated, and discarded upon expiration, with the Dietary Manager responsible for oversight. Review of the facility's food storage policy indicated that open packages of food should be stored in closed containers, labeled, and dated, and that perishable refrigerated items should be dated once opened and used within seven days.
Failure to Follow Hand Hygiene and Glove Change Protocol During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures while providing incontinent care to a female resident with neuromuscular bladder dysfunction, a history of stroke, and diabetes. The resident, who had moderately impaired cognition and required assistance with multiple activities of daily living, was observed receiving care during which the CNA wiped the resident's front and back areas without changing gloves or performing hand hygiene. The CNA then handled clean items, including a brief, barrier cream, linen, and a gown, all while wearing the same contaminated gloves. Hand hygiene was only performed after leaving the resident's room and removing the gloves. Interviews with the CNA revealed a lack of awareness regarding the missed hand hygiene and glove change, despite acknowledging the risk of cross-contamination. The Director of Nursing (DON) and the Administrator both stated that staff are expected to change gloves and perform hand hygiene between dirty and clean tasks, and that training on these procedures is provided at least annually. Facility policies reviewed indicated that hand hygiene is required after contact with body fluids, soiled linens, and before and after personal care or toileting, but these procedures were not followed during the observed incident.
Failure to Timely Submit Abuse Investigation Report to State Agency
Penalty
Summary
The facility failed to report the results of an abuse investigation to the administrator or designated representative and to the state survey agency within the required 5 working days. Specifically, after a resident reported that a PASRR representative placed an item on a store checkout belt and the resident paid for it, the facility initiated an investigation. The incident was reported to the state survey agency, and the local health authority was notified that the representative would no longer be allowed in the facility. The investigation ultimately concluded that the allegation was unconfirmed, and there were no witnesses to the incident. Despite these actions, the facility did not submit the required provider investigation report to the state survey agency within the mandated timeframe. Record review of the TULIP website confirmed that the 5-day report had not been turned in. During interviews, facility leadership was unable to provide proof that the report was submitted, and attempts to contact the previous administrator responsible for the report were unsuccessful. The facility's own policy required that such reports be sent to the state agency within five working days using the designated form, but this was not done in this case.
Failure to Administer Enteral Feeding at Physician-Ordered Rate
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident receiving enteral nutrition via a feeding tube was administered the correct rate of formula as ordered by the physician. The resident, who had severe protein-calorie malnutrition and required a feeding tube for nutrition, had a physician order for Isosource 1.5 calorie formula to be administered continuously at 53 ml/hr. However, multiple observations revealed that the feeding pump was set at 55 ml/hr instead of the prescribed rate. Nursing staff, including an LVN, acknowledged the discrepancy and stated that charge nurses were responsible for verifying orders each shift and each time the feeding was administered. The resident's care plan included interventions to check tube placement and gastric residuals per protocol, and the facility's policy required that enteral feedings be administered as ordered by the physician. Despite these protocols, the incorrect rate was administered on more than one occasion, and the error was confirmed by both nursing staff and facility leadership during interviews. The DON and Administrator both stated that nurses were expected to follow physician orders and that monitoring was their responsibility, but the error was not identified or corrected in a timely manner.
Failure to Properly Store CPAP Mask for Resident Requiring Respiratory Care
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, who required the use of a CPAP device at bedtime, did not have her CPAP mask stored according to professional standards of practice. During observation, the CPAP mask was found placed on top of a bubble gum container on the resident's nightstand, exposed and not stored in a bag as required. The resident, who had intact cognition but required staff assistance for personal care and was unable to reach the mask herself, stated that staff typically left the mask in this manner and did not store it in a bag. Interviews with facility staff, including the ADON, DON, Administrator, and an RN, confirmed that the CPAP mask should have been stored in a bag when not in use to maintain cleanliness and prevent contamination. Staff acknowledged responsibility for ensuring proper storage, with specific mention of daily rounds and assigned duties for checking respiratory equipment. However, the facility's policy on oxygen administration did not address CPAP mask storage, and the mask was not stored as required at the time of the survey.
Failure to Administer Prescribed Medication as Ordered
Penalty
Summary
A deficiency occurred when a nurse (ADON) failed to administer a resident's prescribed Magdelay (magnesium chloride supplement) as ordered. The resident, an elderly female with diagnoses including dementia, hypertension, muscle weakness, and osteoporosis, had an active order for Magdelay 64mg once daily. On the observed date, the ADON prepared and administered a tablet of sloMg instead of the ordered Magdelay. The sloMg bottle had different active ingredient amounts and was not the correct medication or dosage as prescribed. The ADON relied on a handwritten note on the bottle and did not verify the medication or clarify the order with the physician before administration. Interviews with the ADON, DON, and Administrator confirmed that the medication was not administered as ordered and that the nurse was responsible for ensuring accuracy and clarifying any discrepancies. The facility's policy required medications to be administered as prescribed and in accordance with regulations. The error was identified through observation, record review, and staff interviews, which revealed that the resident received an incorrect medication and dosage due to failure to follow proper medication administration procedures.
Medications Left Unsecured at Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments accessible only to authorized personnel, as required by regulation. During an observation, a bottle of Ayr Nasal Solution and biotene dry mouth moisturizing spray were found on the bedside table of a male resident with a diagnosis of diastolic (congestive) heart failure. The resident's care plan indicated he was unable to safely self-medicate and required 24-hour nursing care, and there was no order or assessment in place for self-administration of medications. The resident's cognition was intact, but he had a communication problem related to unclear speech. Interviews with the DON and ADON confirmed that the resident had not been evaluated for self-administration of medications and that no residents in the building were permitted to self-medicate. Both the DON and ADON acknowledged that medications should not be left at the bedside and should be stored in the nurse's cart. The facility's policy required medication rooms, carts, and supplies to be locked or attended by authorized personnel. The presence of medications at the resident's bedside was not detected by staff prior to the surveyor's observation.
Failure to Provide Adequate and Appropriate Diet
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. This deficiency indicates that residents did not consistently receive meals that were adequate in nutrition, taste, or tailored to their individual dietary requirements as required by regulation.
Incorrect Coding of MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status for one resident reviewed for MDS assessment accuracy. Specifically, the discharge MDS assessment for a male resident with chronic combined heart failure was incorrectly coded as 'return not anticipated' instead of 'return anticipated.' The resident was readmitted to the facility from the hospital within the required timeframe, which should have prompted a 'return anticipated' discharge assessment rather than a new admission assessment. The MDS Coordinator, who was responsible for completing the assessment, acknowledged after reviewing the resident's records that the incorrect assessment type was selected and that it should have been modified to reflect the correct status. Interviews with facility staff, including the MDS Coordinator, Regional Reimbursement Nurse, and Administrator, confirmed that the correct assessment was not completed and that there was no specific policy or procedure in place regarding MDS assessment accuracy, with staff relying on the RAI manual for guidance. The error was identified through record review and staff interviews, and it was noted that the correct assessment is important for ensuring continuity of care and an accurate plan of care upon the resident's return.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Failure to Care Plan Oxygen Therapy for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who required oxygen therapy. Record review showed that the resident, an older adult female with diagnoses including abnormal lung findings, neuromuscular bladder dysfunction, stroke, and diabetes, had a physician's order for oxygen at 2-3 liters per minute via nasal cannula every shift for hypoxia. The resident's quarterly MDS assessment indicated she used oxygen and had moderately impaired cognition. However, her care plan, as of the most recent revision, did not include any information or interventions related to oxygen therapy. Observations confirmed that the resident had oxygen equipment in her room and an oxygen sign outside her door, but she was not observed using oxygen during multiple checks. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed that the omission of an oxygen care plan was not recognized until brought to their attention. The facility's policy requires a comprehensive care plan to address all identified needs, including measurable objectives and timeframes, but this was not followed for the resident's oxygen therapy.
Failure to Report and Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and misappropriation of resident property, specifically concerning a resident who was allegedly exploited by a Community Support Advocate. The facility's policy requires all allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property to be reported to the facility administrator, who is responsible for further reporting to the Health and Human Services Commission (HHSC) within specified timeframes. However, in this case, the facility did not adhere to these procedures, as the incident involving the resident's money being used by the Community Support Advocate was not reported to the administrator or the state as required. The resident involved was a cognitively intact male with a BIMS score of 15, indicating full cognitive function. He had several medical diagnoses, including GERD, congestive heart failure, osteoarthritis, muscle weakness, and hypertension. The resident reported that the Community Support Advocate frequently used his money to purchase drinks and exerted undue influence over him during shopping trips. Despite these allegations, the facility staff, including an LVN, did not report the incident to the administrator, assuming that the discussion in a morning meeting was sufficient notification. Interviews with facility staff and the administrator revealed a lack of communication and adherence to the facility's abuse and neglect policy. The administrator, who was also the abuse coordinator, was unaware of the incident until it was too late to report within the required timeframe. The failure to report and investigate the allegations of misappropriation of resident property placed the resident at increased risk for exploitation and highlighted a significant deficiency in the facility's implementation of its abuse prevention policies.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of property involving a resident within the required 24-hour timeframe. The incident involved a community support advocate allegedly using the resident's money to purchase a candy bar. The allegation was not reported to the state agency as required by the facility's policy and state guidelines. This oversight was due to the facility's staff not informing the administrator about the incident, which resulted in a failure to investigate and report the allegation. The resident involved was a cognitively intact male with a history of GERD, congestive heart failure, osteoarthritis, muscle weakness, and hypertension. The resident reported that the community support advocate frequently used his money to buy drinks and claimed authority over him. Despite these claims, the facility did not take immediate action to report or investigate the allegations, as the staff assumed the issue was known to all after a morning meeting discussion. Interviews with the facility's staff, including the LVN and the administrator, revealed a lack of communication and understanding of the reporting procedures. The LVN did not report the incident to the administrator, believing it was already known, and the administrator was unaware of the situation until later. This lack of reporting and investigation could potentially place residents at risk for abuse, as the facility did not adhere to its own policies and state regulations regarding the timely reporting of such incidents.
Failure to Investigate and Report Alleged Misappropriation of Resident's Property
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or mistreatment were thoroughly investigated and reported in accordance with state law. Specifically, the facility did not investigate an allegation of misappropriation of property involving a resident and a Community Support Advocate. The incident involved the alleged use of the resident's money by the advocate to purchase personal items, which was not reported to the facility administrator or the state agency within the required timeframe. The resident involved was a cognitively intact male with a history of GERD, heart failure, osteoarthritis, muscle weakness, and hypertension. He reported that the Community Support Advocate frequently used his money to buy drinks and exerted undue influence over his shopping activities. Despite these allegations, the facility's LVN did not report the incident to the administrator, assuming that the discussion in a morning meeting was sufficient notification. The facility's administrator, who was also the abuse coordinator, was unaware of the incident until it was too late to comply with the reporting requirements. The administrator acknowledged the importance of investigating and reporting such incidents to protect residents from abuse and exploitation. The failure to investigate and report the incident as per the facility's policy and state guidelines placed residents at risk for abuse, neglect, and exploitation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the facility did not perform weekly ulcer assessments and obtain measurements for several residents' pressure injuries. This included a stage 4 pressure injury on a resident's left outer ankle, pressure injuries on another resident's buttocks, and a stage 3 pressure injury on a resident's left buttock. Additionally, wound care treatments were not performed as ordered for multiple residents, and treatment orders did not indicate the correct location of pressure injuries for some residents, leading to further complications and worsening of wounds. The facility also lacked a system to ensure that skin assessments and treatments were completed as ordered. Skin assessments were not performed accurately, and there was a failure to prevent the worsening of moisture-associated skin damage in one resident. The facility did not follow its Skin Integrity Management policy, and the Director of Nursing (DON) failed to provide adequate oversight for wound care management and assessments. This resulted in an Immediate Jeopardy situation, which was identified and later removed, but the facility remained out of compliance due to the need for in-service training and evaluation of corrective systems. Observations and interviews revealed that residents were not receiving timely and appropriate wound care. For instance, one resident's wound vac dressing was not changed as scheduled, and another resident's left ankle wound was not offloaded as required. The treatment nurse admitted to not measuring wounds and not completing ulcer assessments due to staffing issues and lack of training. The DON and other staff members were often unaware of the residents' wound conditions, indicating a significant communication breakdown and lack of proper documentation and follow-up on wound care treatments.
Failure to Ensure Resident Safety from Accident Hazards
Penalty
Summary
The facility failed to ensure the resident environment remained free from accident hazards, leading to several incidents involving four residents. Resident #42 received a first-degree burn from hot coffee due to inadequate safety measures. Despite the incident, the facility did not update the resident's care plan or implement new safety protocols immediately. The dietary manager and nursing staff were unaware of the proper procedures for handling hot liquids, and the coffee temperature logs were inconsistently maintained. The resident's care plan was only updated after surveyor intervention, and the facility's policy on hot liquid spills was not followed effectively. Resident #165 was observed smoking without supervision, contrary to his care plan, which required staff supervision due to safety concerns. The DON and other staff members were unaware of how the resident obtained his cigarettes and lighter, indicating a lapse in the facility's smoking policy enforcement. The administrator acknowledged the need for better smoking process management to prevent safety hazards. Residents #58 and #115 were found to have cigarettes and lighters in their possession, which was against the facility's smoking policy. Both residents were observed smoking unsupervised, posing a significant fire hazard. The DON and other staff members admitted to challenges in enforcing the smoking policy, including difficulties in confiscating smoking materials from residents. The facility's failure to adhere to its smoking policy placed residents at risk of burns and fire hazards.
Removal Plan
- Resident's #42 care plan was updated to include at risk for coffee burn and specialized cup with a lid to help prevent coffee spills by the DON.
- Resident's #42 hot liquid assessment was completed by the DON.
- Hot liquid Assessments were updated on all residents in the facility by the DON.
- Residents at high risk for coffee burns were assessed for the need of assistive devices if consuming hot liquids. Care plans were updated by the DON/Regional Compliance Nurse.
- The medical director was notified of the situation by the administrator.
- An off cycle QAPI meeting was completed with the IDT team and medical director to discuss the immediate jeopardy and plan of removal.
- The ADO will in-service the Administrator and Dietary Manager 1:1 on the following topics.
- All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees.
- Coffee will not be served over 140 degrees. All brewed coffee will have the temperature logged before serving.
- Hot liquid Spills Policy
- Guidelines on serving coffee in a nursing facility policy
- The following in-services were initiated by Administrator, DON, ADON for all staff. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced.
- All new hires will be in-serviced in orientation. All agency staff will be in-serviced prior to assuming shift.
- All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees.
- Coffee will not be served over 140 degrees. All brewed coffee will have the temperature logged before serving.
- Hot liquid Spills Policy
- Guidelines on serving coffee in a nursing facility policy
- The administrator will be responsible daily for ensuring the coffee temperature will be checked and logged prior to serving / making coffee available to residents. Coffee will not be served until the temperature is between 135-140 degrees.
Staffing Shortages Lead to Inadequate Incontinent Care
Penalty
Summary
The facility failed to ensure sufficient staff to provide nursing-related services to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not provide prompt and proper incontinent care for two residents. The record review of time sheets indicated that the number of CNAs working was insufficient to meet the required 110 hours in a 24-hour period based on the facility's assessment. This staffing shortage was confirmed by multiple staff interviews, which highlighted the challenges in providing adequate care due to understaffing, including missed showers and delayed incontinent care. Resident #219, an elderly female with multiple diagnoses including cerebral infarction, type 2 diabetes, and vascular dementia, was observed in a room with a strong urine odor. The resident had not been changed for an extended period, resulting in a wet and stained mattress. The CNAs providing care did not follow proper hygiene protocols, such as changing gloves and using clean wipes for each stroke. Interviews with the CNAs and the LVN confirmed that the resident was not checked on as frequently as required, and proper incontinent care procedures were not followed due to being sidetracked by other duties and nervousness. Resident #54, an elderly female with diagnoses including dementia, stroke, and diabetes, was also found to have received improper incontinent care. The CNA providing care did not clean the entire buttock area, failed to perform hand hygiene after removing soiled gloves, and did not change gloves when moving from dirty to clean areas. The CNA admitted to being in a hurry and nervous, which led to improper care. Interviews with the DON and the Administrator confirmed that the facility was aware of the staffing issues and the potential for infection due to improper incontinent care. The facility's management acknowledged the staffing shortages and the impact on resident care but had not received approval to use agency staff to fill the gaps.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to multiple deficiencies in care practices. Several staff members, including CNAs and nurses, did not follow proper hand hygiene and glove-changing protocols while providing perineal care, dressing changes, and other resident care activities. For instance, a CNA did not wash or sanitize hands when changing gloves between dirty and clean tasks while providing perineal care for a resident, and another CNA placed used wipes and barrier cream on a clean linen cart, contaminating it. Additionally, a treatment nurse failed to use personal protective equipment (PPE) as required by enhanced barrier precautions while completing a dressing change for another resident. The facility also failed to ensure proper cleaning and disinfection of medical equipment between residents. An LVN did not clean a glucometer between checking the blood sugar levels of two residents, increasing the risk of cross-contamination. Furthermore, several staff members did not follow enhanced barrier precautions, such as wearing gowns and gloves, when providing care to residents with specific medical conditions that required such precautions. This included activities like linen changes, resident hygiene, and wound care. In addition to these lapses, the facility did not maintain clean linen carts properly. Observations revealed that clean linen carts were left uncovered, exposing the linens to potential contamination from the environment. Interviews with staff confirmed that they were aware of the requirement to keep linen carts covered but failed to do so consistently. These deficiencies collectively placed residents and staff at risk for cross-contamination and the spread of infections.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life. Specifically, the facility did not document their efforts to resolve concerns collected at the resident council meetings held on multiple dates. The recurring issue of call lights not being answered timely was raised in each meeting, but there was no documentation of any actions taken to address these concerns. This failure was confirmed through interviews with the resident group, the Social Worker, the Activities Director, the DON, and the Administrator, all of whom acknowledged the issue but did not provide evidence of any follow-up actions or resolutions. The resident group consistently reported that call lights were not being answered timely, with instances of residents waiting for hours to receive assistance. Despite these repeated complaints, the facility did not file grievances or document any steps taken to address the issues. The Social Worker, who was responsible for grievances, and the Activities Director, who communicated the concerns to the DON and Administrator, both indicated a lack of knowledge or action regarding the proper grievance process. The Administrator, who had only been at the facility for one month, admitted that the concerns should have been brought to him and distributed to department heads for resolution. The Corporate Nurse was unable to provide the policy regarding grievances when requested.
Failure to Maintain Personal Hygiene and Grooming
Penalty
Summary
The facility failed to ensure necessary services to maintain grooming and personal hygiene for three residents. Resident #14, a male with unspecified dementia and hemiplegia, was not routinely showered or bathed. Despite being scheduled for baths on Monday, Wednesday, and Friday, only one bed bath was documented for the entire month of April. Observations revealed that Resident #14's hair appeared greasy, his shirt was stained, and his skin was dry and flaky. Interviews with staff indicated confusion and lack of communication regarding who was responsible for giving Resident #14 his baths, leading to missed showers and unchanged clothes. Resident #31, a male with heart disease, congestive heart failure, and moderately impaired cognition, also did not receive his scheduled baths. He was supposed to be bathed on Monday, Wednesday, and Friday during the 2 PM-10 PM shift but only received 2 out of 13 scheduled baths in April. Interviews with staff revealed that there had been changes in the shower schedule and a lack of clarity on who was responsible for ensuring the baths were given. The Administrator confirmed that the failure to provide regular baths could lead to poor hygiene and skin breakdown. Resident #16, a male with Down Syndrome and severe cognitive impairment, had long, broken, and uneven fingernails with a brown material under them. Despite requiring extensive assistance for personal hygiene, observations over several days showed that his nails remained untrimmed and dirty. Interviews with staff indicated that CNAs were responsible for nail care on shower days or when needed, but this was not consistently done. The DON and Administrator acknowledged the importance of keeping nails clean to prevent infection and scratching but noted that the responsibility was not clearly assigned or monitored.
Failure to Secure Medications and Medication Carts
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for two of five medication carts and one of twenty-two residents reviewed for pharmacy services. Specifically, Resident #36 had prescribed and over-the-counter medications at her bedside, which were not authorized. The resident had a history of hemiplegia following cerebral infarction, chronic pain, hypertension, cognitive communication deficit, and major depression. The resident's care plan indicated that the facility was responsible for administering her medications, and she was not permitted to self-administer. However, during an observation, the resident was found with a bottle of Tums, a box of stomach relief tablets, and a tube of silver sulfadiazine cream on her bedside table, none of which were ordered for her use at the time. The Director of Nursing (DON) confirmed that the resident should not have had these medications in her room and that no residents were allowed to self-administer medications. Additionally, the treatment nurse left the medication cart used for treatments unlocked while attending to a resident in another room. The cart remained unattended and unlocked for approximately 19 minutes. The treatment nurse admitted to being nervous and forgetting to lock the cart, acknowledging that anyone could have accessed the medications and treatments. Furthermore, an LVN was observed sitting at the nurse's station while the medication cart on Hall 200 was left unlocked. The LVN was unaware that the cart was open and acknowledged that it posed a potential hazard for residents. Both the DON and the Administrator confirmed that all medication carts should be locked when unattended to prevent unauthorized access and potential misuse of medications. The facility's policies on medication administration and medication carts clearly state that medication carts must be locked when not in use or under direct supervision. The failure to adhere to these policies was confirmed through interviews with the DON, LVN, and the Administrator, who all acknowledged the risks associated with leaving medication carts unlocked and medications at residents' bedsides. The Administrator emphasized that no resident could self-administer medications and that all medications should be kept in medication carts or the medication storage area to ensure safety and proper monitoring.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for five of six residents reviewed for pharmacy services. Specifically, Resident #26 did not receive timely administration of buspirone, gabapentin, duloxetine, and metoprolol succinate. The medication administration audit report indicated multiple instances where these medications were administered late, beyond the 1-hour grace period, potentially affecting the resident's treatment for anxiety, pain, depression, and blood pressure management. Resident #26's care plan and medication orders were not followed as prescribed, leading to significant delays in medication administration on several occasions. Resident #218 also experienced delays in the administration of spironolactone, metoprolol, venlafaxine hydrochloride, and pregabalin. The medication administration audit report showed that these medications were consistently administered late, beyond the 1-hour grace period. The resident's care plan did not address the use of these medications, and the MDS assessment was still in progress. The delays in medication administration could have impacted the resident's treatment for fluid buildup, high blood pressure, depression, and nerve pain. Additionally, Resident #165 did not receive timely administration of aspirin, omeprazole, Lyrica, and carisoprodol. The medication administration record revealed that these medications were either not given or administered late. RN A admitted to not giving the prescribed medications due to being in a hurry and not reading the MAR correctly. The DON was unaware of the late medications and stated that staff had not informed her of the issue. The facility's medication administration procedures were not followed, leading to potential adverse effects on the residents' health.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was given psychotropic medication to treat a specific diagnosis. The resident, a [AGE] year-old female with a history of vascular dementia, anxiety disorder, chronic obstructive pulmonary disease, hypertension, and cerebral infarction, was administered Seroquel (Quetiapine Fumarate) without an appropriate diagnosis to support its use. The resident's significant change MDS assessment indicated moderate cognitive impairment, but there was no diagnosis to justify the use of the antipsychotic medication. Despite this, the resident received Seroquel on a routine basis, and the pharmacy consultant did not make any recommendations regarding its use for dementia. Interviews with facility staff revealed a lack of awareness and understanding regarding the appropriate diagnoses for Seroquel use. An LVN acknowledged that Seroquel should not be given to residents with dementia and expressed concerns about the potential risks and side effects. The DON confirmed that dementia was not an approved diagnosis for Seroquel and stated that the resident had been taking the medication for a while without proper justification. The Administrator admitted to not being familiar with antipsychotic medications and their indications. The facility's policy indicated that unnecessary drugs should not be used without adequate indications, highlighting a failure in adhering to this policy.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that it was free of medication error rates of 5 percent or greater, resulting in a medication error rate of 10.0%. This was based on 4 errors out of 40 opportunities, involving two residents. One resident did not receive the correct dose of Aspirin 81 MG and Omeprazole 40 MG, and was also not administered Lyrica 75 MG as ordered. Another resident was given the wrong type of Aspirin 81 MG, receiving an enteric-coated tablet instead of the prescribed chewable form. These errors were observed during medication administration by RN A. The first resident, a male with a history of fracture, diabetes, coronary artery disease, and hypertension, did not receive his prescribed Lyrica and was given incorrect doses of Aspirin and Omeprazole. The second resident, a female with diabetes, high blood pressure, and congestive heart failure, received the wrong type of Aspirin. The Director of Nursing (DON) acknowledged the errors and attributed them to staffing issues, while the Administrator emphasized the importance of administering medications as ordered. The facility's policy requires immediate reporting of medication errors to the physician and the DON, along with a medication error report to prevent recurrence.
Inadequate Incontinent Care and Hygiene Practices
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Resident #219, an elderly female with diagnoses including cerebral infarction, type 2 diabetes mellitus, and vascular dementia, was not provided prompt and proper incontinent care. During an observation, it was noted that Resident #219 had a strong urine odor in her room and had not been changed for an extended period. CNA G and SNA H provided incontinent care but failed to follow proper hygiene protocols, such as changing gloves and using clean wipes for each stroke. The mattress was found to be wet, and the resident had a dark brown stain extending up her buttocks, indicating prolonged exposure to urine and feces. Both CNAs admitted to not following proper procedures due to being sidetracked and nervousness, respectively. The DON and Administrator acknowledged the importance of proper incontinent care but noted lapses in oversight and adherence to protocols by the staff. Additionally, the facility failed to ensure CNA C properly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #54. Resident #54, an elderly female with severe cognitive impairment and a history of UTI, was observed receiving inadequate incontinent care. CNA C did not clean the entire buttock area, failed to change gloves appropriately, and did not perform hand hygiene after removing soiled gloves. CNA C admitted to knowing the correct procedures but did not follow them due to being in a hurry. The DON and Administrator reiterated the importance of proper incontinent care and hand hygiene to prevent infections but acknowledged the need for better oversight and adherence to protocols. The facility's policy on perineal care emphasizes the importance of maintaining resident dignity, preventing infections, and following proper hygiene protocols. However, the observations and interviews revealed significant lapses in following these procedures, putting residents at risk for infections and decreased quality of life. The DON and Administrator recognized the deficiencies and the need for improved oversight and adherence to established protocols to ensure residents receive appropriate care.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that respiratory care was provided consistent with professional standards of practice for two residents. For Resident #19, the handheld nebulizer was observed lying at the bedside and not stored in a bag, exposing it to the air and surroundings. Interviews with the LVN and DON confirmed that handheld nebulizers should be stored in a bag to prevent infection, and it was the responsibility of the nursing staff to ensure proper storage. The resident's medical history included chronic obstructive pulmonary disease, and the care plan indicated the use of aerosol or bronchodilators as ordered. However, the nebulizer was not stored correctly, posing a risk of respiratory infections or complications for the resident. The DON acknowledged the oversight and emphasized the importance of proper storage for infection control. The LVN admitted to not noticing the improper storage and reiterated the risk of infection due to exposure to germs. The facility's policy on oxygen administration was reviewed, which stated that tubing and equipment should be changed or cleaned when visibly contaminated. However, the policy was not followed in this instance, leading to the deficiency. For Resident #8, the nasal cannula was observed on the floor, and the oxygen concentrator filter was covered in gray fuzzy material. The resident's medical history included dementia and acute respiratory failure with hypoxia, and the care plan indicated the use of oxygen therapy. Interviews with the LVN and DON confirmed that it was the nurse's responsibility to ensure the nasal cannula was properly stored and the oxygen concentrator was cleaned. The LVN admitted to not ensuring the proper storage and cleaning, and the DON emphasized the importance of these actions to prevent infection. The facility's policy on oxygen administration was reviewed, which stated that tubing and equipment should be changed or cleaned when visibly contaminated. However, the policy was not followed in this instance, leading to the deficiency.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to ensure that all residents had the right to a safe, clean, comfortable, and homelike environment, specifically in the case of one resident's room. Resident #4, a [AGE] year-old female with diagnoses including seizures, Pseudobulbar affect, high blood pressure, and dementia, was observed in a room that smelled of urine and bowel. The resident required total assistance with toileting and was always incontinent of bowel and bladder. Despite the care plan indicating that staff should check for incontinent episodes every 2 hours and assist as needed, the room was repeatedly found to have a strong odor of urine and bowel during the survey period from 04/28/24 to 05/02/24. Multiple observations and interviews confirmed the persistent odor issue. On 04/28/24, Resident #4 was found in bed with no clothes on, and the room smelled of urine and bowel. On 04/29/24, the room continued to smell of urine during different times of the day. The treatment nurse and housekeeper both acknowledged the odor, with the housekeeper noting that she cleaned the mattress and fall mats daily but still noticed the smell. The administrator also confirmed the urine odor and identified soiled clothes in the resident's closet as a potential source. The roommate of Resident #4 also mentioned the urine smell but did not report it, thinking it could have been her own issue.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #54, who had multiple diagnoses including insomnia, high blood pressure, dementia, stroke, and diabetes. The resident's quarterly MDS assessment indicated severe cognitive impairment and extensive assistance required for daily activities. Despite having a physician's order for Trazodone to manage insomnia and mood, the medication use was not included in the resident's care plan. This omission was confirmed during an observation and interview with the MDS nurse, who acknowledged that the care plan should have included the medication and related interventions. The Director of Nursing (DON) and the Administrator both confirmed that the MDS nurse was responsible for completing the care plans, and the DON was the overseer. They admitted that the care plan should have been complete and accurate to ensure the resident received appropriate care. The deficiency was identified during a state survey, and it was noted that the care plan was updated only after the surveyor's intervention to include the use of Trazodone and related interventions. The facility's policy on comprehensive care planning mandates the development and implementation of a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to ensure that a resident received the necessary incontinent care, resulting in neglect. The resident, an elderly female with a history of cerebral infarction, type 2 diabetes mellitus, and vascular dementia, was found in a room with a strong urine odor and wet, brown stains on her sheets and mattress. The care plan for the resident indicated that she required assistance with personal hygiene and had a potential for pressure ulcer development, necessitating incontinent care after each episode and the application of a moisture barrier. However, the resident had not been changed for an extended period, leading to the observed conditions. During an observation and interview, it was revealed that the resident had not been changed since around 12:30 PM, despite the requirement for checks every two hours. CNA G admitted to not checking on the resident as frequently as needed due to other duties, while SNA H confirmed that the last change was before breakfast. Both aides acknowledged the importance of frequent incontinent care to prevent infections and skin breakdown. The LVN and DON also confirmed that the lack of prompt incontinent care could lead to pressure injuries and infections, and the DON noted that the incident could be considered neglect. The Administrator confirmed the incident, stating that the resident had not been changed and that it could be considered neglect. The facility's policy on abuse and neglect emphasized the resident's right to be free from neglect, defined as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The failure to provide timely incontinent care for the resident was a clear violation of this policy, as confirmed by multiple staff members and the facility's administration.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit neglect and abuse for one resident reviewed for abuse and one staff member reviewed for abuse training. The Social Worker did not immediately report Resident #11's allegation of verbal abuse by Resident #219 to the Administrator, as required by the facility's policy. Resident #11, who had intact cognition and a history of anxiety disorder, reported that her roommate, Resident #219, had threatened to kill her. The Social Worker, who had been employed for three months, did not consider the threat as abuse initially and planned to report it the next day, which was against the facility's policy of immediate reporting of abuse allegations. Additionally, the facility failed to ensure that LVN K completed abuse training upon hire. LVN K was hired on 03/05/24 but did not complete the required abuse prevention training until 03/25/24, which was 20 days late. The Human Resource Coordinator acknowledged that the training should have been completed within 3-5 days of hire and was responsible for ensuring its timely completion. The delay in training meant that LVN K was not adequately prepared to identify and report abuse during the initial period of employment. The facility's policy on abuse and neglect, revised on 03/29/18, mandates immediate reporting of any suspected abuse, neglect, exploitation, or mistreatment to the facility administrator. The policy also requires new employee orientation to include training on abuse prevention. The failure to adhere to these policies could place residents at risk of abuse, neglect, and decreased quality of life.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required. Specifically, the Social Worker did not report Resident #11's allegation of verbal abuse and a death threat by her roommate, Resident #219, to the Administrator immediately. Resident #11, who had intact cognition and a history of anxiety disorder, reported that Resident #219 had cussed at her and threatened to kill her with a gun. The Social Worker, who had been employed at the facility for only three months, did not believe Resident #219 was capable of carrying out the threat and decided to wait until the next morning meeting to report the incident, which was against the facility's policy for immediate reporting of abuse allegations. Resident #11's care plan indicated she had difficulty coping with her roommate, and the Social Worker and staff were supposed to monitor the situation. Despite this, the Social Worker did not take immediate action when Resident #11 reported the threat. During an interview, the Social Worker admitted that he did not initially consider the threat as abuse but rather as a grievance, and he acknowledged that he should have reported it immediately to the abuse coordinator. The facility's policy on abuse and neglect, revised in 2018, clearly stated that any suspected abuse, neglect, exploitation, or mistreatment should be reported immediately to the Abuse Preventionist or designee. The Administrator confirmed that any threats or resident-to-resident altercations should be reported immediately. The failure to report the incident promptly could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
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.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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