Kirkland Court Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Amarillo, Texas.
- Location
- 1601 Kirkland Dr, Amarillo, Texas 79106
- CMS Provider Number
- 675336
- Inspections on file
- 42
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 8 (3 serious)
Citation history
Health deficiencies cited at Kirkland Court Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple serious health conditions and on hospice care had a DNR order that was not properly completed, as the physician's signature was not dated. Staff interviews revealed confusion about responsibility for DNR documentation, and a second DNR form from hospice was also invalid due to improper witnessing by direct care staff. As a result, the resident's wishes regarding resuscitation were not properly documented.
A resident had a bed rail installed without a physician order, informed consent, or inclusion in the care plan. Staff interviews and record reviews confirmed that required assessments and documentation were not completed, despite facility policy mandating these steps for bed rail use.
A medication cart on the west wing was observed unlocked and unattended while residents were nearby. The RN responsible admitted forgetting to lock the cart, and both the ADON and ADM confirmed that this practice could allow residents to access medications not prescribed to them, in violation of facility policy.
Two residents were involved in an incident where a male resident with cognitive impairment accessed an unsecured hand saw from a maintenance closet and used it to threaten a female resident and damage her walker. The female resident, who has Alzheimer's and other mental health conditions, was left fearful and distressed. Staff confirmed the male resident obtained the saw from an unlocked area, and the facility failed to prevent this access, resulting in abuse and neglect.
Two residents with cognitive impairments were involved in an incident where one obtained a hand saw from an unlocked maintenance closet, threatened another, and damaged her walker. Staff and administration failed to promptly report or investigate the event as required by policy, and hazardous items were accessible due to an unlocked door. The incident was not addressed until surveyors intervened.
Two residents experienced significant lapses in supervision and environmental safety: one resident with impaired cognition and mobility eloped from the facility in a wheelchair while awaiting hospital transport, and another resident with dementia accessed a hand saw from an unlocked maintenance office and used it on another resident's walker, also making threats. Both incidents were confirmed by staff interviews and direct observation, highlighting failures in accident prevention and supervision.
A resident with cognitive impairment obtained a hand saw from an unsecured maintenance area, threatened another resident, and damaged her walker. Although several staff members became aware of the incident and removed the saw, the event was not reported to the administrator or state authorities within required timeframes, and no investigation was initiated until prompted by surveyors. Facility policy requiring immediate reporting and investigation of abuse or neglect was not followed.
A male resident with cognitive impairment obtained a hand saw from the maintenance office, threatened a female resident with it, and damaged her walker. Staff removed the saw but did not initiate or document a thorough investigation or report the incident as required by facility policy, and administrative staff expressed uncertainty about the need to report or investigate the event until prompted by surveyors.
A resident with cognitive impairment and on anticoagulant therapy was found with a nasal decongestant spray at bedside without authorization for self-administration, contrary to facility policy. Additionally, an LVN left a medication cart and another LVN left a treatment cart unlocked and unattended, allowing potential unauthorized access. Facility policies and staff interviews confirmed these actions were not permitted.
Surveyors found that food items in the kitchen, including dairy, meat, juices, and baked goods, were not properly labeled, dated, or stored according to facility policy and professional standards. Staff interviews confirmed that all dietary staff were responsible for these tasks, but lapses were observed throughout the kitchen, increasing the risk of serving spoiled or contaminated food to residents.
A resident with newly documented bipolar disorder and PTSD was not referred for a new PASRR Level I assessment following a significant change in status. Despite updated diagnoses and care plans indicating serious mental illness, staff did not initiate the required reassessment, and facility policy lacked guidance on re-screening for new qualifying conditions.
A resident with multiple complex medical conditions was admitted without a baseline care plan being developed or implemented within 48 hours, as required by facility policy. Staff interviews confirmed the omission and acknowledged its potential negative impact on care, with no documentation of a baseline care plan found in the EHR during the review period.
An LVN failed to disinfect a glucometer between blood glucose checks for multiple residents, despite facility policies requiring cleaning and disinfection between uses. This was confirmed through direct observation and staff interviews, which acknowledged the risk of cross-contamination and infection.
A resident with hemiplegia, hemiparesis, and kidney failure, who was assessed as requiring two-person assistance for transfers and toileting, was consistently assisted by only one staff member. Staff did not follow the care plan or review it, and the resident was unable to assist due to left-sided weakness. Leadership interviews revealed confusion about care requirements and reliance on MDS assessments, resulting in care that did not meet the resident's documented needs.
A facility failed to document an altercation between two residents in their medical records. The incident involved a cognitively impaired female resident and a male resident with paranoid schizophrenia. Despite being recorded in an incident report, the altercation was not noted in the residents' progress notes, contrary to facility policy. Staff interviews revealed that the charge nurse was overwhelmed and forgot to document the event, which could lead to staff being unaware of the incident and unable to monitor for related behavioral changes.
Two CNAs failed to use proper PPE during catheter care for a resident with an indwelling catheter and feeding tube, despite a sign indicating Enhanced Barrier Precautions. The resident had severe cognitive impairment and multiple medical conditions. Interviews revealed staff confusion about the necessity of these precautions, and the facility's policy was not consistently applied.
A resident with a history of falls and mobility issues experienced an unwitnessed fall resulting in a hip fracture. The facility failed to immediately notify the resident's family and physician, as required by policy. Attempts to contact the family were not documented until five days later, highlighting a lapse in communication and adherence to protocol.
The facility failed to store, label, and date food items in the pantry, refrigerator, and freezer, as observed during a survey. Interviews with staff confirmed that this could lead to food not being servable and potentially causing illness to residents. The facility's policy mandates proper labeling and dating of all refrigerated, ready-to-eat foods.
The facility failed to submit complete and accurate direct care staffing information to CMS for FY Quarter 1 2024 due to human error by IT Corp, who oversees multiple buildings. The facility's policy requires quarterly submission of this data.
The facility failed to provide an ongoing program of activities that met the interests and well-being of residents. Observations and interviews revealed that the Activity Director primarily offered coloring activities, which were not suitable for all residents, and the activity calendar was not accurately followed or legible. This deficiency placed residents at risk of boredom and a decline in their quality of life.
The facility failed to ensure the Activities Director (AD) was certified, despite the AD working for six months and waiting for the facility to pay for the classes. The ADM, ADON, and DON were aware of this deficiency, and staff expressed concerns about the potential negative impact on resident activities. The AD's personnel file lacked any training or certification, and a relevant policy was not provided.
The facility failed to ensure proper storage and labeling of medications, including leaving medication carts unlocked and unattended, and using expired insulin. This placed residents at risk for drug diversion, overdose, and incorrect administration.
The facility failed to maintain an effective infection prevention and control program, with multiple instances of staff not performing proper hand hygiene and glove changes during blood sugar checks, medication administration, incontinent care, and wound care. Interviews with staff confirmed these deficiencies, and facility policies were not followed.
A resident had bed rails installed without proper assessment, physician orders, or informed consent. The facility's policy on bed rail use was not followed, leading to potential safety risks.
The facility failed to ensure proper techniques in wound care, incontinent care, and medication administration via gastrostomy tube by an LVN. Observations revealed lapses in hand hygiene and glove-changing protocols, and the LVN admitted to not receiving adequate training. The facility lacked competency checkoffs for staff, contributing to these deficiencies.
A facility failed to ensure residents were free from significant medication errors when an LVN administered insulin to a resident using another resident's insulin pen. The resident involved had multiple chronic conditions and required insulin as per a sliding scale. The error occurred despite the facility's policies on medication administration and resident identification.
Failure to Ensure Proper Completion of Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was properly honored. A review of the resident's records revealed that a Do Not Resuscitate (DNR) order was present but was not properly completed, as the physician's signature was not dated. The paper DNR was signed and dated by the resident and two witnesses, but the physician's signature lacked a date, rendering the document incomplete. Interviews with facility staff, including the LVN, ADON, SW, and DON, confirmed that the DNR was not valid due to this omission, and there was confusion among staff regarding responsibility for ensuring the DNR was correctly completed and maintained. Further review found that a second DNR document obtained from the hospice agency was also invalid, as both witnesses were direct care staff, which did not meet the requirements outlined in the DNR instructions. The facility's policy stated that advance directives would be respected in accordance with state law and facility policy, but the documentation and staff interviews demonstrated that this was not followed in practice. The resident, who had significant medical conditions and was on hospice care, expressed her wish to be a DNR, but due to incomplete and improperly executed documentation, her wishes were not properly documented or ensured.
Failure to Obtain Consent and Document Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rail use with a resident or their representative and did not obtain informed consent prior to installing a bed rail. Specifically, a one-half length bed rail was installed on the right side of a resident's bed without a physician order, without documented informed consent, and without inclusion of bed rail use in the resident's comprehensive care plan. The resident's care plan did not address bed rail use, despite the resident being identified as high risk for falls with a history of falls prior to admission. The electronic medical record and active physician orders did not contain any documentation authorizing bed rail use or consent for its installation. Staff interviews confirmed the absence of a physician order and informed consent for the bed rail, and the DON acknowledged that the lack of an order prevented the addition of bed rail use to the care plan. The facility's policy required consent and care plan documentation for side rail use, but these steps were not followed. The resident was observed using the bed rail and expressed that it made her feel safe and aided her mobility, but the required assessments, documentation, and consents were not completed as per facility policy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that the west wing medication cart was left unlocked and unattended while unidentified residents were walking freely around it. The RN responsible for the cart returned after a short period and locked it, stating during an interview that she had forgotten to lock the cart. The RN acknowledged that leaving the cart unlocked could allow residents to take medications from it. Further interviews with the Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed that leaving medication carts unlocked could result in residents accessing and taking medications not prescribed to them. A review of the facility's medication administration policy, dated April 2019, indicated that medication carts are to be kept closed and locked when out of sight of the medication nurse or aide. The failure to follow this policy was directly observed and confirmed by staff interviews.
Failure to Prevent Resident-to-Resident Abuse and Neglect Due to Unsecured Hazardous Equipment
Penalty
Summary
The facility failed to protect two residents from abuse and neglect. One resident, a female with Alzheimer's disease, intermittent explosive disorder, psychotic disorder with delusions, and major depressive disorder, reported that a male resident threatened to cut off her foot with a hand saw and then used the saw to cut a groove into her walker. This incident was corroborated by direct observation of the damaged walker and by interviews with staff and the male resident, who admitted to both threatening the female resident and using the saw on her walker. The female resident expressed fear and distress following the incident, and her family member confirmed that she was upset and scared when recounting the event. The male resident involved had diagnoses including Parkinson's disease, unspecified dementia, major depressive disorder, anxiety disorder, muscle wasting, and muscle weakness. He was noted to have a history of being resistive to care and potentially physically and verbally aggressive due to cognitive impairment. On the day of the incident, he was able to obtain a hand saw from an unlocked maintenance closet, which he then used in the presence of other residents and staff. Staff interviews confirmed that the saw was taken from him after he was seen with it, and that he had accessed it from the maintenance office, which was not secured at the time. The facility's failure to keep hazardous equipment, such as the hand saw, secured and inaccessible to residents directly led to the incident. Staff interviews indicated that while they were trained to recognize and report abuse and neglect, the maintenance office was left unlocked, allowing the male resident to access the saw. The incident was reported to facility administration after the fact, and the female resident was left feeling unsafe and distressed as a result of the threat and the damage to her mobility aid.
Failure to Prevent and Report Resident-to-Resident Abuse Involving Hazardous Item
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not implement its abuse policy when a male resident obtained a hand saw from an unlocked maintenance closet and used it to threaten a female resident and to saw a groove into the top, front bar of her walker. The incident was not promptly reported or investigated according to facility policy, and staff responses were inconsistent and delayed. The female resident involved had a history of Alzheimer's disease with late onset, intermittent explosive disorder, psychotic disorder with delusions, and major depressive disorder. She had moderately impaired cognition and required assistance with activities of daily living. The male resident had diagnoses including Parkinson's disease, unspecified dementia, major depressive disorder, and anxiety disorder, with moderately impaired cognition but was independent in ADLs. He admitted to obtaining the saw from the maintenance area and threatening the female resident, as well as using the saw on her walker. Multiple staff members were aware of the incident, with some witnessing the male resident in possession of the saw and using it on the female resident's walker. However, there was confusion and lack of clarity among staff and administration regarding the necessity and process for reporting the incident as abuse. The maintenance closet was found to be unlocked, allowing resident access to hazardous items. The incident was not reported to the DON or state authorities in a timely manner, and no immediate investigation or protective measures were initiated until prompted by surveyor inquiry.
Failure to Prevent Resident Elopement and Access to Hazardous Items
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who had a history of cerebral infarction, aphasia, hemiplegia, and recent cranioplasty surgery, was able to elope from the facility in his manual wheelchair while awaiting transport to the hospital for severe hernia pain. Despite being identified as a wanderer with impaired cognition and requiring supervision, the resident was left unsupervised long enough to leave the building and travel half a mile to the hospital, where he was found by hospital staff. Interviews with staff and family confirmed that the resident was not wearing appropriate clothing or assistive devices and that staff were unaware of his absence until after he had left the premises. Another resident, with diagnoses including Parkinson's disease, unspecified dementia, and major depressive disorder, was able to access a hand saw from an unlocked maintenance office. This resident, who had a care plan noting potential for physical aggression and impaired cognition, was observed by staff using the saw on another resident's walker and admitted to threatening to cut off a fellow resident's foot. Staff interviews and direct observation confirmed that the maintenance office door was not consistently locked, allowing the resident to obtain the saw without restriction. The maintenance staff acknowledged the possibility of leaving the door unlocked due to being busy and in a hurry. Both incidents were confirmed through interviews, record reviews, and direct observation, demonstrating lapses in supervision and environmental safety. The facility's failure to prevent elopement and restrict access to hazardous items resulted in situations where residents were placed at risk of harm. The events were recognized as deficiencies by surveyors, with immediate jeopardy identified due to the severity of the lapses in care and safety.
Failure to Timely Report and Investigate Resident-to-Resident Threat and Property Damage
Penalty
Summary
The facility failed to immediately report and investigate an incident involving two residents, where one resident obtained a hand saw from an unlocked maintenance closet and used it to threaten another resident and damage her walker. The incident occurred when a male resident, with a history of Parkinson's disease, dementia, and behavioral issues, accessed the maintenance area and took a hand saw. He then threatened a female resident, who had Alzheimer's disease and moderate cognitive impairment, by stating he would cut off her foot and proceeded to saw a groove into her walker. Multiple staff members, including CNAs and nurses, became aware of the incident, and the saw was taken away from the resident at the time. Despite staff awareness, the incident was not reported to the facility administrator or to state authorities within the required federal timeframes. Interviews revealed that some staff reported the event to supervisors, but there was confusion and lack of clarity among the administrative team regarding the necessity and urgency of reporting the incident. The administrator and assistant director of nursing expressed uncertainty about whether the event constituted a reportable incident and did not initiate an investigation or ensure resident safety until prompted by surveyors during the inspection. Facility policy required immediate reporting of any allegations or suspicions of abuse, neglect, exploitation, or misappropriation of resident property to the administrator and appropriate authorities, with specific timeframes depending on the severity of the incident. However, the policy was not followed in this case, as the incident was not reported within the mandated two-hour or 24-hour windows, and no investigation was initiated until after surveyor intervention. This lapse was confirmed by staff interviews and review of facility records.
Failure to Investigate Resident-to-Resident Threat and Property Damage
Penalty
Summary
The facility failed to thoroughly investigate an incident involving two residents, one of whom threatened the other with a hand saw and used the saw to damage the other's walker. The incident occurred when a male resident, who had diagnoses including Parkinson's disease, unspecified dementia, and major depressive disorder, obtained a hand saw from the maintenance office. He then threatened a female resident, who had Alzheimer's disease, intermittent explosive disorder, and psychotic disorder, by stating he would cut off her foot and proceeded to cut a groove into her walker. Multiple staff members, including CNAs and an LVN, observed or were informed of the incident, and the saw was taken away from the resident by staff. Despite the seriousness of the event, there was no evidence that the facility initiated or completed a thorough investigation as required by their own policies and federal regulations. Interviews with staff revealed confusion about whether the incident needed to be reported, and some staff did not communicate the event to the appropriate administrative personnel. The administrator and ADON expressed uncertainty about the necessity of reporting or investigating the incident, and there was no documentation of an investigation or protective measures taken until surveyors began asking questions. The facility's policies require that all allegations of abuse, neglect, or exploitation be thoroughly investigated, with specific steps outlined for reviewing documentation, interviewing involved parties, and protecting residents from further harm. However, in this case, the required investigation was not conducted, and the incident was not reported in a timely manner. The lack of action persisted until the survey process prompted staff to address the situation.
Failure to Secure Medications and Prevent Unauthorized Resident Access
Penalty
Summary
The facility failed to ensure proper storage and control of drugs and biologicals as required by state and federal regulations. One resident with moderately impaired cognition and a history of anticoagulant use was found to have a nasal decongestant spray at his bedside without an order for self-administration. The resident stated he kept the medication nearby for nosebleeds, referencing a physician's recommendation, but there was no documentation in his care plan or physician orders permitting self-administration. Facility staff, including the administrator and director of nursing, confirmed that residents are not allowed to keep medications in their rooms, and policies prohibit such practices unless specifically authorized by the care team. Additionally, staff failed to secure medication and treatment carts as required. Observations revealed that a medication cart on one hall and a treatment cart on the east wing were left unlocked and unattended by LVNs while they performed other tasks. Interviews with staff acknowledged the potential for unauthorized access to these carts, and facility policy mandates that carts must be locked when not in use and never left unattended. Facility records and policies reviewed during the survey confirmed that only authorized personnel should have access to medications, and that all drugs and biologicals must be stored in locked compartments under proper conditions. The facility's own admission materials and policies reinforce these requirements, stating that medications are not allowed in resident rooms except under specific circumstances with physician orders. Despite these policies, the survey found multiple instances of non-compliance involving both resident access to medication and unsecured medication storage by staff.
Failure to Properly Store, Label, and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage, labeling, and dating in the facility's kitchen. Specifically, items in the walk-in refrigerator, such as bags of cream, ground beef, turkeys, glasses of milk and orange juice, and an open container of cranberry cocktail juice, were found either unlabeled, undated, or past their use-by dates. In the walk-in freezer, an open box of biscuits and an unlabeled, undated bag were noted. Additionally, cookies were found on the kitchen counter in an open bag without a date. These observations were corroborated by interviews with dietary staff and the dietary manager, who confirmed that all staff were responsible for ensuring food items were properly covered, labeled, and dated, and acknowledged that failure to do so could result in serving spoiled food. A review of the facility's Food Receiving and Storage Policy indicated that all refrigerated foods should be covered, labeled, and dated with a use-by date, and that repackaged foods should be stored in sanitary containers with clear labeling. The FDA Code was also referenced, highlighting the risk of pathogen contamination and growth in improperly stored food. The facility's failure to adhere to these standards placed all residents consuming food from the kitchen at risk of cross-contamination and food-borne illness.
Failure to Complete PASRR Reassessment for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder for a Level II PASRR review upon a significant change in status assessment. Specifically, a female resident with diagnoses of bipolar disorder and post-traumatic stress disorder (PTSD) was not reassessed with a new PASRR Level I screening, despite these qualifying diagnoses being documented after her initial admission. The original PASRR Level I assessment, completed prior to admission, indicated the resident was negative for mental illness, but subsequent records, including the MDS and care plan, reflected the presence of bipolar disorder and PTSD. Interviews with facility staff revealed a lack of understanding regarding the need for a new PASRR Level I assessment when a qualifying diagnosis is identified after admission. The DON, responsible for PASRR assessments, believed that a new screening was unnecessary if the diagnosis was presumed to be present prior to admission. The facility's policy on admission criteria did not address the need for re-screening based on new or newly identified qualifying diagnoses.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. Record reviews showed that the resident, a female with multiple complex diagnoses including hypertensive heart disease, vascular dementia, epilepsy, breast cancer, Crohn's disease, and osteoporosis, did not have a baseline care plan initiated or documented in the electronic health record under any relevant tabs. No comprehensive MDS assessments or care plans were found for the resident within the required timeframe. Interviews with facility staff, including the DON, ADON, and ADM, confirmed that a baseline care plan had not been completed within 48 hours of the resident's admission. Staff acknowledged that the absence of a timely baseline care plan could negatively impact the care provided, as it is essential for identifying and addressing the immediate needs of newly admitted residents. The facility's own policy requires a baseline plan of care to be developed within 48 hours of admission, but this was not followed in this instance.
Failure to Disinfect Glucometer Between Resident Uses
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during blood glucose monitoring for three residents. Observations revealed that LVN D performed blood glucose checks on multiple residents without cleaning or disinfecting the glucometer between uses. Specifically, after checking the blood glucose of one resident, LVN D did not clean the glucometer before using it on another resident, and this pattern was repeated with additional residents. These actions were directly observed by surveyors during their visit. Interviews with LVN D, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed awareness of the negative outcomes associated with not disinfecting equipment between residents, including the risk of cross-contamination and infection. Review of facility policies, including those on obtaining fingerstick glucose levels and blood sampling, indicated clear requirements to clean and disinfect reusable equipment between resident uses, following manufacturer instructions and infection control standards. The observed practices were not in compliance with these established policies.
Failure to Implement Two-Person Assist for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with hemiplegia, hemiparesis, kidney failure, and muscle wasting. The resident's care plan, dated 5/6/25, specified a requirement for two-person assistance with transfers, toileting, and bed mobility due to her physical limitations and risk for falls. The resident's MDS assessment also documented total dependence on staff for these activities, indicating that two or more helpers were required. Despite these documented needs, staff consistently transferred and toileted the resident with only one person. Observations confirmed that a CNA transferred the resident from bed to wheelchair and assisted with toileting alone, using a gait belt, while the resident did not assist due to left-sided weakness. Interviews with the CNA and the resident revealed that this one-person assist had been the standard practice since admission, and the CNA was unaware of the care plan's requirement for two-person assistance. The CNA admitted to not reviewing the care plan and relied on training and information from other staff. Further interviews with facility leadership, including the DON, indicated a lack of clarity regarding the resident's required assistance level and a reliance on MDS lookback periods to determine care needs. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these were not followed in practice for this resident, resulting in care that did not align with the resident's assessed needs.
Failure to Document Resident Altercation in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents involved in an altercation. On 12/4/2024, an incident occurred between Resident #1, a female with severe cognitive impairment due to conditions such as cerebral infarction and vascular dementia, and Resident #2, a male with intact cognition but diagnosed with paranoid schizophrenia and unspecified dementia. The altercation involved Resident #1 attempting to take a cup of juice that belonged to Resident #2, leading to an interaction that was not documented in either resident's clinical records, despite being noted in an incident report. Interviews with facility staff revealed that the incident was not documented in the residents' progress notes, which is a requirement according to the facility's policy on resident-to-resident altercations. The Assistant Director of Nursing (ADON) acknowledged the oversight and noted that the charge nurse on duty, LVN A, failed to document the incident due to being overwhelmed. The lack of documentation could lead to staff being unaware of the incident and unable to monitor for related behavioral changes, as noted by the ADON.
Inadequate Infection Control Practices During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by two certified nursing assistants (CNAs) during catheter care for a resident. The CNAs, identified as CNA B and CNA C, did not wear the required gowns for Enhanced Barrier Precautions while performing catheter care on a resident who had an indwelling catheter and a feeding tube. This oversight was observed despite a sign on the resident's door indicating the need for Enhanced Barrier Precautions, which include wearing gloves and gowns during high-contact resident care activities. The resident involved was a male with multiple medical conditions, including hemiplegia, seizures, an intracranial abscess, neuromuscular dysfunction of the bladder, malnutrition, and a gastrostomy. His clinical records indicated severe cognitive impairment and dependency on staff for all activities of daily living. Despite these conditions, there were no specific orders or care plans for Enhanced Barrier Precautions for this resident, which contributed to the oversight by the CNAs. Interviews with the CNAs and facility staff revealed a lack of understanding and implementation of Enhanced Barrier Precautions. The CNAs were unaware of the necessity for these precautions, and the Director of Nursing (DON) expressed skepticism about their benefits. The Assistant Director of Nursing (ADON) acknowledged providing verbal training on infection control but lacked documentation to confirm it. The facility's policy, aligned with CDC guidelines, recommended Enhanced Barrier Precautions for residents with indwelling medical devices, yet this was not consistently applied or understood by the staff.
Failure to Notify Family and Physician After Resident's Fall
Penalty
Summary
The facility failed to immediately inform a resident's representative and consult with the resident's physician following an accident that resulted in injury and required hospital transfer. The incident involved a male resident who had a history of cellulitis, repeated falls, muscle weakness, and reduced mobility. The resident experienced an unwitnessed fall in the facility's lobby, resulting in a displaced subcapital femoral neck fracture of the right hip. Despite the severity of the injury and the subsequent ambulance transfer to the hospital, the resident's emergency contact was not notified immediately. Interviews and record reviews revealed that the facility's staff did not follow the established protocol for notifying the resident's family and physician after a significant change in condition. The Licensed Vocational Nurse (LVN) responsible for contacting the family attempted to reach the emergency contact twice on the day of the fall but failed to document these attempts until five days later. The Director of Nursing (DON) confirmed the lack of timely documentation and notification. The facility's policy mandates prompt notification of the resident's representative and physician in such situations, which was not adhered to in this case.
Failure to Properly Store, Label, and Date Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed multiple instances of improperly stored, labeled, and dated food items in the walk-in pantry, refrigerator, and freezer. Specifically, the pantry contained an opened package of turkey gravy mix, boxes of oatmeal creme pies, cereal boxes, cereal bowls, and loaves of bread, all without labels or dates. The walk-in refrigerator had a partially used loaf of raisin bread, bags of hamburger buns, shredded purple cabbage, shredded carrots, bags of a yellow substance possibly liquid eggs, packages of ham, packages of chili, and boxes of margarine, all without labels or dates. The freezer contained large packages of meat in a tray with no labels or dates. Interviews with kitchen staff and the Dietary Manager (DM) confirmed that the lack of labeling and dating could result in food not being servable and potentially causing illness to residents. The facility's policy, dated October 2009, mandates that all refrigerated, ready-to-eat foods must be properly covered, labeled, and dated with a use-by date. The policy also states that leftovers must be dated and are only good for three days before they must be discarded. The failure to adhere to these guidelines was evident in the observations made during the survey.
Failure to Submit Direct Care Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit to CMS complete and accurate direct care staffing information for FY Quarter 1 2024 (October 1-December 31). This deficiency was identified based on interview and record review. The CMS PBJ report indicated that the facility did not submit the required staffing data for the specified quarter. During an interview, the Administrator (ADM) stated that IT Corp was responsible for uploading the PBJ data. In a subsequent phone interview, IT Corp admitted that the failure to upload the data was due to human error, as they oversee fifteen buildings and missed this particular facility. The facility's undated staffing policy mandates that direct care staffing information, including agency and contract staff, be submitted to the CMS payroll-based journal system at least once a quarter.
Failure to Provide Engaging Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of residents, as evidenced by observations, record reviews, and interviews. Specifically, the facility did not ensure that three of the seven residents interviewed received adequate notification of activities, nor did it provide activities that met the residents' needs or desires. The Activity Director (AD) was observed engaging in coloring activities with residents, which were not suitable for all participants, particularly one resident who had a contracture from a stroke and could not participate in coloring. Additionally, the activity calendar did not accurately reflect scheduled activities, and the font size was too small for residents to read, further hindering their participation. The bulletin board in the dining room, which could have been used to announce activities, was blank and not utilized. Interviews with residents and staff revealed that the activities provided were not engaging or beneficial, and the AD did not offer a variety of stimulating activities. The Director of Nursing (DON) acknowledged that the AD was responsible for ensuring engaging activities for residents and recognized the potential negative outcomes of not providing such activities. Despite the facility's policy allowing residents to participate in social, religious, and community group activities, the AD primarily offered coloring pages, which were not engaging for all residents. The lack of stimulating activities and inadequate communication about scheduled activities placed residents at risk of boredom and a decline in their quality of life. The facility's failure to provide an appropriate and engaging activity program was evident through multiple observations and interviews, highlighting a significant deficiency in meeting residents' needs and preferences.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. The Activities Director (AD) had been working at the facility for about six months without the necessary certification, as she was waiting for the facility to pay for the classes. The Administrator (ADM), Assistant Director of Nursing (ADON), and Director of Nursing (DON) were all aware of the AD's lack of certification. Interviews with staff indicated concerns that the lack of certification could result in activities that were not beneficial or stimulating for the residents. A review of the AD's personnel file confirmed the absence of any training or certification related to activities. Additionally, a policy regarding certified staff for activities was requested but not provided before the survey exit.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles. During observations, it was found that a medication cart for Hall 300 and part of Hall 200 contained a loose pill, and three insulin medications without open dates. Additionally, three insulin medications in Hall 100 and part of Hall 200 were past their expiration dates. LVN A left two bubble packs of medication unattended on top of the medication cart while administering medications to a resident, and LVN B did not lock her medication cart while going into a resident's room to administer medication. Interviews with LVN B, LVN A, the ADON, and the DON confirmed the potential negative outcomes of these actions, including the risk of drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. The facility's policies on securing medication carts and administering medications were reviewed, revealing that the medication carts must be securely locked at all times when out of the nurse's view, and that expiration dates must be checked prior to administering medications. The facility's failure to adhere to these policies placed residents at risk for adverse reactions and complications.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not performing proper hand hygiene (HH) and glove changes. LVN B did not perform HH before or after donning and doffing gloves while performing blood sugar checks and administering insulin to a resident. Similarly, LVN A did not perform HH before preparing medication for a resident with a gastrotomy tube and failed to clean the bedside table before setting up the medication. Additionally, LVN A did not perform HH during incontinent care or wound care for a resident with a Stage 3 wound to the coccyx. CNA D also failed to perform HH or change gloves after cleaning a resident during incontinent care. During an observation, CNA D cleaned the resident's bottom but did not perform HH or change gloves before touching the clean brief or draw sheet. In another instance, LVN A, while performing incontinent care and wound care for a resident, did not remove gloves or perform HH after cleaning stool from the resident before touching the resident's gown or other items. LVN A only performed HH after removing gloves and before starting wound care, but did not perform HH or change gloves between the dirty and clean portions of the wound care procedure. Interviews with staff, including CNA D, LVN A, the ADON, and the DON, confirmed the lack of proper HH and glove changes during these procedures. The facility's policies on perineal care, wound care, and hand hygiene were reviewed and found to be in place, but not followed by the staff. No policy for medication administration via gastrotomy tube was provided by the facility.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails, and obtain informed consent prior to installation of bed rails with residents or their resident representatives. Specifically, Resident #12 had two one-quarter bed rails installed on both sides of his bed without any documentation of physician orders, consent, or a safety assessment prior to installation. This oversight was identified through observation, interview, and record review, revealing that the facility did not follow its own policy regarding the proper use of side rails, which mandates an assessment, consent, and documentation in the resident's care plan. Resident #12, a male with diagnoses including muscle weakness, vascular dementia, muscle wasting and atrophy, and neuroleptic-induced parkinsonism, was found to have bed rails installed without the necessary procedural steps being followed. The resident's care plan and clinical records lacked any mention of bed rail use, physician orders, or a bed rail safety assessment. Interviews with the ADON, CNA, and DON confirmed that the facility's policy was not adhered to, and they acknowledged the potential risks associated with improper bed rail use. The facility's policy on the proper use of side rails, dated December 2016, was not followed, leading to this deficiency.
Deficiencies in Nursing Competencies and Infection Control
Penalty
Summary
The facility failed to ensure that LVN A used proper techniques when providing wound care, incontinent care, and administering medications via gastrostomy tube. During an observation, LVN A was seen administering medication via a PEG tube to a resident and encountered difficulties because the resident had received a bolus feeding before medication administration. LVN A admitted to not having received training for administering medications via PEG tube at the facility. The DON confirmed that there were no competency checkoffs for gastrostomy tube care and medication administration for LVN A. Further observations revealed that LVN A and CNA E did not follow proper hand hygiene (HH) and glove-changing protocols during incontinent care and wound care for a resident. LVN A failed to change gloves and perform HH after cleaning the resident's stool and before touching the resident's gown and other items. Additionally, LVN A did not change gloves or perform HH between the dirty and clean portions of wound care. Both LVN A and the ADON acknowledged that these lapses could increase the risk of infection for residents. Record reviews showed that LVN A had an annual training but no return demonstration of competency was performed. The facility's policies on medication administration, perineal care, wound care, and hand hygiene were not followed. The BOM confirmed that the facility did not have competency checkoffs for staff, which contributed to the deficiencies observed in the care provided by LVN A.
Significant Medication Error Involving Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically involving the administration of insulin. During an observation of medication administration, an LVN administered insulin to a resident using an insulin pen that belonged to another resident. The LVN confirmed the open date on the insulin pen and administered 10 units of Novolog to the resident. After returning to the medication cart, the LVN realized the insulin pen belonged to another resident. Although there was no adverse reaction since the medication and dosage were correct, the error was significant as it involved the use of another resident's medication. The resident involved was a male with multiple diagnoses, including Type 1 diabetes mellitus, chronic obstructive pulmonary disease, end-stage renal disease, and other chronic conditions. The resident had a moderate cognitive impairment and required assistance with various activities of daily living. The resident's care plan indicated that he was insulin-dependent, and his physician's orders specified a sliding scale for insulin administration. Interviews with the ADON and DON highlighted the potential negative outcomes of such medication errors, including the risk of resident injury and complications. The facility's policies on medication administration and adverse consequences were reviewed, revealing that new personnel should be accompanied by a charge nurse for a minimum of three days to ensure proper procedures are followed. The LVN involved in the incident was on her first day back at the facility after a while, and the error occurred despite the facility's established procedures for medication administration and resident identification.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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