Kirkwood Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in New Braunfels, Texas.
- Location
- 2590 Loop 337 N, New Braunfels, Texas 78130
- CMS Provider Number
- 455732
- Inspections on file
- 38
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kirkwood Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple cardiac diagnoses was admitted with a hospital order for cloNIDine 0.1 mg to be taken PO twice daily PRN for HTN, but the facility entered the drug as a scheduled BID medication with hold parameters in the electronic record. The MAR reflected administration of cloNIDine according to the incorrect scheduled order, and the CMA reported giving all prescribed BP medications without awareness that one was intended as PRN. The admitting RN stated she entered the medications after NP approval and later learned the order had been entered incorrectly, while the NP confirmed the drug should have been PRN to allow dosing based on BP and pulse. The DON acknowledged that admitting nurses are expected to validate medication orders with the physician and that inaccurate order entry could lead to a change in condition, despite a facility policy requiring medications to be administered as prescribed by the attending physician.
A nurse administered insulin from an unlabeled pen to a resident with diabetes and severe cognitive impairment. The pen, brought in by the resident's family, was not labeled with the resident's name as required by facility policy. The nurse identified the pen based on the resident's medication regimen but only labeled it after the incident was observed. Facility leadership confirmed that all insulin pens should be labeled and that this was not in accordance with established procedures.
An insulin flex pen used for diabetes management was found on a medication cart without a resident's name label. An LVN assumed the pen belonged to a resident with severe cognitive impairment and administered the medication. Staff interviews confirmed that insulin pens are usually labeled, but in this case, the pen was not, and the facility's policy requiring individual labeling and separate storage was not followed.
The facility failed to maintain a safe and comfortable environment, with water temperatures in shower rooms below the safe range, a hole around an electrical outlet in a resident's room, and broken tiles in a shower room. These issues persisted despite staff awareness and resident complaints, highlighting deficiencies in maintenance and safety protocols.
A LTC facility failed to maintain an effective infection control program, as evidenced by several deficiencies. An LVN did not sanitize hands between glove changes during colostomy care, another LVN failed to wear a gown while administering medications to a resident on Enhanced Barrier Precautions, and a Medication Aide did not clean a blood pressure cuff between uses. Additionally, a washcloth with feces was left in a shower room without proper sanitation. These actions increased the risk of infection among residents.
A facility failed to ensure accurate PASRR Level 1 Screening for a resident with bipolar disorder, as the screening did not indicate a mental illness despite the diagnosis and medication for mania. Staff interviews revealed uncertainty about the PASRR process, and the facility did not verify the accuracy of PASRRs against residents' diagnoses upon admission.
A facility failed to update a resident's care plan to reflect the current order for releasing a seatbelt and harness every 2 hours, instead of every 4 hours. Staff interviews revealed a lack of awareness of the updated order, and the Director of Nursing confirmed the care plan should match the most recent orders to ensure continuity of care.
A resident identified as a fall risk due to dementia and a history of falls was found without a required floor mat on the right side of their bed, as specified in their care plan and physician orders. The oversight was observed during a survey, and interviews revealed that the mat was not placed as required, compromising the resident's safety.
A resident with bowel and bladder incontinence did not receive proper care, as CNA-D failed to separate and clean the labia and did not fully clean a bowel movement, risking urinary tract infections. The resident had multiple health conditions and required assistance for transfers. The facility's perineal care policy was not adhered to, as confirmed by the DON.
The facility failed to provide appropriate respiratory care for two residents. One resident's oxygen tubing was not changed weekly as ordered, and another resident's nasal cannula and Bi-pap mask were left uncovered, risking infection. Interviews confirmed these practices did not align with physician orders or infection control standards.
A facility failed to discard an insulin Lispro pen 28 days after opening, as required by policy, for a resident with diabetes. The pen, opened on January 10, was still in use on February 19, despite the facility's policy to discard opened vials without an open date. This oversight was confirmed by the ADON and LVN, who acknowledged the potential for reduced medication effectiveness.
The facility failed to lock a medication cart on the 400-hall, leaving it unattended and accessible, and did not properly label a resident's insulin pen, which lacked an open date. The unlocked cart contained various medications, posing a risk of unauthorized access. The resident, with a history of diabetes and other conditions, was receiving daily insulin injections, but the LVN was unsure about discarding the undated insulin pen.
A facility failed to implement a policy for the use and storage of foods brought by visitors, leading to a deficiency. A resident's personal refrigerator contained an unlabeled and undated cup of hot sauce, which was supposed to be monitored daily by facility nurses. The resident had severe cognitive impairment and multiple health issues. The facility's policy required monitoring and education on safe food handling, which was not effectively enacted.
A resident missed three doses of Anastrozole due to the facility's failure to reorder the medication in a timely manner. The oversight was discovered during the resident's discharge process, revealing that the medication was unavailable for three consecutive days. The involved LVN did not report the issue, and the facility's medical director confirmed that the missed doses did not adversely affect the resident's condition.
The facility failed to ensure a resident received treatment and care according to professional standards and the care plan. Staff did not document vital signs before administering digoxin, failed to administer midodrine as ordered, and did not properly assess the resident's ongoing nausea. The resident was eventually discharged to the hospital and expired in the emergency room.
A resident with multiple diagnoses did not receive digoxin and midodrine as prescribed, leading to significant medication errors. The facility staff failed to hold digoxin per physician's parameters and did not administer midodrine when the resident's SBP was below 100, as required.
A facility failed to document vital signs before administering digoxin and midodrine for a resident with complex medical conditions. This lack of documentation occurred over multiple days, leading to incomplete medical records and potential risks for the resident.
Incorrect Entry and Administration of PRN Antihypertensive Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate order entry and administration of medications for a resident with essential hypertension, heart failure, and atrial fibrillation. The resident, who had severe cognitive impairment with a BIMS score of 6/15, was admitted with hospital discharge paperwork indicating cloNIDine 0.1 mg to be taken by mouth twice daily as needed (PRN) for hypertension. However, the facility’s Order Summary Report listed cloNIDine HCl 0.1 mg as a scheduled medication to be given twice daily with specific hold parameters for blood pressure and pulse. The March MAR showed that cloNIDine HCl was administered on one date when the resident’s blood pressure was 142/52 and pulse 58. During interviews, the CMA who administered the medication stated she gave all prescribed blood pressure medications as ordered and was not aware of a PRN blood pressure medication or any parameters on the order. The RN who admitted the resident reported that she sent the hospital medication list to the NP for approval and then entered the approved medications into the electronic record, later learning that one medication had been entered incorrectly as scheduled instead of PRN. The NP confirmed that cloNIDine HCl should have been ordered as PRN to allow it to be held or staggered based on blood pressure and pulse readings. The DON stated that the admitting nurse should validate medication orders with the physician and acknowledged that inaccurate order entry could result in a resident having a change in condition. The facility’s medication administration policy stated that medications shall be administered as prescribed by the attending physician.
Unlabeled Insulin Pen Administered to Resident
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered insulin to a resident using an insulin pen that was not labeled with the resident's name. The insulin pen, which was for Aspart 100 units/mL, was found on the medication tray with an open date but no identifying label. The LVN stated she usually labels insulin pens but did not know why this one was not labeled. She identified the pen as belonging to the resident because the resident was the only one on the hall using that type of insulin. The Director of Nursing (DON) confirmed that insulin pens are required to be labeled and that the pen should not have been on the medication cart without a name. The Assistant Director of Nursing (ADON) indicated that insulin pens are logged and accounted for upon arrival, but in this case, the family had brought in the insulin and labeling was missed. The resident involved had multiple diagnoses, including cerebral palsy, type 2 diabetes mellitus, mild intellectual disabilities, and anxiety, and was severely cognitively impaired, requiring staff assistance for activities of daily living and daily insulin injections. The facility's policy and the LVN's training both required adherence to the six or seven rights of medication administration, including verifying the correct resident and medication. Despite this, the insulin was administered from an unlabeled pen, which was only labeled after the deficiency was observed.
Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
A deficiency occurred when an insulin flex pen (Aspart) used for diabetes management was found on a medication cart without a resident's name labeled on it. The pen was assumed by an LVN to belong to a specific resident, who was a female with cerebral palsy, type 2 diabetes mellitus, mild intellectual disabilities, and severe cognitive impairment. The resident was dependent on staff for activities of daily living and received daily insulin injections as per physician's orders. The insulin pen was observed on the medication tray with an open date but lacked the required resident identification label. Interviews with staff revealed that the insulin pens were typically labeled with the resident's name, but in this instance, the pen was not labeled, and the staff could not explain how it ended up on the cart without proper identification. The Director of Nursing and other staff acknowledged that the pen should have been labeled and that it was not safe to have an unlabeled medication on the cart. Facility policy required medications to be labeled for individual residents and stored separately from floor stock, but this protocol was not followed in this case.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for its residents, as evidenced by several deficiencies observed during the survey. The water temperature in the 600 E and W shower rooms was found to be below the safe range of 100 to 110 degrees Fahrenheit, with temperatures recorded at 95.5 and 97.1 degrees, respectively. This issue persisted despite previous complaints from residents, including one who expressed dissatisfaction with the lukewarm water and the inability to take a hot shower. The Assistant Director of Nursing (ADON) and the Administrator confirmed the water temperature issues, and it was noted that the problem had been ongoing for several weeks, affecting multiple residents. Additionally, a safety hazard was identified in Resident #68's room, where a long hole was found around an electrical outlet beside the resident's bed. Although the resident was unaware of the hole, it posed a potential electrical danger. The Licensed Vocational Nurse (LVN) acknowledged the risk, and the Administrator admitted that the facility was unaware of the issue until it was pointed out. The facility's policy emphasized maintaining a safe environment, yet this hazard had not been addressed. Furthermore, broken tiles were observed in the 600 E shower room, which had been present for months. Staff members, including a Certified Nursing Assistant (CNA) and an LVN, were aware of the broken tiles but had not reported them to maintenance. The Maintenance Supervisor (MS) was also aware of the issue but had not prioritized its repair, considering it part of a future renovation plan. The facility's maintenance policy required work orders for repairs, but no such orders had been submitted for the broken tiles, which posed a risk of skin injuries to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several observed deficiencies. One incident involved a Licensed Vocational Nurse (LVN-C) providing colostomy care to a resident without sanitizing or washing her hands between glove changes. This resident, who had intact cognition and a history of paraplegia and other medical conditions, was at risk of infection due to the improper hand hygiene practices of the nurse. The Director of Nursing (DON) confirmed that the nurse should have sanitized or washed her hands to prevent possible infection. Another deficiency was observed when an LVN (LVN-A) entered the room of a resident on Enhanced Barrier Precautions (EBP) and administered medications via a gastrostomy tube without wearing a gown. The resident had severe cognitive impairment and required tube feeding due to dysphagia. Despite the presence of a sign indicating the need for gloves and a gown during high-contact care activities, the LVN failed to comply, increasing the risk of infection. The DON acknowledged that the LVN should have worn a gown as per the EBP guidelines. Additionally, a Medication Aide (Medication Aide-I) failed to clean a blood pressure cuff before using it on another resident, which could lead to cross-contamination. The resident, who had intact cognition and a history of atrial fibrillation, was at risk due to the aide's oversight. Furthermore, a washcloth with feces was left in a shower room, and the area was not sanitized, posing a risk of infection transmission. The Assistant Director of Nursing (ADON) and DON both recognized the need for proper handling and sanitation of soiled linens and shower areas to prevent infection spread.
Inaccurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure the accuracy of the PASRR Level 1 Screening for a resident diagnosed with bipolar disorder. The resident's PASRR Level 1 Screening did not indicate the presence of a mental illness, despite the resident having a diagnosis of bipolar disorder and being prescribed risperdal for mania. This oversight meant that the resident was not screened again for possible services, which could impact the resident's ability to receive necessary services to maintain their highest functional ability. Interviews with facility staff revealed a lack of clarity and understanding regarding the PASRR process for residents with mental illness. The Social Worker, Administrator, and Admissions Coordinator all expressed uncertainty about whether residents with mental illness should be screened for PASRR services. The Admissions Coordinator admitted that the facility did not verify the accuracy of PASRRs against residents' diagnoses upon admission. This lack of verification and understanding contributed to the deficiency in ensuring that residents with mental illness were appropriately screened and referred for necessary services.
Failure to Update Care Plan for Resident's Restraint Schedule
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team to reflect the current orders. Specifically, the care plan did not reflect the updated order to release the resident's seatbelt and harness every 2 hours for 10 minutes, as opposed to the previous order of every 4 hours. This discrepancy was identified during a review of the resident's records, which showed that the order to release the seatbelt and harness every 2 hours was dated 01/09/2025, but the care plan printed on 02/20/2025 still stated every 4 hours. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), and the Director of Nursing (DON), revealed a lack of awareness regarding the current order for the seatbelt and harness release schedule. The LVN and CNA were not aware of the specific frequency required by the order, and the DON acknowledged that the care plan should reflect the most recent orders to ensure continuity of care. The facility's policy on comprehensive person-centered care planning requires that the care plan be reviewed and revised by the interdisciplinary team after each assessment, but this was not adhered to in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Specifically, nursing staff did not place a floor mat on the right side of a resident's bed, which was intended as a preventative device to reduce the risk of falls. This oversight was observed during a survey, where it was noted that the resident, who was identified as a fall risk, was lying in bed without the required floor mat in place. The resident in question had been admitted with a diagnosis of unspecified dementia and was assessed as a high risk for falls due to disorientation and a history of falls. The care plan and physician orders specified the use of a floor mat as an intervention to minimize injury risk. However, during interviews, it was revealed that the mat was not placed as required, and the Director of Nursing acknowledged the importance of using the mat to maintain resident safety. The lack of adherence to the care plan and physician orders contributed to the deficiency.
Inadequate Incontinence Care Poses Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a potential risk of urinary tract infections. During an observation, CNA-D did not separate the resident's labia or clean the base of her labia while providing incontinence care. Additionally, CNA-D did not completely clean the resident's bowel movement, which was observed by a state surveyor who requested further cleaning. The CNA-D admitted to being nervous and forgetting to separate the labia, which resulted in incomplete cleaning. The resident involved was an elderly female with a history of atherosclerotic heart disease, transient ischemic attack, hypertension, pulmonary fibrosis, and gastroesophageal reflux disease. Her quarterly MDS indicated intact cognition and consistent bowel and bladder incontinence, requiring partial assistance for transfers. The facility's policy on perineal care, which emphasizes thorough cleaning to prevent infection, was not followed, as confirmed by the Director of Nursing. This oversight could lead to cross-contamination and increased risk of urinary tract infections.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in following physician orders and maintaining infection control standards. Resident #70, a female with a history of pulmonary fibrosis and other health conditions, had a physician's order to change her oxygen tubing and humidifier bottle every Wednesday night shift. However, observations revealed that the tubing was not changed as per the order, with the last change dated 02/03/2025. Interviews with the LVN and DON confirmed that the tubing should have been changed weekly to prevent possible respiratory infections, but the order was not followed. Resident #52, a female with chronic respiratory failure and other diagnoses, was observed to have her nasal cannula and Bi-pap mask left uncovered when not in use. The facility lacked a specific policy for covering these items, which could lead to potential infections. Interviews with the LVN and DON confirmed that the nasal cannula and mask should have been covered in plastic bags when not in use to prevent infections. The facility's policy on oxygen therapy did not address this specific issue, contributing to the deficiency.
Failure to Discard Insulin Pen After 28 Days
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the management of insulin medication. The resident, a female with a history of anemia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, and muscle wasting, was receiving insulin injections as per a sliding scale order. However, the insulin Lispro pen, which was opened on January 10, 2025, was not discarded after the required 28 days, as it was still found in use on February 19, 2025. This oversight was confirmed through observation and interviews with the Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN), who acknowledged the error and the potential for reduced effectiveness of the medication. The facility's policy on medication access and storage mandates that any opened vial without an open date should be discarded immediately. Despite this policy, the insulin pen was not discarded as required, and the Director of Nursing (DON) confirmed that the nurses should have documented the open date to ensure timely disposal. The failure to adhere to these procedures could lead to inaccurate drug administration and inadequate therapeutic effects for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an unlocked and unattended medication cart on the 400-hall. During an observation, the 400-hall medication aide cart was found unlocked and unattended while the Medication Aide was passing medications. This allowed access to multiple medication blister packs, scissors, and bottles of medications. The Medication Aide admitted to not realizing the cart was left unlocked and acknowledged the importance of keeping it locked for the safety of residents, visitors, and staff. The Director of Nursing (DON) confirmed that the cart should not have been left unlocked, as it posed a risk of unauthorized access to medications. Additionally, the facility failed to properly label and store Resident #83's insulin flex pen (NovoLog) for diabetes. The insulin pen was found inside the 200-hall nursing cart without an open date, contrary to the facility's policy that requires opened and undated insulin to be discarded. Resident #83, a male with a history of cerebral infarction, type 2 diabetes mellitus, hemiplegia, hypertension, and muscle wasting, was receiving daily insulin injections. The Licensed Vocational Nurse (LVN) was unaware of when the insulin pen was opened and expressed uncertainty about whether it should be discarded due to the lack of an open date. This oversight could lead to the use of expired insulin, potentially affecting the resident's diabetes management.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, which resulted in a deficiency. Specifically, a personal refrigerator in a resident's room contained a small plastic cup with red-colored food, identified as hot sauce, that was neither dated nor labeled. This oversight was observed during a survey, and it was noted that the facility nurses were supposed to check the refrigerator daily, but this was not done. The resident involved was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 0 out of 15. She had multiple diagnoses, including Parkinsonism, urinary tract infection, hypertension, muscle wasting, and gastroesophageal reflux disease. The facility's policy required that food brought from outside sources be monitored for safety, and that residents and individuals bringing food be educated on safe food handling and storage. However, this policy was not effectively enacted, as evidenced by the lack of labeling and dating of the food item in the resident's refrigerator.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident undergoing chemo treatment. The resident, a female with a history of type 2 diabetes mellitus, atrial fibrillation, heart failure, chronic kidney disease stage 3, and hemiplegia, missed three doses of Anastrozole due to the medication not being reordered in a timely manner. This lapse occurred over three consecutive days, during which the medication was unavailable. The deficiency was identified when the Director of Nursing (DON) discovered the missed doses during the resident's discharge process. The resident's Medication Administration Record indicated that the Anastrozole was not administered because it was not available. The facility's Medication Error Report confirmed the oversight, noting that the medication was not reordered in advance as required by the facility's policy. Interviews with the involved staff revealed that the Licensed Vocational Nurse (LVN) responsible for administering the medication did not recall the specific reason for the oversight, as it occurred nearly a year prior. The LVN, who was an agency nurse, failed to report the unavailability of the medication to the DON or Assistant Director of Nursing (ADON). The facility's medical director confirmed that the missed doses did not adversely affect the resident's condition, as the medication was intended for prophylactic purposes.
Failure to Administer Medications and Assess Change of Condition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The staff administered digoxin to the resident without documenting the required blood pressure and pulse readings for 23 days and failed to hold the medication as ordered on two specific dates. Additionally, the staff did not administer midodrine as ordered when the resident's systolic blood pressure was below 100 on five instances. These actions were not in line with the physician's orders and the resident's care plan, leading to a lack of proper monitoring and medication administration. The facility staff also failed to assess the resident for a change of condition related to continued complaints of nausea over several days. Despite the resident's ongoing symptoms, there was insufficient documentation and assessment of the resident's condition. The resident was eventually discharged to the hospital by EMS and expired in the emergency room. The lack of timely and appropriate assessment and intervention contributed to the resident's deteriorating condition. The deficiencies in care included not documenting vital signs before administering medications with specific parameters, not administering medications as ordered, and failing to properly assess and respond to changes in the resident's condition. These failures placed the resident at risk of critically low pulse and blood pressure, inadequate blood flow, missed signs and symptoms of illness, hospitalization, and death.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was reviewed for medication errors. The staff did not hold the resident's digoxin medication as per the physician's ordered parameters on two occasions. Additionally, the staff failed to administer midodrine as ordered on five separate instances when the resident's systolic blood pressure (SBP) was below 100. These failures were identified through interviews and record reviews, which showed discrepancies between the physician's orders and the actual administration of medications as documented in the electronic medical records (EMAR) and electronic health records (EHR). The resident involved had multiple diagnoses, including heart failure, atrial fibrillation, atherosclerotic heart disease, and acute kidney failure. The resident's care plan included specific instructions for digoxin therapy and the administration of midodrine for low blood pressure. Despite these instructions, the facility's staff did not adhere to the prescribed medication administration guidelines, leading to potential risks for the resident. The facility's policy on medication administration, which mandates that medications be given as prescribed by the physician, was not followed in these instances.
Failure to Document Vital Signs for Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident, specifically regarding the administration of digoxin and midodrine. The staff did not document blood pressure and pulse readings before or after administering digoxin, which had specific parameters to hold the medication if the readings were outside the set limits. This lack of documentation occurred over multiple days in February and March, leading to incomplete medical records for the resident. Additionally, the staff failed to document blood pressure readings every 8 hours as required for the administration of midodrine, a medication used to treat low blood pressure, throughout February and part of March. The resident involved had a complex medical history, including osteomyelitis, atrial fibrillation, atherosclerotic heart disease, and acute kidney failure. The resident's care plan included specific interventions for digoxin therapy and monitoring of an indwelling Foley catheter. Despite these detailed care plans, the facility's electronic medical records (EMAR) and electronic health records (EHR) showed significant gaps in the required documentation of vital signs, which are crucial for the safe administration of the prescribed medications. Interviews with the Director of Nursing (DON) and other staff members revealed that the facility was aware of the documentation issues and had started in-service training to address them. However, the DON was still investigating how the vital sign entry was dropped from the MAR. The physician acknowledged that while it would be ideal to have the vital signs documented as ordered, the lack of documentation did not contribute to the resident's hospitalization. The facility's policy on medication administration emphasized the importance of following the physician's orders and the resident's service plan, which was not adhered to in this case.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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