La Hacienda De Paz Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eagle Pass, Texas.
- Location
- 3333 Bob Rogers Dr, Eagle Pass, Texas 78852
- CMS Provider Number
- 676419
- Inspections on file
- 26
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at La Hacienda De Paz Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility did not ensure that residents were seen by a physician at the required intervals, with several residents missing timely in-person physician visits both during the first 90 days after admission and in the ongoing care period. Documentation showed that some residents with complex medical needs and cognitive impairments were not seen as required, and staff interviews revealed a lack of awareness of the correct regulatory schedule for physician visits.
The facility failed to ensure accurate resident assessments, with multiple instances where MDS documentation did not reflect actual skin conditions, medication use, or primary diagnoses. Several residents had discrepancies between their care plans, medication records, and MDS entries, including missing documentation of pain, antiplatelet, and antidepressant medications. Additionally, a resident was incorrectly coded regarding mental illness status and primary diagnosis on the MDS and PASARR screening, despite clear medical records. Staff interviews confirmed these inaccuracies and inconsistent review processes.
A resident with multiple diagnoses and on anticoagulant therapy did not receive all three physician-ordered guaiac stool tests, with only two documented in the medical record. Additionally, new onset bruising was not reported to the physician as required by the care plan and facility policy. The DON confirmed the missing test result and lack of reporting during the survey.
The facility did not ensure that controlled substance reconciliation logs for two medication carts were consistently signed by staff during shift changes, as required by policy. Although medication counts matched records, missing signatures on the logs indicated that the reconciliation process was not fully completed by nursing staff.
Surveyors found a loose, unlabeled pill in one medication cart and observed another cart left unlocked and unattended. Nursing staff and the DON confirmed that all medications should be properly labeled and carts should remain locked when unattended, in accordance with facility policy.
A resident with multiple health conditions and on anticoagulant and aspirin therapy had abnormal lab results indicating low hemoglobin, hematocrit, and red blood cell count. Staff did not promptly notify the physician or document the abnormal findings, and the physician was not made aware until weeks later, resulting in delayed follow-up testing and incomplete collection of ordered stool samples.
Surveyors found multiple opened and undated food items in the nourishment room fridge, including milk, soup, cheese, and meat, with the Dietary Manager unaware of their origin. The nourishment room, accessible to staff and families, is supposed to follow kitchen policies requiring opened food to be dated and properly stored, but these standards were not met.
A nurse failed to follow proper hand hygiene protocols during wound care for a resident with stage 4 pressure ulcers. After washing hands, the nurse touched the privacy curtain and door handle with bare hands before putting on gloves and continuing wound care, contrary to the facility's infection control policy. Both the nurse and DON acknowledged that this could result in contamination.
A resident with multiple serious health conditions and severe cognitive impairment had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order that was not valid due to a missing physician signature. Although the resident's representative requested DNR status and staff documented this in the electronic record, the required physician signature was not obtained, and staff acknowledged the deficiency during interviews. The facility's process for finalizing OOH-DNR orders involved multiple departments and was delayed by physician availability, resulting in the resident's end-of-life wishes not being legally documented.
A resident with severe cognitive impairment and on anticoagulant and antiplatelet therapy developed multiple bruises over several weeks, which were documented by nursing staff but not reported to the physician as required by care plan and facility policy. The DON and the resident's physician confirmed that the physician was not notified of the bruising until much later, despite clear protocols for reporting significant changes in condition.
A resident with severe cognitive impairment and on anticoagulant therapy developed multiple unexplained bruises on her arms and legs over several weeks. Despite documentation of these bruises in weekly skin assessments, staff did not promptly report the findings to the charge nurse, physician, or DON as required by policy. The failure to report and investigate these injuries of unknown source resulted in a deficiency related to timely reporting and investigation of suspected abuse, neglect, or injury.
A resident with severe cognitive impairment and on anticoagulant therapy was found with multiple unexplained bruises on both arms. Staff acknowledged the resident bruised easily and used protective sleeves, but did not complete an incident report or notify the DON or physician as required. The facility did not conduct a thorough investigation or report the incident to the state agency within the mandated timeframe, resulting in a deficiency for failing to respond appropriately to potential abuse or neglect.
A resident with severe cognitive impairment and a history of wandering was not adequately supervised, resulting in a witnessed incident where he sexually abused another cognitively impaired resident. Despite prior behavioral concerns and care plans noting risks, the facility's monitoring measures were insufficient to prevent the abuse.
A staff member misappropriated $891 from a cognitively impaired resident by making unauthorized Cash App withdrawals from the resident's bank card. The incident was discovered when the Business Office Manager found insufficient funds in the resident's account, leading to an internal investigation and police involvement. Staff interviews confirmed awareness of abuse and misappropriation protocols, and no other residents reported similar incidents.
Two residents with significant medical conditions were transported to medical appointments in their wheelchairs across a street, rather than being taken in the facility van as per policy. One experienced pain due to her condition, while the other felt embarrassed and was not given a choice in transportation method. Staff interviews confirmed that residents were not routinely asked for their preferences, and required transportation procedures were not followed.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential risks for missed care. One resident's cardiac pacemaker was not documented, despite being a significant part of his medical history, while another resident's history of falls was omitted. These omissions were due to oversight by a new MDS nurse, highlighting the importance of accurate documentation as emphasized by facility staff and policies.
A resident with a cardiac pacemaker did not receive the required apical pulse monitoring as per their care plan. RN C, responsible for the resident's care, used a machine and cuff for vital signs and was unaware of the pacemaker, despite initialing off on the apical pulse check. The resident confirmed that only the doctor listened to his heart, and the DON acknowledged the importance of apical pulse monitoring for such residents.
A resident with a history of stroke, atrial fibrillation, heart failure, and dysphasia received peri and wound care without proper hand hygiene by CNA D and RN C. Both staff members failed to sanitize their hands between glove changes, risking cross-contamination. The DON confirmed the necessity of hand hygiene to prevent infections.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals as mandated by regulation. Specifically, four residents were not seen by a physician at least once every 30 days for the first 90 days after admission, and ten additional residents were not seen at least once every 60 days thereafter. Documentation reviewed for these residents showed significant lapses in the required physician visits, with some residents only being seen once or not at all within the required timeframes. The medical records for these residents included diagnoses such as pneumonia, diabetes, acute metabolic acidosis, dependence on renal dialysis, heart disease, fractures, osteoporosis, depression, and other chronic conditions. Many of these residents were also noted to have severe or moderate cognitive impairment and were receiving complex medication regimens, including antipsychotics, antidepressants, anticonvulsants, and hypoglycemics. Interviews with facility staff revealed a lack of awareness and understanding of the regulatory requirements for physician visit frequency. The DON confirmed that nurse practitioners were not utilized and that physician assistants assisted only once a week. The Administrator stated that the facility followed a schedule of physician visits every 30 days for new admissions and every 90 days thereafter, which does not align with the regulatory requirement of every 60 days after the first 90 days. The Medical Director also stated he was not aware of the 60-day requirement and believed visits every three months were sufficient. He relied on nursing staff to communicate any patient problems and had not discussed visit frequency with the DON or Administrator. Record review and staff interviews confirmed that the facility did not have a clear policy or consistent practice to ensure compliance with the required physician visit schedule. The documentation provided by the facility often included hospital records or telehealth/telephone visits instead of in-person physician visits, and in some cases, no recent physician visit could be found in the medical record. The lack of timely physician visits was identified for residents with significant medical and cognitive needs, and the surveyors noted that these failures could place residents at risk for medical conditions not being identified and care needs not being met.
Inaccurate Resident Assessments and Medication Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of multiple residents, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation and medication records. For several residents, the MDS assessments did not include accurate information regarding skin conditions, medication usage, and primary diagnoses. For example, one resident's significant change MDS incorrectly documented the presence of unhealed pressure ulcers, despite care plans and physician orders indicating ongoing skin care interventions. Another resident's quarterly MDS omitted documentation of pain and antiplatelet medication, even though these medications were actively prescribed and administered, as shown in the Medication Administration Records (MAR) and care plans. Additional deficiencies were observed in the documentation of antidepressant and antiplatelet medication use for other residents. In one case, a resident's MDS failed to reflect the use of both antidepressant and antiplatelet medications, despite active orders and administration records confirming their use. Similarly, another resident's MDS did not document the use of prescribed antidepressant medications, even though the care plan and MAR indicated regular administration of these drugs. These omissions were confirmed through interviews with the MDS Case Manager and Director of Nursing (DON), who acknowledged the importance of accurate MDS documentation and the expectation that staff use available medical records to complete assessments. The facility also failed to accurately code a resident's primary diagnosis and mental illness status on the MDS and PASARR Level 1 Screening. One resident was incorrectly coded with a primary diagnosis of dementia and no mental illness, despite having a documented diagnosis of bipolar disorder. Interviews with facility staff revealed a lack of clarity regarding the process for verifying and correcting PASARR assessments, as well as uncertainty about the identification of primary versus secondary diagnoses. Facility policies required review of PASARR forms for accuracy prior to admission, but documentation and interviews indicated this process was not consistently followed.
Failure to Complete Ordered Guaiac Tests and Report Bruising per Care Plan
Penalty
Summary
The facility failed to ensure that services provided or arranged, as outlined in the comprehensive care plan, met professional standards of quality for a resident with multiple medical conditions, including sepsis, cognitive decline, atherosclerotic heart disease, and dementia. The resident was on aspirin and anticoagulant therapy, with care plan interventions requiring immediate reporting of bruising and other signs of bleeding to the charge nurse and physician. Despite physician orders for three consecutive days of guaiac (fecal occult blood) testing following abnormal lab results indicating low hemoglobin, hematocrit, and red blood cell count, only two tests were completed and documented. The third required test was not found in the resident's medical records, and facility staff were unable to account for its absence. Additionally, the facility failed to report new onset bruising to the physician as directed in both the physician orders and the care plan. The facility's policy required timely notification and documentation of significant changes in resident status, including changes such as bruising, but there was no evidence that this was done. The Director of Nursing confirmed that only two guaiac test results were available and could not explain the missing third test. These failures were identified through interviews and record reviews conducted by surveyors.
Failure to Complete Controlled Substance Reconciliation Logs at Shift Change
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an account of all controlled drugs was periodically reconciled for two of six medication carts reviewed. During observations of the 500/600 hall PO cart and the 100/200/600 hall PO cart, sample inventories of controlled medications showed no discrepancies between the quantities documented on individual controlled substance logs and the actual number of pills present. However, review of the comprehensive controlled medication reconciliation logs used for cart audits during shift changes revealed missing signatures: two signatures were absent on the 500/600 hall PO cart log, and one signature was missing on the 100/200/600 hall PO cart log. Interviews with nursing staff and facility leadership confirmed the expectation that the controlled substance reconciliation logs should be signed by both the staff member relinquishing and the staff member taking control of the cart at each shift change. The facility's policy requires a physical inventory of all controlled medications at each shift change, conducted by two licensed nurses or a nurse and a qualified medication aide, with documentation on an audit record. The absence of required signatures indicated that the reconciliation process was not consistently followed as outlined in facility policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified two deficiencies related to medication storage and labeling. On the 300/400 hall medication cart, a loose, unlabeled pill was found in the bottom of a drawer during an observation. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the presence of an unlabeled pill meant staff could not identify the medication or determine for which resident it was prescribed. The DON and Administrator both stated their expectations that all medications should be accurately labeled, properly contained, and that there should be no loose pills in the carts. Additionally, the 500/600 hall medication cart was observed to be left unlocked and unattended. Staff interviews confirmed that the cart was assigned to two nurses and that it should never be left unlocked and unattended, as unauthorized individuals, including residents who wander, could access the medications. The DON reiterated that medication carts should always be locked when unattended to prevent unauthorized access. Facility policy also requires that medications and biologicals be stored securely and that medication carts be locked or attended by authorized personnel.
Failure to Promptly Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal laboratory results for one resident. The resident, an elderly female with a history of sepsis, cognitive decline, atherosclerotic heart disease, and dementia, was on anticoagulant and aspirin therapy. Her care plan required immediate reporting of symptoms or lab findings indicating complications from these medications. On 4/10/25, laboratory results showed significantly low hemoglobin, hematocrit, and red blood cell count. Despite these abnormal findings, there was no documentation in the nursing progress notes between 4/10/25 and 4/25/25 indicating that the physician was notified of these results. The physician did not review the abnormal labs or provide further orders until 5/13/25, at which point a guaiac test was ordered. The facility subsequently collected only two of the three required stool samples for this test, and both were negative for occult blood. The Director of Nursing confirmed that staff should have immediately notified the physician of the abnormal labs and documented this action, but was unable to explain the delay in physician review or the incomplete collection of ordered tests. Facility policy required prompt physician notification and documentation for abnormal lab results, which was not followed in this instance.
Undated Opened Food Items Found in Nourishment Room Fridge
Penalty
Summary
Surveyors observed that the nourishment room fridge contained multiple opened food items that were not dated, including a bottle of chocolate milk, containers with soup-like substances, a to-go box, an item wrapped in foil, cheese slices in plastic wrap, and a container of meat. These items appeared to have been previously opened and were not labeled with dates, contrary to facility policy. The Dietary Manager confirmed responsibility only for snacks placed in the fridge by dietary staff, which are labeled and dated daily, but was unaware of the origin or status of the other items found during the inspection. Further interviews revealed that the nourishment room is accessible to all staff and families, with no code required for entry, and is intended for resident use only. The Administrator stated that the nourishment room is subject to the same policies as the kitchen, which require opened food packages to be stored in closed containers or sealed bags and dated when opened. The presence of undated, opened food items in the fridge indicated a failure to follow these professional standards for food storage and safety.
Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
A deficiency occurred when a nurse failed to maintain proper hand hygiene during wound care for a male resident with two stage 4 pressure ulcers. The resident, who had severe cognitive impairment and a history of pressure injuries, required daily wound care as per physician orders. During an observed wound care procedure, the nurse washed her hands in the resident's bathroom but then touched the privacy curtain and door handle with her bare hands before donning gloves and continuing wound care. This sequence of actions was observed twice during the same procedure, once for each wound. The facility's infection control policy required hand hygiene before and after resident care, after contact with potentially contaminated surfaces, and after removing gloves. The nurse did not use hand sanitizer or rewash her hands after touching potentially contaminated surfaces before resuming wound care. Both the nurse and the Director of Nursing acknowledged during interviews that this practice could result in the transfer of germs to the resident, which is inconsistent with the facility's infection control protocols.
Failure to Obtain Physician Signature on OOH-DNR Order
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) order was valid, as the required physician's signature was missing from the form. The resident in question was an elderly male with multiple significant medical conditions, including acute kidney failure, dependence on renal dialysis, hypertension, hyperlipidemia, and heart failure. He was severely cognitively impaired and required regular dialysis treatments. Documentation showed that the resident's representative had requested DNR status, and the facility's records, including the electronic profile and care plan, reflected a DNR order. However, the OOH-DNR form lacked the physician's signature, rendering it invalid according to state requirements. Interviews with facility staff revealed a lack of clarity and consistency in the process for obtaining and finalizing OOH-DNR orders. Nursing staff, the ADON, and the SW all confirmed that the resident was listed as DNR in the electronic record, but upon review, the OOH-DNR form was found to be incomplete due to the missing physician signature. The SW, who was responsible for auditing OOH-DNR forms, acknowledged the deficiency and stated that the facility was still waiting for the physician to sign the document. The DON and other staff described a process in which the OOH-DNR form was initiated at admission, signed by the resident or representative, and then routed through various departments before being presented to the physician for signature. Delays in obtaining the physician's signature were attributed to the physician's availability and the process of delivering the form to the physician's office. Despite the lack of a valid OOH-DNR form, staff indicated that they would honor the family's wishes based on the signed request for DNR status, even though the form was not legally valid without the physician's signature. The Medical Director stated that the OOH-DNR should be signed within 24 hours of the order being entered into the electronic record, and that without the physician's signature, the resident would be considered full code. Facility policy and state guidance both require a properly executed OOH-DNR form, including all necessary signatures, for the order to be valid and honored by health professionals.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, specifically the development of multiple bruises over several weeks. The resident, an elderly female with diagnoses including sepsis, cognitive decline, atherosclerotic heart disease, and dementia, was on anticoagulant and antiplatelet therapy, which increased her risk for bleeding and bruising. Despite care plan and physician orders requiring staff to monitor for and report signs of bruising or bleeding, documentation showed that a nurse recorded the presence of multiple bruises on the resident's arms and legs on three separate weekly skin assessments but did not notify the physician as required. Observations and interviews confirmed that the resident had extensive bruising on both arms, which had been present for about 15 days. The resident was unable to recall the cause of the bruises and was noted to have severe memory impairment. Staff interviews indicated that the resident was known to bruise easily, and protective measures such as geri sleeves were used. However, the nurse responsible for the resident's care acknowledged that she had not communicated the bruising to the physician, despite being aware of the ongoing issue and the care plan's instructions. The Director of Nursing (DON) confirmed that the nurse should have completed an incident report and notified both the DON and the physician about the bruising. The resident's primary physician stated he was not made aware of the recent bruising until notified by the DON, and he indicated that he would have provided different medical orders had he been informed earlier. Facility policy required timely physician notification and documentation of significant changes in resident status, which was not followed in this case.
Failure to Timely Report and Investigate Unexplained Bruising
Penalty
Summary
A resident with a history of sepsis, cognitive decline, atherosclerotic heart disease, and dementia was noted to have multiple bruises on her upper and lower extremities over several weeks. The resident was on anticoagulant and antiplatelet therapy, and her care plan included specific interventions to monitor and report signs of bleeding or bruising. Despite repeated documentation of bruising in weekly skin assessments, there was no evidence that these findings were promptly reported to the charge nurse, physician, or Director of Nursing (DON) as required by facility policy. The resident herself was unable to explain the origin of the bruises, and staff interviews confirmed that the bruising was known but not recently reported to appropriate authorities. Facility policy mandates that injuries of unknown source, especially those that are unexplained by the resident and are suspicious due to their extent or location, must be identified, investigated, and reported to the DON, administrator, state, and/or adult protective services. In this case, the LVN acknowledged not reporting the bruises, and the DON confirmed that an incident report should have been completed and notifications made. The failure to report and investigate the bruising as potential abuse, neglect, or injury of unknown source constitutes a deficiency in timely reporting and investigation as required by regulation and facility policy.
Failure to Investigate and Report Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate and report unexplained bruising found on a resident who was severely cognitively impaired and taking anticoagulant and antiplatelet medications. The resident was observed with multiple dark purplish bruises on both arms, extending from the knuckles to the upper arms, and was unable to explain the cause of the bruising. Staff interviews confirmed that the resident was known to bruise easily, and protective arm sleeves were used as an intervention. However, there was no evidence that an incident report was completed, nor was there documentation of timely notification to the Director of Nursing (DON) or the resident's physician regarding the bruising as required by facility policy. Record reviews showed that the resident had a history of multiple bruises documented during weekly skin assessments, but these findings were not escalated for further investigation. The DON confirmed that staff should have reported the bruising, completed an incident report, and notified the physician. The facility's policy requires that any unexplained injury, especially when the source is unknown or the resident cannot explain it, must be identified, investigated, and reported as a potential case of abuse or neglect. Despite the presence of multiple bruises over time and the resident's inability to provide an explanation, the facility did not initiate a thorough investigation or report the findings to the state survey agency within the required five working days. This lack of action was contrary to both facility policy and regulatory requirements, resulting in a deficiency for failing to respond appropriately to alleged violations of abuse, neglect, or mistreatment.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident who also had significant cognitive and behavioral issues. The incident involved a male resident with diagnoses including dementia, severe cognitive impairment (BIMS score of 5), and a history of wandering into female residents' rooms. Despite being identified as having the potential for physical behaviors related to dementia, the male resident was not adequately supervised, and on the date of the incident, he was found by a CNA in a female resident's room with his hand under her brief, touching her genital area. The female resident was also severely cognitively impaired, unable to consent, and had a history of stroke, aphasia, and hemiplegia. Prior to the incident, the male resident had been observed frequently entering other residents' rooms, particularly those of female residents, under the pretense of looking for his mother or wife. Observation logs indicated that he had been placed on intermittent increased observation at night due to his wandering, but these measures were not sufficient to prevent the incident. The female resident's care plan noted a psychosocial well-being problem related to a previous abuse allegation, but interventions focused on communication and referrals rather than enhanced supervision or protection from other residents. Staff interviews and record reviews confirmed that the facility had provided training on abuse, neglect, and misappropriation of property, and staff were aware of reporting protocols. However, the actions taken to monitor and supervise the male resident were not effective in preventing the abuse of the female resident. The failure to provide adequate supervision and protection resulted in a witnessed incident of nonconsensual sexual contact, constituting a failure to ensure residents' rights to be free from abuse and neglect.
Staff Misappropriation of Resident Funds
Penalty
Summary
A deficiency occurred when a staff member, identified as HSK B, misappropriated funds from a resident with impaired cognitive function. The resident, a female with diagnoses including sepsis, mild cognitive impairment, and Type 2 Diabetes Mellitus, was admitted to the facility and had a BIMS score of 8, indicating impaired cognition. The resident enjoyed ordering food through delivery services, which involved the use of her bank card. On attempting to pay the resident's applied income, the Business Office Manager discovered insufficient funds in the resident's account due to multiple unauthorized Cash App withdrawals made to HSK B. The facility's investigation revealed that the withdrawals were made directly from the resident's bank card, with at least one transaction linked to HSK B's boyfriend, who was not employed at the facility. When confronted, HSK B denied taking the money. The incident was reported to the police, and the case was referred to the Criminal Investigation Division. The police investigation was delayed due to the need for additional documents from the resident, who was reportedly planning to move out of the country. Staff interviews confirmed that employees had received training on abuse, neglect, and misappropriation of resident property, and were aware of the protocols for reporting such incidents. The facility's policy defined misappropriation as the deliberate or wrongful use of a resident's belongings or money without consent. No other residents reported similar issues during subsequent safe surveys and grievance log reviews.
Failure to Ensure Dignified and Respectful Transportation for Residents
Penalty
Summary
The facility failed to treat residents with respect and dignity by not providing appropriate transportation methods for medical appointments, as evidenced by the experiences of two cognitively intact female residents. One resident, who had a history of sepsis, pyogenic arthritis, COPD, and acute pyelonephritis, reported being transported in her wheelchair across a bumpy street to a doctor's office instead of being taken in the facility van. This method of transportation caused her significant knee pain, especially as she was scheduled to receive a knee injection at the appointment. There was no documentation in her medical record explaining why the van was not used for her transport. Another resident, with diagnoses including aftercare following joint replacement, overactive bladder, difficulty walking, anxiety disorder, and Type 2 Diabetes Mellitus, also reported being taken to a doctor's appointment in her wheelchair. She stated that the van driver told her it would be too much trouble to load her into the van for a short trip across the street. This resident expressed feeling embarrassed by being pushed in her wheelchair down the street and indicated she was not given a choice regarding her preferred method of transportation. Interviews with other residents and staff confirmed that transporting residents in wheelchairs across the street was a common practice, and that residents were not routinely asked for their preferences regarding transportation. The facility's policy required that residents be transported in a safe manner by a licensed driver, secured by seat belt in the vehicle, and assisted in and out of the vehicle by trained staff, but these procedures were not followed in the cases described.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks for missed or inaccurate care. Resident #42's quarterly MDS assessment did not reflect the presence of a cardiac pacemaker, despite it being a significant part of his medical history. His comprehensive care plan and active orders indicated the need for daily monitoring of his apical pulse due to the pacemaker, yet this critical information was omitted from the MDS assessment. Interviews with staff revealed that a new MDS nurse, who was still learning, completed the assessment and missed this diagnosis. Resident #84's quarterly MDS assessment failed to document her history of falls since admission. Her comprehensive care plan highlighted her high risk for falls due to limited mobility, impaired vision, and other factors. Despite a fall occurring on 06/04/2024, and her being assessed as high risk for falls, this information was not included in the MDS assessment. The omission was attributed to oversight by the MDS nurse, who acknowledged the need to review falls more thoroughly. Interviews with facility staff, including the ADM, MDS nurses, and the DON, emphasized the importance of accurate MDS assessments as they form the basis of care plans. The facility's policy and the CMS Long-Term Care Facility Resident Assessment Instrument Manual both stress the necessity for assessments to accurately reflect residents' statuses. The inaccuracies in the MDS assessments for Residents #42 and #84 were recognized as potentially leading to missed care, underscoring the critical nature of precise documentation.
Failure to Monitor Apical Pulse for Resident with Pacemaker
Penalty
Summary
The facility failed to ensure that a resident with a cardiac pacemaker received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, RN C did not perform an apical pulse check for the resident as ordered to monitor the function of his cardiac pacemaker. Despite the resident's care plan and active orders specifying the need for daily apical pulse monitoring, RN C admitted to using a machine and cuff for vital signs and was unaware of the resident's pacemaker. This oversight was confirmed during an interview where RN C acknowledged initialing off on the apical pulse check without actually performing it. The resident, who was cognitively intact and able to communicate, confirmed that only the doctor listened to his heart, not the nurses. The Director of Nursing (DON) stated that nurses were trained to take apical pulses and emphasized its importance for residents with pacemakers. However, the deficiency was evident as RN C, despite being signed off as satisfactory in cardiovascular assessment skills, did not follow the prescribed procedure. The facility's policy on permanent pacemakers and apical pulse monitoring was not adhered to, leading to a failure in providing the necessary care for the resident's condition.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of CNA D and RN C during the care of a resident. During peri care, CNA D did not sanitize her hands between glove changes, which was observed at 9:21 a.m. This lapse in protocol was acknowledged by CNA D during an interview, where she admitted that not sanitizing her hands could lead to cross-contamination and potentially result in an infection or hospitalization for the resident. Similarly, RN C was observed performing wound care for the same resident without sanitizing her hands between glove changes. This was noted at 9:45 a.m., and RN C also acknowledged in an interview that she should have sanitized her hands to prevent cross-contamination. The Director of Nursing confirmed that both the nurse and CNA should have followed proper hand hygiene practices to prevent infections. The resident involved had a history of cerebral infarction, chronic atrial fibrillation, heart failure, and dysphasia, and was frequently incontinent of bowel and bladder.
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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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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