Lakewest Rehabilitation And Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 2450 Bickers St, Dallas, Texas 75212
- CMS Provider Number
- 676276
- Inspections on file
- 44
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Lakewest Rehabilitation And Skilled Care during CMS and state inspections, most recent first.
The facility failed to ensure call lights were accessible for four residents with conditions including muscle weakness, lack of coordination, paralysis, unsteadiness, and moderate cognitive impairment. Each resident’s comprehensive care plan included interventions related to using the call light, yet observations found call lights on the floor or hanging on lower bed rails, out of residents’ reach, while they were in bed and in need of assistance. Residents reported not knowing where their call lights were when they wanted help, and staff, including CNAs, an LVN, the Unit Manager, the ADON, and the DON, acknowledged that call lights should be within reach in accordance with facility policy requiring accessible call systems at bedside.
A resident with acute respiratory failure and intact cognition had physician orders for BiPAP therapy with supplemental O2 at bedtime, but the comprehensive care plan did not include any plan of care for BiPAP use. Review of records and staff interviews showed that the BiPAP device was coded and ordered, yet not incorporated into the care plan despite facility policy requiring all services identified in the comprehensive assessment to be care planned with measurable objectives and timeframes. Multiple staff, including the unit manager, ADON, MDS nurse, and DON, acknowledged that BiPAP use should have been care planned and described differing role expectations for who was responsible for updating the care plan.
A resident with acute respiratory failure, receiving BiPAP with supplemental O2 and scheduled Ipratropium-Albuterol nebulizer treatments, was found with both the BiPAP and nebulizer masks left unbagged on a nightstand when not in use. An LVN, the unit manager, ADON, and DON all acknowledged that respiratory delivery devices should be bagged when not in use to avoid infection, and the facility’s oxygen administration policy required keeping such devices covered in an antimicrobial bag, which was not done.
A resident with intact cognition and a history of major depressive disorder and generalized anxiety disorder reported receiving Amazon packages that had already been opened. The Business Office Manager stated she routinely opened and retained residents’ bank and insurance mail instead of giving it to them, and opened all mail for cognitively impaired residents, including personal cards and gift cards. The Receptionist reported that she brought resident packages to the assigned nurse, who would feel soft packages and open boxed packages to check contents before allowing delivery. The DON stated nursing was not responsible for handling resident mail and was unaware of any policy requiring such checks, while the Administrator stated residents’ mail and packages should not be opened before delivery, although the facility’s communication policy did not address residents’ rights to receive closed mail.
The facility did not coordinate assessments with the PASRR program and failed to refer a resident for necessary services, resulting in noncompliance with assessment and referral requirements.
A resident with multiple complex medical conditions was found with several pills left unattended on her tray table after a medication pass. The medication aide did not observe the resident taking all her prescribed medications and left the room, contrary to facility policy requiring direct observation. This resulted in medications being left unsecured and unconsumed in the resident's room.
A resident with multiple chronic conditions was readmitted after a hospital stay, but the facility failed to accurately transcribe and administer medication changes as ordered by the hospital. The resident received incorrect dosages and frequencies of several medications, and staff interviews revealed breakdowns in communication and adherence to procedures for updating and verifying medication orders.
Several residents at risk for pressure ulcers did not receive proper care when their pressure-relieving mattresses were either not functioning correctly or not set to the appropriate weight. Staff were observed to lack understanding of mattress settings, and required checks were not consistently performed, resulting in improper use of pressure reduction devices as ordered in care plans and physician directives.
Staff members, including a CNA, CMA, and housekeeper, entered a resident's room under contact isolation for suspected C. diff without wearing required PPE, despite posted signage and physician orders. The resident had a history of limb amputation and was awaiting C. diff test results. Staff interviews revealed gaps in awareness and understanding of infection control protocols, resulting in non-compliance with established precautions.
A resident with a history of limb amputation and respiratory risk factors did not receive appropriate respiratory care due to a malfunctioning oxygen concentrator that was not promptly identified or replaced by staff. Despite care plan and physician orders for oxygen therapy, the resident's equipment continuously signaled low oxygen and service needs, and staff failed to ensure the device was functioning as required by facility policy and manufacturer instructions.
The facility did not maintain an effective pest control program, resulting in ongoing issues with roaches and water bugs in resident rooms and bathrooms on one hall. Multiple residents and staff reported frequent sightings of pests, and surveyors observed live and dead bugs as well as structural openings that allowed pest entry. Facility records showed repeated pest incidents and treatments, but the problem persisted due to gaps in cleaning, maintenance, and pest control follow-up.
A CMA physically and verbally abused a male resident with multiple medical conditions by throwing water on him and using profanity during a confrontation over medication refusal. The resident, who was cognitively intact but unsteady, became upset and attempted to pursue the CMA, resulting in a chaotic scene that required staff and a family member to intervene. Witnesses confirmed the staff member's aggressive actions and the escalation of the incident.
The facility failed to maintain food safety standards by not sealing food items properly, not taking temperatures of certain foods before serving, and not ensuring staff wore effective hair restraints during meal service. These deficiencies were observed in the kitchen, with staff acknowledging the oversights and the potential risks of contamination.
The facility failed to provide adequate personal hygiene and ADL care for four residents, leading to issues such as untrimmed and dirty fingernails and missed showers. A resident with severe cognitive impairment had long, discolored nails, while another lacked tools to trim his own. A cognitively intact resident missed a scheduled shower due to a staff oversight, and another resident was found with suspected feces around his nails, with staff failing to report care refusals. These deficiencies highlight lapses in care delivery and communication.
The facility failed to ensure proper handling of medications on three medication carts, as medications in unsecure blister packs were found. Staff responsible for these carts did not identify broken blister seals during shift change counts, posing a risk for drug diversion. The ADON confirmed that broken blister pack medications should be discarded, but staff failed to adhere to this policy.
The facility failed to maintain infection control protocols, as a CNA did not perform hand hygiene between glove changes during incontinence care for a resident, and an LVN and another CNA did not wear appropriate PPE during wound care for a resident under enhanced barrier precautions. These lapses could expose residents to infections.
A resident with limited mobility and a history of diabetes and dementia did not receive consistent foot care, resulting in dry, flaky skin. Despite the facility's policy on maintaining foot health, staff interviews revealed that foot care was sporadic, with CNAs responsible for cleaning and moisturizing feet under nursing supervision. This deficiency highlights a lapse in adhering to professional standards of practice.
A resident with cognitive impairment and swallowing difficulties did not receive sufficient fluids, as staff failed to provide water until later in the day. The resident expressed thirst, and staff interviews confirmed the delay in water distribution, contrary to the facility's hydration policy.
The facility failed to serve a lunch meal at an appetizing temperature, with a cold hamburger and undercooked vegetables. Residents had previously complained about improperly cooked food. Dietary staff acknowledged the importance of checking food temperatures to prevent foodborne illness, and the Resident Council had noted concerns about food temperature.
A resident requiring oxygen therapy did not receive proper respiratory care due to the facility's failure to label and date the oxygen humidity bottle and nasal cannula. Despite having a care plan for shortness of breath, the equipment was found unlabeled during an observation. Interviews revealed that the facility's practice was to change and date supplies weekly, but this was not followed, leading to a deficiency in care.
The facility failed to implement its abuse prevention policy in two incidents involving residents. In one case, a CNA observed a male resident touching a female resident's shoulder, but no investigation or documentation followed. In another case, a CNA witnessed a male resident hitting another with a cane, yet no assessment or documentation was conducted. The facility's policy requires immediate reporting and investigation, which was not adhered to, potentially placing all residents at risk.
The facility failed to investigate two alleged abuse incidents involving residents, as required by its abuse policy. In one case, a CNA reported a resident touching another resident's shoulder, but no investigation or documentation followed. In another case, a CNA witnessed a resident hitting another resident with a cane, but again, no investigation or documentation occurred. The facility's policy mandates immediate investigation and documentation of such incidents, but these steps were not taken, potentially placing residents at risk.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call light systems were accessible to four residents reviewed for resident rights. For a female resident with muscle weakness, moderate cognitive impairment, and identified as a fall risk, the comprehensive care plan required that her call light be within reach. On observation, she was lying in bed with her call light found on the floor under the bed, contrary to her care plan and the facility’s call light accessibility policy. A second female resident with a history of stroke and paralysis of the left side, who had intact cognition and required assistance with self-care and mobility, had a care plan intervention to encourage use of the call light. During observation, she was in bed with her call light hanging on the lower portion of the left side rail, out of her reach, and she stated she was trying to get staff to help reposition her but did not know where her call light was. A male resident with lack of coordination, muscle weakness, unsteadiness on his feet, moderate cognitive impairment, and requiring assistance with self-care and mobility also had a care plan intervention to encourage use of the call light. He was observed in bed with his call light hanging on the lower portion of the left side rail, out of reach, and he stated he did not know where his call light was and wanted it to contact staff. Another male resident with lack of coordination, muscle weakness, moderate cognitive impairment, and a need for assistance with personal care and mobility had a care plan intervention to encourage use of the call light. He was observed lying in bed, stating he did not know where his call light was, and the call touch pad was found on the floor out of his reach. Multiple staff members, including CNAs, an LVN, the Unit Manager, the ADON, and the DON, acknowledged during interviews that call lights should be within reach of residents and that it was everyone’s responsibility to ensure this, and the facility’s written policy specified that the call system must be accessible to residents while in bed or other sleeping accommodations.
Failure to Care Plan BiPAP Use for Resident With Acute Respiratory Failure
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident using a BiPAP device. Record review showed that a male resident with a diagnosis of acute respiratory failure was admitted to the facility and had an intact cognitive status per a Quarterly MDS Assessment. The resident’s physician orders, dated after admission, specified BiPAP settings of 20/8 with 2L O2 at bedtime. However, review of the resident’s Comprehensive Care Plan revealed no care plan addressing the use of the BiPAP device, despite the resident’s respiratory diagnosis and active treatment order. During interviews, multiple staff members acknowledged that the resident’s BiPAP use should have been included in the care plan. The Unit Manager stated the BiPAP should have been care planned but reported she was not responsible for updating care plans. The ADON stated that the MDS nurse, ADON, DON, and Treatment Nurse updated care plans and confirmed that BiPAP use should be care planned so treatment could be monitored. The MDS nurse acknowledged that since the device was coded on her end, she should have updated the care plan and noted that failure to do so could place the resident in respiratory distress. The DON stated that BiPAP use should be care planned as a special device and explained that if the resident arrived with the device, the MDS nurse should update the care plan, and if new orders were obtained in-house, it was the responsibility of the DON and ADON. The facility’s written policy on Comprehensive Care Plans required inclusion of measurable objectives and timeframes for all services identified in the comprehensive assessment, which was not followed in this case.
Improper Storage of Respiratory Masks for Resident on BiPAP and Nebulizer
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice and its own policy for a resident requiring BiPAP and nebulizer treatments. The resident was an adult male with a diagnosis of acute respiratory failure, admitted in February and assessed as cognitively intact on a recent Quarterly MDS, with an active diagnosis of acute respiratory failure. Physician orders in early March included BiPAP settings of 20/8 with 2L O2 at bedtime and Ipratropium-Albuterol inhalation solution every six hours. On the morning of 03/05/26, a surveyor observed the resident’s BiPAP mask and nebulizer mask lying unbagged on top of the nightstand when not in use. When shown the equipment, an LVN stated the masks should be bagged when not in use to avoid infection. The Unit Manager, ADON, and DON each acknowledged in separate interviews that the masks should have been bagged when not in use to avoid infections and that staff, including charge nurses and department heads, were responsible for ensuring respiratory delivery devices were bagged and dated. The facility’s written Oxygen Administration policy, revised 01/2025, specified that oxygen delivery devices are to be kept covered in an antimicrobial bag when not in use, which was not followed in this instance.
Failure to Protect Resident Privacy and Rights Related to Mail and Packages
Penalty
Summary
The facility failed to ensure residents’ rights to send and receive unopened mail and packages, including privacy of such communications, for one resident reviewed for resident rights. Resident #65, a cognitively intact [AGE]-year-old female with major depressive disorder and generalized anxiety disorder, reported that her Amazon packages had been received already opened, with the most recent occurrence around December 2025. Her face sheet and MDS showed an original admission in 2021, a recent readmission in 2025, and a BIMs score of 15, indicating intact cognition. The Business Office Manager stated that when resident mail was received, it was passed out to residents, but she routinely opened mail related to medical insurance claims and bank statements for all residents, scanned it, and filed it in residents’ electronic and physical files instead of giving it to them. She also reported opening all mail for cognitively impaired residents, including birthday cards and gift cards, before giving it to them, and acknowledged that she was unaware of the policy on delivering packages. The Receptionist reported that she received Amazon packages and other mail at the front desk and, before delivering packages to residents, showed them to the assigned nurse; if the package was a soft envelope, the nurse would feel it to determine if it could be given, and if it was a box, the nurse would open it to check for medications or items the resident could not have before delivery. The DON stated nursing was not responsible for resident mail or packages and was unaware of any policy requiring nursing to check them, and acknowledged that staff opening residents’ mail and packages affected residents’ privacy rights. The Administrator stated that mail should be sorted and given to residents unopened, including Amazon packages, and that there was no reason for staff to open residents’ mail, but the facility’s written communication policy did not address residents’ rights to receive closed mail.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Medications Left Unsecured and Unconsumed in Resident Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access, as required by professional standards. During observation, a resident was found in her room with two cups containing a total of seven pills left on her tray table, along with a nutritional supplement. The resident stated that staff usually waited with her to ensure she swallowed her medication, but on this occasion, the medication aide left the pills and supplement in the room and departed. The medications had been left there since the morning, and the resident was unsure of what all the pills were. Record review showed that the resident had multiple diagnoses, including paraplegia, diabetes, osteomyelitis, cognitive communication deficit, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, pruritis, and hypertension. The medication administration record indicated that all morning medications were marked as given by the medication aide. Interviews with the DON and the medication aide confirmed that the aide did not observe the resident taking all her medications, contrary to facility policy, which requires direct observation of medication consumption. This lapse resulted in medications being left unsecured and unconsumed in the resident's room.
Failure to Accurately Transcribe and Administer Medications After Hospital Readmission
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not correctly transcribing medication changes for a resident who was readmitted after a hospital stay. Upon the resident's return, the admitting nurse was responsible for entering the new medication orders into the electronic medical record (EMR) and ensuring they matched the hospital discharge instructions. However, the review of records showed discrepancies between the hospital discharge orders and the facility's active physician orders and medication administration records (MAR). Specifically, the dosages and administration frequencies for medications such as Bisacodyl, Buspirone, and Hydroxyzine were not accurately transcribed, resulting in the resident receiving incorrect medication regimens for an extended period. The resident involved had a history of chronic obstructive pulmonary disease with acute exacerbation, respiratory failure with hypoxia, constipation, pain, insomnia, and anxiety disorder. The resident was cognitively intact and able to communicate concerns about the medication regimen, reporting that the volume and timing of medications made him excessively sleepy and affected his ability to function. The MAR indicated that medications were administered as transcribed by the facility, not as ordered by the hospital, and there was no documentation of changes to the medication regimen following the resident's readmission. Interviews with staff revealed gaps in communication and process adherence. The admitting nurse who transcribed the orders was no longer employed at the facility, and the ADON described issues with providing an updated medication list to the hospital due to a malfunctioning fax machine. The hospital pharmacist reported recurring problems with obtaining accurate and current medication lists from the facility, leading to delays and potential complications in patient care. Facility policies required clarification and accurate transcription of new medication orders, but these procedures were not followed in this instance.
Failure to Ensure Proper Use and Function of Pressure-Relieving Mattresses
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent the development and worsening of pressure ulcers for four out of five residents reviewed. Observations and record reviews revealed that pressure-relieving mattresses were not functioning properly or were not set to the correct weight settings for several residents at risk for pressure ulcers. Specifically, one resident's pressure-relieving mattress was found to be beeping and set to static mode, which staff acknowledged would prevent the mattress from circulating air as intended. Staff interviews indicated a lack of understanding regarding the operation and significance of the mattress settings. For three other residents, the pressure-relieving mattresses were not set to the correct weight according to the residents' actual weights. In one case, a mattress was set to a weight significantly lower than the resident's actual weight, while in another, the setting was much higher than the resident's weight. Staff interviews revealed that some nurses were unaware of the correct settings or had not checked the beds since returning from leave. Additionally, one resident reported discomfort and feeling a hole in the bed, further indicating improper mattress function or settings. Record reviews showed that physician orders and care plans required the use of pressure-relieving mattresses and regular checks for proper functioning. However, these orders were not consistently followed, as evidenced by the incorrect mattress settings and lack of staff knowledge. The facility's own policy emphasized the importance of pressure reduction surfaces and regular monitoring, but these standards were not met for the residents reviewed.
Failure to Enforce Contact Isolation Precautions for Resident with Suspected C. diff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was under contact isolation precautions due to suspected Clostridioides difficile (C. diff) infection. Despite clear signage and physician orders requiring the use of personal protective equipment (PPE) such as gowns and gloves before entering the resident's room, multiple staff members—including a Certified Medication Aide (CMA), a Certified Nursing Assistant (CNA), and a housekeeper—entered the room without donning the required PPE. Observations showed that the CNA entered the room to address the resident's concerns about lunch, the CMA entered to deliver medication, and the housekeeper entered to clean the room while the resident was at dialysis, all without using PPE. Staff interviews revealed a lack of awareness or understanding of the isolation requirements, with one CNA stating she was unaware of the need for PPE due to just returning from vacation and not being informed, and the housekeeper believing PPE was unnecessary if the resident was not present. The resident involved was a male with a history of limb amputation and tobacco use, who had been tested for C. diff with results pending at the time of the observations. The care plan included interventions for respiratory symptoms and the use of oxygen, and the resident had a moderate level of cognition. Facility policy required the use of PPE for contact precautions, and staff interviews confirmed that all staff were expected to follow infection control protocols. However, the observed failures to comply with these protocols placed residents at risk for cross-contamination and the potential spread of infection.
Failure to Ensure Proper Functioning of Oxygen Concentrator for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to a resident requiring oxygen therapy. The resident, who had a history of limb amputation and tobacco use, was at risk for shortness of breath and chest pain, with care plan interventions including the application of oxygen as ordered and monitoring for effectiveness. Despite physician orders for oxygen administration via nasal cannula and non-rebreather mask as needed, the resident's oxygen concentrator was observed to be malfunctioning, with continuous beeping and warning lights indicating low oxygen concentration and a need for service. The resident reported that the machine had been malfunctioning since admission and that the beeping had become a persistent issue. Staff interviews revealed that the malfunctioning concentrator had not been previously reported or addressed, and the resident continued to rely on the faulty equipment for respiratory support. Observations confirmed that multiple concentrators in the facility were not functioning properly, requiring several attempts to find a working device for the resident. Facility policy and manufacturer guidelines specified the need for staff to verify proper functioning of oxygen concentrators and to place warning signs, but these procedures were not consistently followed, resulting in the resident not receiving respiratory care consistent with professional standards and the care plan.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in the presence of roaches and water bugs in resident rooms and bathrooms on Hall 100. Multiple residents reported seeing live roaches in their rooms and bathrooms, particularly at night, and expressed that the ongoing pest issue was bothersome. Staff interviews confirmed the presence of roaches and water bugs in resident rooms, closets, and bathrooms, and noted that the problem was ongoing and facility staff were aware of it. Observations by surveyors corroborated these reports, with live and dead bugs found in resident rooms, bathrooms, and glue traps, as well as structural issues such as a 1-inch opening in a floorboard where pests were seen entering. Housekeeping and maintenance staff indicated that pest sightings were documented and that pest control services were called, but there was a lack of clarity regarding the frequency and thoroughness of deep cleaning in affected rooms. The pest control representative confirmed recent treatment for roaches and water bugs, noting that pests were coming from drains and possibly from under commodes that were not properly sealed. However, the representative could not specify which rooms were treated, and facility records showed repeated pest sightings and treatments over several months, indicating a persistent issue. Review of facility logs and pest control documentation revealed ongoing reports of roaches and water bugs in various rooms, with service dates recorded for some but not all incidents. The facility's pest control policy required maintaining an effective program and a reporting system for issues between scheduled visits, but interviews and record reviews indicated gaps in implementation and follow-up. The deficiency was identified based on direct observations, resident and staff interviews, and review of facility records.
Failure to Protect Resident from Physical and Verbal Abuse by Staff
Penalty
Summary
A certified medication aide (CMA) engaged in physical and verbal abuse toward a male resident with a history of aphasia, dysarthria, hemiplegia, bipolar disorder, major depressive disorder, and unsteadiness on his feet. The incident occurred when the resident refused medication, leading to a confrontation in which the CMA threw a pitcher of water at the resident, causing him and his bed to become wet. Multiple witnesses, including staff and a family member, observed the CMA using profanity and antagonizing the resident, while the resident also used profanity and attempted to pursue the CMA despite being unsteady and falling during the altercation. The resident was cognitively intact, as indicated by a BIMS score of 15, and was generally independent in activities of daily living. During the incident, the resident became upset, attempted to go after the CMA, and was described as very unsteady on his feet, ultimately falling but getting back up. Staff and a family member intervened by trying to separate the two and placing a medication cart between them. The situation escalated with both parties yelling and using profane language, and the resident continued to pursue the CMA until additional staff arrived and the situation was brought under control. Interviews and documentation confirmed that the CMA was physically aggressive and abusive toward the resident, including the act of throwing water and engaging in a verbal altercation. The facility's investigation, as well as statements from staff and witnesses, corroborated the occurrence of both physical and verbal abuse by the CMA. The incident was self-reported by the facility, and the abuse was substantiated through interviews, record reviews, and direct observations of the aftermath, such as the resident and his bed being wet and the presence of water on the floor.
Food Safety and Hair Restraint Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. In the walk-in refrigerator, food items were not properly sealed, and some produce showed signs of expiration. Specifically, a container labeled 'Burger Toppings' was not sealed, and the lettuce inside was turning brown. Additionally, a bin of tomatoes contained several bruised items, and an open box of bacon was not sealed. The Dietary Manager acknowledged these issues and stated that the lettuce and tomatoes would be discarded, and the bacon would be sealed. During meal service, the facility did not take the temperatures of certain food items before serving them to residents. Hamburger patties, chicken nuggets, fries, ice cream, and gelatin dessert were served without temperature checks. Dietary staff admitted to not taking the temperatures, citing the need to serve food on time as a reason for the oversight. The Dietary Manager confirmed that the expectation was to take temperatures of all food items to ensure they were served at safe temperatures. Additionally, staff members did not wear effective hair restraints during meal service. Observations revealed that an LVN, a Dietary Aide, and a Dishwasher had hair not covered by hair restraints while handling food. Interviews with the staff confirmed that they were aware of the expectation to cover all hair to prevent contamination. The Dietary Manager acknowledged that some staff had not been in-serviced about effective hair restraints, which posed a risk of hair falling into food and drinks, potentially causing contamination.
Deficiency in Personal Hygiene and ADL Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Four residents were affected by this deficiency. Resident #69, a male with severe cognitive impairment, was observed with long, discolored fingernails with dark residue underneath, indicating a lack of personal hygiene care. Similarly, Resident #86, also with severe cognitive impairment, had chipped and untrimmed fingernails and expressed that he lacked the tools to trim them himself. The staff, including CNAs and LVNs, were responsible for nail care, but this was not adequately provided. Resident #47, who was cognitively intact but required assistance due to right-sided hemiplegia, did not receive a scheduled shower. The resident reported that he did not refuse the shower, contrary to what was documented by CNA L. The CNA did not return to provide the shower after initially lacking bed linens, leading to a missed care opportunity. This discrepancy between the resident's account and the staff's documentation highlights a failure in communication and care delivery. Resident #33, with moderate cognitive impairment and dependency on staff for self-care, was observed with a dark brown substance around his fingernail cuticles, suspected to be feces. Despite the resident's frequent refusals of care, the CNA did not report this to the charge nurse, as required by protocol. The Assistant Director of Nursing (ADON) acknowledged that nail care should be provided as needed, especially during shower times, and that refusals should be reported to the charge nurse. The facility's policy on activities of daily living emphasizes the importance of providing care for bathing, dressing, grooming, and oral care, which was not adhered to in these cases.
Medication Handling Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, as evidenced by the improper handling of medications on three medication carts. Specifically, medications in unsecure blister packs were found on the Nurses Cart Hall 300, Med Aide Cart Hall 300/400, and Nurses Cart Hall 400. LVN D, responsible for Nurses Cart Hall 300, was unaware of when or how the blister pack seals for controlled medications were broken, posing a risk for drug diversion. Similarly, MA E, responsible for Med Aide Cart Hall 300/400, and LVN F, responsible for Nurses Cart Hall 400, also failed to identify broken blister seals during their shift change counts, despite being responsible for checking these packs. Interviews with the staff revealed a lack of awareness and adherence to the facility's policy regarding the handling of medications with broken seals. The Assistant Director of Nursing (ADON) confirmed that broken blister pack medications should be discarded to prevent drug diversion and infection control issues. The facility's policy mandates that the pharmacy and medication rooms be routinely inspected for discontinued, outdated, or defective medications, yet the staff failed to comply with these procedures, leading to the observed deficiencies.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two separate incidents involving residents. In the first incident, a Certified Nursing Assistant (CNA) did not perform hand hygiene between glove changes while providing incontinence care to a resident with severe cognitive impairment and incontinence issues. The CNA acknowledged the lapse in protocol, which could expose the resident to infections. In the second incident, a Licensed Vocational Nurse (LVN) and another CNA did not wear the appropriate personal protective equipment (PPE) while performing wound care on a resident under enhanced barrier precautions due to a pressure ulcer. The LVN, who was new to the facility, admitted to not noticing the precautionary signage, while the CNA misunderstood the signage's applicability. Both staff members recognized the risk of infection due to their actions.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident #40, who was observed to have dry, flaky skin on her feet. This deficiency was identified through observation, interview, and record review. Resident #40, a cognitively intact female with a BIMS score of 15, required extensive assistance for activities of daily living (ADLs) due to limited mobility. Her medical history included hypertension, diabetes mellitus, and non-Alzheimer's dementia. Despite these needs, the resident reported receiving bed baths only three times a week, with foot cleaning and lotion application occurring sporadically. During an observation, a CNA acknowledged the need to clean and moisturize the resident's feet, recognizing the potential for infection and skin breakdown. Interviews with facility staff, including an LVN and the ADON, revealed that it was the CNAs' responsibility to provide foot care, with oversight from nursing staff. The facility's policy on skin integrity and foot care, revised in February 2023, emphasized the importance of maintaining good foot health. However, the lack of consistent foot care for Resident #40 indicated a failure to adhere to this policy, placing residents at risk for skin issues and infections.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to ensure that a resident was offered sufficient fluid intake to maintain proper hydration. This deficiency was identified for a resident who was moderately cognitively impaired and required set-up assistance with eating. The resident, who was on hospice services and had a mechanically altered diet due to a swallowing disorder, expressed thirst and reported not receiving water from the staff during the morning shift. The resident's care plan included encouragement of dietary and fluid intake, but the staff did not provide water until later in the day. Interviews with facility staff revealed that the CNAs did not have time to pass out water before breakfast, and water was only provided right before lunch. The staff acknowledged the risk of dehydration and increased confusion due to insufficient fluid intake. The facility's policy on hydration emphasized offering sufficient fluids to maintain proper hydration and health, but this was not adhered to in the case of the resident, leading to the identified deficiency.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food at an appetizing temperature and palatable texture during a lunch meal, specifically serving a cold hamburger and undercooked vegetables. This issue was identified through observation, interviews, and record reviews. During a confidential group interview, residents expressed concerns about food not being cooked properly, with instances of overcooking. Observations revealed that the 400 hall trays were the last to be served, and a test tray showed that the vegetable medley was hard and undercooked, while the hamburger was cold. Interviews with dietary staff highlighted the importance of checking food temperatures to ensure they are at least 165°F to prevent foodborne illness. The Dietary Manager acknowledged that the vegetables should not be hard, as this could make them difficult for residents to chew and potentially lead to illness. The Resident Council Minutes also reflected dietary concerns about food temperature. The facility's policy on date marking for food safety was reviewed, indicating procedures for checking and discarding expired food items, but it did not address the specific issue of serving food at the correct temperature.
Failure to Label and Date Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the lack of labeling and dating on the oxygen humidity bottle and nasal cannula. The resident, a female with intact cognition, was readmitted to the facility with diagnoses including anemia, cirrhosis, hepatic failure, and septicemia. Her care plan indicated resistance to care related to shortness of breath, with orders for oxygen therapy as needed. However, during an observation, it was noted that the oxygen equipment was not labeled or dated, which could increase the risk of respiratory infection. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the facility's practice was to change and date oxygen supplies weekly, but this was not done in this instance. The DON acknowledged the oversight and stated that the nighttime nursing staff was responsible for this task. The facility's policy on oxygen administration, revised in October 2023, requires adherence to professional standards of practice, but there was no specific policy for labeling and dating oxygen equipment. This lapse in procedure was identified as a deficiency in the facility's care practices.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement and follow its abuse, neglect, and exploitation policy, resulting in two incidents involving residents. In the first incident, a CNA observed a male resident touching a female resident's shoulder in a manner that made the CNA uncomfortable, given the male resident's history of inappropriate behavior. Despite reporting the incident to an LVN and the Administrator, no documentation or investigation was conducted, and the Administrator was unaware of the incident until informed by the CNA the following day. The Administrator and DON did not follow the facility's policy to ensure resident safety and investigate the situation. In the second incident, a CNA witnessed a male resident hitting another male resident on the head with a cane. The CNA intervened and reported the incident to the ADONs and the Administrator, but no documentation or investigation followed. The Administrator and DON were aware of the incident but did not assess the residents for harm or document the event, as they did not believe physical contact occurred. The facility's policy was not implemented to ensure resident safety or investigate the incident. Both incidents highlight the facility's failure to adhere to its abuse prevention policy, which requires immediate reporting, investigation, and documentation of any allegations or suspicions of abuse. The lack of action and documentation in these cases could place all residents at risk for abuse and psychosocial harm, as the facility did not ensure the safety and protection of its residents during and after the incidents.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to investigate alleged or suspected abuse involving two residents, which could potentially place all residents at risk for abuse and psychosocial harm. In the first incident, a CNA observed a resident touching another resident's shoulder in a manner that made the CNA uncomfortable due to the resident's history of inappropriate behavior. Despite reporting the incident to an LVN and the Administrator, no investigation was conducted, and there was no documentation of the incident in the residents' progress notes. The Administrator and DON were unaware of the incident until it was reported the following day, and they did not follow the facility's abuse policy to ensure resident safety. In the second incident, a CNA witnessed a resident hitting another resident on the head with a cane. The CNA intervened and reported the incident to the ADONs and the Administrator, but again, no investigation was conducted, and there was no documentation of the incident. The Administrator and DON were present during the incident but did not assess the residents or document any findings. The facility's abuse policy was not implemented, and the residents were not assessed for harm. The facility's policy requires immediate investigation of all alleged abuse, neglect, or exploitation, with thorough documentation and reporting. However, in both incidents, the facility failed to follow its policy, resulting in a lack of investigation and documentation. The Regional Nurse confirmed that the facility did not adhere to its abuse policy, as there was no investigation or documentation of the incidents, and the residents were not assessed for harm.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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