Lavaca Bay Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Lavaca, Texas.
- Location
- 118 Trinity Shores Drive, Port Lavaca, Texas 77979
- CMS Provider Number
- 676481
- Inspections on file
- 33
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lavaca Bay Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and a history of falls had bruises on the knee and cheek that were not documented in weekly skin assessments, despite being observed by staff and required by the care plan. Staff interviews revealed inconsistent reporting and documentation practices, and the facility's policy for thorough head-to-toe skin assessments was not followed.
The facility failed to implement its policies to prevent abuse and misappropriation for two residents. One resident reported missing money, and another had a discrepancy in narcotic medication. The facility did not conduct required training following these incidents, contrary to its policies. The lack of timely training and communication among staff contributed to the deficiencies observed.
Two residents received inadequate incontinence care, risking infections. A female resident with severe cognitive impairment was improperly cleaned by CNAs, leaving stool residue. A male resident with an indwelling catheter was not fully cleaned, as CNA-L forgot to clean his penis. The facility's policy outlines proper care procedures, but these were not followed, potentially risking infections.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, as required by policy. In November 2024, RN coverage was insufficient on 5 days, with hours ranging from 5 to 6.23. Interviews with staff revealed that consulting nurses began in December, and the acting DON acknowledged potential delays in resident care due to this deficiency.
A facility failed to maintain complete and accurate clinical records for several residents placed in a secure unit. Consents and physician orders were missing for residents with severe cognitive impairments and elopement risks. The absence of these documents was acknowledged by the DON as a potential violation of residents' rights.
The facility failed to provide mandatory restraints training for five staff members, including the Activity Director, two CNAs, a PTA, and a Speech Therapist. This deficiency was identified through interviews and a review of the training log, which showed no evidence of completed training. The acting HR Coordinator expressed uncertainty about training oversight responsibilities, highlighting a lack of clarity in roles. The absence of required training could potentially place residents at risk of being cared for by untrained staff.
The facility failed to provide mandatory QAPI training to 10 staff members, including a housekeeper, MA, CNA, food service director, RN, LVNs, speech therapist, social worker, and occupational therapist. This deficiency was confirmed through a review of the training log and interviews with the HR Manager and acting HR Coordinator, who acknowledged the lack of training oversight. The facility's policies require effective training programs and sufficient staff competencies, which were not met due to the missing QAPI training.
The facility failed to provide required behavioral health training for two staff members, RN V and a Physical Therapist, as identified through a review of training logs and confirmed by interviews with HR personnel. There was a lack of clarity regarding training oversight, with the Administrator temporarily responsible until a new HR Coordinator is appointed. This deficiency could impact resident safety and well-being.
A facility failed to respect residents' rights to privacy and dignity when a laundry aide entered multiple rooms without knocking. A resident expressed discomfort with this practice, highlighting the invasion of privacy. The aide admitted to not knocking, assuming open doors meant no residents were present, despite being trained to announce herself. The facility's Administrator acknowledged this as a violation of resident rights.
The facility failed to distribute mail to residents on Saturdays, as the Receptionist did not work weekends and mail remained in the mailbox until Monday. This practice was confirmed by both the Receptionist and the Activity Director, and the Administrator acknowledged that residents should receive mail daily. The facility's policy mandates mail delivery within 24 hours, including Saturdays, but this was not adhered to, potentially impacting residents' quality of life.
A CNA failed to properly clean a resident's genital area during catheter care, despite having passed a skills checklist. The resident, with severe cognitive impairment and other health issues, was at risk for infection due to this oversight. The DON confirmed the proper procedure was not followed.
A facility failed to provide adequate pharmaceutical services, resulting in two missing hydrocodone tablets for a resident with a history of joint replacement, cancer, and pain. The LVN responsible left the medication cart unsecured and failed to document the administration of the medication, leading to a discrepancy in the narcotic count. The facility's policy on securing and accounting for controlled substances was not followed.
The facility failed to act on pharmacist recommendations for two residents. One resident's Mirtazapine dose reduction was not communicated to the physician, and another resident's Diltiazem 'Do Not Crush' instruction was not added to the medication record. The DON acknowledged the oversight, citing a recent leadership change.
A facility failed to secure drugs properly, as five loose pills were found in a nurse medication cart. An LVN and the acting DON acknowledged the risks of residents consuming unprescribed medications, which could lead to adverse effects or allergic reactions. The facility's policies emphasized the need for control and surveillance of medications.
A facility failed to coordinate hospice care and maintain documentation for a resident receiving hospice services. The resident, with severe cognitive impairment due to Alzheimer's, required hospice aide and nurse visits twice a week. However, the visit log showed only one documented visit, and interviews revealed a lack of communication and documentation between facility staff and hospice representatives. The DON acknowledged the absence of a specific hospice policy and the responsibility of facility nurses to communicate and document hospice care.
A CNA in an LTC facility failed to change gloves during incontinent care for a resident with severe cognitive impairment and multiple medical conditions, leading to a breach in infection control. The CNA admitted to the oversight, and the DON confirmed the proper procedure was not followed.
The facility failed to provide mandatory effective communications training to an RN, as required by their training program. A review of the training log showed no evidence of such training for the RN, and interviews confirmed the oversight. The acting HR Coordinator was unsure who was responsible for training oversight, indicating a lack of clarity in roles. This failure could place residents at risk of being cared for by untrained staff.
A facility failed to accurately document a resident's showers in the electronic record system, leading to discrepancies in the resident's care records. The resident, with severe cognitive impairment, was supposed to receive showers on specific days, but the records inaccurately showed missed showers. A CNA admitted to possibly forgetting to document the showers, and the administrator acknowledged the requirement for documentation but was unaware of the oversight.
The facility did not update the Daily Nurse Staffing Report for four consecutive days, displaying outdated information from 11/6/2024. The Administrator attributed this to a new staffing coordinator unfamiliar with requirements. This oversight could risk residents, families, and visitors by not providing current staffing and census data.
A resident with multiple health conditions was transferred to a psychiatric facility without proper written notification to the resident's representative or the LTC Ombudsman. The facility did not update the discharge notice recipients promptly, and interviews revealed that the necessary parties were not informed about the discharge, leading to an appeal allowing the resident to return.
A resident's DNR wishes were not honored due to an invalid OOHDNR form lacking a physician's signature. Despite the resident's electronic chart indicating a DNR status, LVN and RN administered CPR, believing the resident was a full code. The resident was pronounced dead after EMS continued CPR due to the invalid form. The deficiency was identified as Immediate Jeopardy and corrected before the survey began.
Failure to Accurately Document Resident Skin Assessments
Penalty
Summary
The facility failed to ensure that skin assessments accurately reflected the resident's current condition for one resident reviewed. Specifically, the skin assessments completed on two separate dates did not document the presence of a bruise on the resident's knee or a bruise on the resident's cheek, despite these being observable during care and reported by staff and the resident's representative. The resident's care plan required regular skin inspections and documentation of any redness, open areas, scratches, cuts, or bruises, but these requirements were not met in this instance. Interviews with staff revealed that both CNAs and nurses were responsible for checking and reporting skin issues during routine care, such as bathing or dressing. However, the staff involved either did not notice the bruises or failed to document them in the resident's medical record. The treatment nurse and DON confirmed that weekly skin assessments were required and that any findings should be documented and reported, but there was a lack of clarity among staff regarding monitoring and reporting procedures. The skin assessment policy required a thorough head-to-toe examination and documentation of any skin conditions, including bruising, which was not followed in this case. The resident involved had multiple diagnoses, including Alzheimer's disease, heart failure, COPD, diabetes, major depressive disorder, hypertension, delusional disorder, and dementia, and was at risk for falls as noted in the care plan. The failure to document observed bruises meant that the resident's medical record did not accurately reflect his condition, and the facility did not follow its own policy and care plan requirements for skin assessment and documentation.
Failure to Implement Policies on Abuse and Misappropriation
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and misappropriation for two residents. The first incident involved a resident who reported that $20 was missing from his belongings after a hospital visit. The resident's family informed the past interim Administrator about the missing money, but the facility did not conduct the required abuse and neglect training following the allegation. The past Administrator acknowledged that the training should have been conducted as part of the facility's policy, but it was not done until after the surveyor's entrance. The second incident involved another resident who was prescribed hydrocodone for pain management. A discrepancy in the narcotic count revealed that two pills were missing. The past Administrator was informed of the missing narcotics during a shift change, and the medication cart was secured pending an investigation. The investigation found that the cart had been left unsecured by an LVN, who accepted responsibility for the missing pills. However, no in-service training was conducted for the staff regarding this incident, contrary to the facility's policy. Both incidents highlight the facility's failure to adhere to its policies for preventing and addressing abuse, neglect, and misappropriation. The lack of timely training and communication among staff members contributed to the deficiencies observed. The facility's policies require immediate training and investigation following such allegations, but these were not adequately implemented, leaving residents at risk.
Inadequate Incontinence Care Leads to Potential Infection Risks
Penalty
Summary
The facility failed to provide appropriate incontinence care for two residents, leading to potential risks of urinary tract infections. Resident #23, a female with severe cognitive impairment and chronic kidney disease, was observed receiving improper incontinence care. CNA Y, assisted by CNA Z, wiped Resident #23's anal area in the wrong direction, from back to front, on three occasions, leaving copious amounts of stool. This improper technique was acknowledged by the CNAs, who admitted they had not received training on incontinence care at the current facility, although they had been trained at a sister facility. The Director of Nursing (DON) confirmed that the facility had recently provided competency training on incontinence care and emphasized the importance of wiping from front to back to prevent infections. Resident #74, a male with severe cognitive impairment and an indwelling urinary catheter, also received inadequate care. During an observation, CNA-L and CNA-M were seen providing catheter care but failed to clean the resident's penis, which is a necessary step to prevent urinary tract infections. CNA-L admitted to being nervous and forgetting to clean the resident's penis, despite having passed a clinical skills checklist for perineal care earlier in the month. The DON stated that the previous DON had completed the checklist and that it was her responsibility to monitor the CNAs' skills. The facility's policy on perineal care, dated October 2022, outlines the correct procedures for cleaning residents to prevent infections and skin breakdown. However, the observed deficiencies in care for Residents #23 and #74 indicate a failure to adhere to these procedures, potentially placing residents at risk for infections. The report highlights the need for proper training and adherence to established care protocols to ensure resident safety and well-being.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required by their policy. This deficiency was observed for 5 days in November 2024, specifically on 11/10, 11/16, 11/18, 11/23, and 11/30, where the RN coverage was less than 8 hours. The timesheets revealed that on these days, the RN coverage ranged from 5 to 6.23 hours. This lack of adequate RN coverage could potentially result in residents not receiving the necessary services to meet their needs. Interviews conducted with facility staff, including the VP of Clinical and the acting Director of Nursing (DON), highlighted the facility's staffing challenges. The VP of Clinical mentioned that nurses began entering the facility on a consulting basis in early December 2024, and the acting DON assumed their role on 12/09/24. The acting DON acknowledged that the absence of an RN for the required hours could lead to residents needing to be transferred to a hospital for services or experiencing delays in receiving necessary care. The facility's policy, dated 10/24/22, mandates the use of RN services for at least 8 consecutive hours per day, 7 days a week, which was not adhered to during the specified days in November 2024.
Deficiency in Secure Unit Placement Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for five residents, specifically regarding their placement in a secure unit. For Resident #23, the facility did not obtain consent for her to reside in the secure unit, despite her being severely cognitively impaired and at risk for elopement. The resident's care plan indicated her need for supervision due to her cognitive impairment, but the necessary consent documentation was missing from her electronic health record. Resident #25 was placed in the secure unit without a physician's order, although consent was obtained from the resident's representative. The resident had severe cognitive impairment and was identified as an elopement risk, necessitating his placement in the secure unit. However, the absence of a physician's order was acknowledged by the Director of Nursing (DON) as a potential violation of the resident's rights. Similarly, Residents #73, #74, and #78 were also residing in the secure unit without the required consents and physician orders. These residents were all severely cognitively impaired and had histories of wandering or exit-seeking behaviors, which justified their placement in the secure unit. However, the lack of proper documentation, including consents and physician orders, was noted as a deficiency in maintaining accurate and complete medical records, as required by professional standards.
Failure to Provide Mandatory Restraints Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on restraints for five staff members, including the Activity Director, two CNAs, a PTA, and a Speech Therapist. This deficiency was identified through interviews and a review of the facility's training log, which showed no evidence of completed training for these individuals. The absence of this training was confirmed during multiple interviews with the acting HR Coordinator and the Regional HR Manager, who acknowledged the missing training records. The acting HR Coordinator expressed uncertainty about who was responsible for training oversight at the facility, indicating a lack of clarity in roles and responsibilities. The facility's policies on training requirements and nursing services emphasize the importance of maintaining an effective training program and ensuring sufficient staff with appropriate competencies. However, the failure to provide the required training on restraints could potentially place residents at risk of being cared for by untrained staff, as noted by the acting HR Coordinator.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance Performance Improvement (QAPI) training to 10 out of 25 staff members sampled for licensure and training. These staff members included a housekeeper, medical assistant, certified nursing assistant, food service director, registered nurse, licensed vocational nurses, speech therapist, social worker, and occupational therapist. The absence of this training was confirmed through a review of the facility's training log, which showed no evidence of QAPI training for the mentioned staff. Interviews with the Regional HR Manager and the acting HR Coordinator further verified that these staff members were missing the required federal or state QAPI training. During interviews, the acting HR Coordinator and the Regional VP of Operations acknowledged the lack of training oversight at the facility. The acting HR Coordinator admitted uncertainty about who was responsible for ensuring staff received necessary training at this facility. The facility's Training Requirements policy mandates the development and maintenance of an effective training program for all staff, but this was not adhered to, as evidenced by the missing QAPI training. The Nursing Services and Sufficient Staff policy also emphasizes the need for sufficient staff with appropriate competencies to ensure resident safety and well-being, which was compromised due to the training deficiency.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training for two of the 25 employees sampled for licensure and training, specifically RN V and the Physical Therapist. This deficiency was identified through a review of the facility's training log, which showed no evidence of the mandatory training for these staff members. Interviews conducted with the Regional HR Manager and the acting HR Coordinator confirmed that several employees were missing required federal or state trainings, including the behavioral health training for the two staff members in question. During interviews, it was revealed that there was a lack of clarity regarding who was responsible for overseeing training at the facility. The acting HR Coordinator, who is responsible for training at another facility, was unsure of the oversight at this location. The Regional VP of Operations indicated that the Administrator would be responsible for staff training until a new HR Coordinator was appointed. The facility's policies on training requirements and nursing services emphasize the importance of providing sufficient staff with appropriate competencies to ensure resident safety and well-being, which was not adhered to in this instance.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and privacy, as evidenced by the actions of Laundry Aide X on the 300 unit. During an observation, it was noted that Laundry Aide X entered multiple resident rooms without knocking, which is a violation of the residents' rights to a dignified existence and privacy. Resident #75, who is cognitively intact, expressed discomfort with staff entering her room without knocking, highlighting the invasion of privacy and potential exposure to embarrassing situations. Laundry Aide X admitted to entering rooms without knocking, assuming that open doors indicated no resident presence. However, she acknowledged the importance of knocking and announcing herself before entering, as per her training and facility policy. The facility's Administrator confirmed that staff are expected to knock and announce themselves before entering a resident's room, recognizing this as a resident rights issue. The facility's policy on Resident Rights emphasizes treating residents with respect and dignity, which was not adhered to in this instance.
Failure to Distribute Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail in a timely manner, specifically on Saturdays. During a confidential resident group meeting, three out of ten members reported that they did not receive mail on Saturdays because the Receptionist was off on weekends. The Receptionist confirmed that she worked Monday through Friday and did not collect mail on weekends. She stated that during the week, she collected mail from the mailbox and the local post office, placed it in a designated area, and the Activity Director or Activity Aide distributed it to residents. However, any mail delivered on Saturday remained in the mailbox until the following Monday. The Activity Director corroborated the Receptionist's account, acknowledging that mail delivered on Saturdays was not distributed until Monday. The Administrator confirmed that residents should receive their mail every day, as it is a resident right. A review of the facility's policy on mail and electronic communication revealed that mail and packages should be delivered to residents within twenty-four hours of delivery, including Saturdays. This failure to distribute mail on Saturdays resulted in residents not receiving their mail promptly, which could diminish their quality of life.
Inadequate Perineal Care by CNA
Penalty
Summary
The facility failed to ensure that licensed staff demonstrated the necessary competencies and skill sets to care for residents' needs, specifically in the case of a certified nursing assistant (CNA-L) who did not properly clean a resident's genital area during incontinent and indwelling urinary catheter care. This deficiency was observed during an incident involving a male resident with severe cognitive impairment, dementia, peripheral vascular disease, neuromuscular dysfunction of the bladder, urinary tract infection, and hypertension. The resident required substantial assistance for toileting hygiene and was always incontinent of bowel. During the observation, CNA-L, assisted by another CNA, cleaned the resident's groin area and catheter but failed to clean the resident's penis, which is a critical step in preventing urinary tract infections. Despite having passed a clinical skills checklist for perineal care earlier in the month, CNA-L admitted to forgetting this step due to nervousness. The Director of Nursing (DON) confirmed that the proper procedure was not followed, which could potentially lead to cross-contamination and infections.
Failure in Pharmaceutical Services Leads to Missing Narcotics
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the accurate acquiring, receiving, dispensing, and administering of drugs, as evidenced by the case of a resident with missing hydrocodone tablets. The resident, a 74-year-old male with a history of joint replacement, cancer, and pain, was prescribed hydrocodone for pain management. However, two tablets were unaccounted for during a narcotic count on November 27, 2024. The resident's Medication Administration Record (MAR) showed no documentation of the medication being administered on the dates in question, and there were no corresponding nurse notes to verify administration. The investigation revealed that the Licensed Vocational Nurse (LVN) responsible for the medication cart left it unsecured while attending to another resident, potentially allowing access to the narcotics. The LVN admitted to forgetting to document the administration of the medication and leaving the cart unsecured. The Director of Nursing (DON) confirmed that the narcotic count was off by two pills, and the LVN accepted responsibility for the oversight. The facility's Controlled Substances policy mandates that controlled substances be secured and accurately accounted for, which was not adhered to in this instance.
Failure to Act on Pharmacist Recommendations for Drug Regimen
Penalty
Summary
The facility failed to act upon drug regimen irregularities reported by the Pharmacist Consultant for two residents. For one resident, the pharmacist recommended a gradual dose reduction of Mirtazapine for depression, but the facility did not communicate this recommendation to the resident's primary care physician. The resident, who had a diagnosis of dementia and depression, continued to receive the medication without the suggested dose reduction. For another resident, the pharmacist recommended adding a 'Do Not Crush' instruction to the medication administration record for Diltiazem, which was not done. This resident had severe cognitive impairment and was diagnosed with hypertension, among other conditions. The absence of the 'Do Not Crush' instruction could have led to incorrect medication administration. The Director of Nursing (DON) acknowledged the lack of action on these recommendations, noting that the leadership group had recently changed due to a new company acquiring the facility. The DON was unaware of why the previous leadership did not follow the pharmacist's recommendations, and it was noted that it was the DON's responsibility to report all pharmacy recommendations to the physicians.
Medication Security Lapse in Nurse Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly secured and distributed, as evidenced by the presence of five loose pills in the nurse medication cart for the 300 hall. During an observation and interview, it was revealed that these loose pills were found in the bottom of the cart drawers that held blister packs. LVN F acknowledged that if these pills were consumed by a resident for whom they were not prescribed, it could lead to severe consequences, including allergic reactions. The acting DON confirmed that the presence of loose pills could result in residents not receiving their necessary medications, leading to a delay in therapy. Additionally, if a resident consumed medication not prescribed to them, it could cause adverse effects or allergic reactions. The facility's policy on medication carts and supplies emphasized the importance of appropriate control and surveillance of resident-assigned medications, and the policy on disposal of medications highlighted the need to secure unused and unwanted medications until they are destroyed.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to effectively collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified through interviews and record reviews, which revealed that the facility did not monitor hospice aide and nursing visits according to the hospice plan of care. Additionally, the facility failed to maintain the correct visit log sheet in the resident's hospice binder. The resident, an elderly female with severe cognitive impairment due to Alzheimer's disease, was admitted to hospice care for Alzheimer's disease. The hospice plan of care required hospice aide and nurse visits twice a week, but the visit log only showed a single visit, and there was no documentation for other visits. Interviews with the hospice clinical director and facility staff indicated a lack of communication and documentation regarding hospice visits. The hospice clinical director confirmed that visits occurred but were not documented in the visit log. Facility staff, including an LVN and the DON, acknowledged the oversight in monitoring and documenting hospice visits. The DON admitted that the facility lacked a specific hospice policy and that facility nurses were responsible for communicating with hospice staff and maintaining hospice documentation. This lack of communication and documentation could potentially lead to inadequate end-of-life care for residents receiving hospice services.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not follow proper glove-changing procedures during incontinent and indwelling urinary catheter care for a resident. The resident, a male with severe cognitive impairment and multiple medical conditions including dementia, peripheral vascular disease, and a urinary tract infection, required substantial assistance with personal hygiene. During care, the CNA used old and dirty gloves to handle a new and clean brief, which was against the facility's infection control policy. The incident was observed by surveyors, and the CNA admitted to the oversight, attributing it to nervousness and forgetfulness. The Director of Nursing (DON) confirmed that the CNA should have used clean gloves when handling the new brief. The facility's policy on perineal care clearly outlined the need for glove removal and hand hygiene before handling clean items, which was not adhered to in this instance.
Failure to Provide Mandatory Training for RN
Penalty
Summary
The facility failed to provide mandatory effective communications training to one of the sampled staff members, RN V, as required by their training program. A review of the facility's training log showed no evidence of such training for RN V. Interviews with the Regional HR Manager and the acting HR Coordinator confirmed that RN V was missing this required training. The acting HR Coordinator was unsure who was responsible for training oversight at the facility, indicating a lack of clarity in roles and responsibilities. The facility's Training Requirements policy mandates the development, implementation, and maintenance of an effective training program for all staff, including those under contractual arrangements and volunteers. Additionally, the Nursing Services and Sufficient Staff policy requires the facility to provide sufficient staff with appropriate competencies to ensure resident safety and well-being. The failure to ensure RN V received effective communications training could place residents at risk of being cared for by untrained staff, potentially leading to neglect or adverse outcomes.
Inaccurate Documentation of Resident Showers
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of showers in the electronic record system (POC). The resident, a 78-year-old female with severe cognitive impairment and multiple diagnoses including dementia and Alzheimer's disease, was supposed to receive showers on specific days. However, the POC documentation inaccurately reflected that the resident did not receive showers on several scheduled days in October and November 2024. This discrepancy was noted despite the resident being well-groomed and able to confirm receiving assistance with showers, although she could not recall specific dates. Interviews with facility staff revealed that a CNA, who had worked with the resident on many of the listed shower days, admitted to possibly forgetting to document the showers. The facility's administrator acknowledged that nursing staff are required to document when a resident receives or refuses a shower, but was unaware of why the documentation was not completed in this case. This lack of documentation could result in an incomplete view of the resident's care and services.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information for four consecutive days, specifically on 11/19/2024, 11/20/2024, 11/21/2024, and 11/22/2024. During observations on these dates, it was noted that the Daily Nurse Staffing Report displayed was dated 11/6/2024, indicating that the information had not been updated for several days. This report was found in a plastic sheet protector taped inside a glass cabinet on the 100 hall, and it did not reflect the current staffing data or the resident census for the days in question. During an interview on 11/22/2024, the facility Administrator acknowledged the oversight and attributed it to the staffing coordinator being new to her position and not yet familiar with all the staffing requirements. The Administrator confirmed that it is a state requirement to have the staffing information posted daily, although there was no specific policy in place at the facility regarding this requirement. The lack of updated staffing information could potentially place residents, their families, and visitors at risk by not providing access to current staffing levels and resident census data.
Failure to Notify Resident and Representative of Discharge
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident and their representative regarding the resident's discharge and transfer to a psychiatric facility. The resident, a male with multiple diagnoses including hypertension, diabetes mellitus type 2, cognitive deficit, and mood disorder, was initially admitted to the facility and later discharged to a hospital before being transferred to a psychiatric facility for medication review and behavioral placement. Despite the resident's cognitive intactness, as indicated by a BIMS score of 14, the facility did not provide written notification of the discharge to the resident's representative or the LTC Ombudsman. The deficiency was further compounded by the facility's failure to update the recipients of the discharge notice as soon as practicable once updated information became available. The resident had exhibited aggressive behavior, including hitting another resident, which led to his transfer to a behavioral hospital. However, there was no documentation of written notification to the resident's representative or the LTC Ombudsman regarding the discharge, and the facility did not notify the Ombudsman by phone or in writing. Interviews with facility staff, the resident's representative, and the Ombudsman revealed that the facility did not follow proper procedures for notifying the necessary parties about the resident's discharge. The resident's representative was not informed about the transfer and discharge to another facility, and the Ombudsman was not notified of the discharge, which led to an appeal being accepted, allowing the resident to return to the facility. The facility's policy on transfer or discharge, which requires a 30-day advance written notice and notification to the LTC Ombudsman, was not adhered to in this case.
Failure to Honor Resident's DNR Wishes Due to Invalid OOHDNR Form
Penalty
Summary
The facility failed to comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) by not ensuring that Resident #1's Do Not Resuscitate (DNR) wishes were honored. Resident #1's Responsible Party (RP) had requested a DNR code status, but the Out-of-Hospital Do Not Resuscitate (OOHDNR) form was not valid as it lacked a physician's signature. Consequently, when Resident #1 was found unresponsive, Licensed Vocational Nurse (LVN) A and Registered Nurse (RN) B administered Cardiopulmonary Resuscitation (CPR) because they believed the resident was a full code. This action was taken despite the resident's electronic chart indicating a DNR status, which was not properly validated due to the missing physician's signature on the OOHDNR form. The resident was pronounced dead after CPR was continued by Emergency Medical Services (EMS) due to the invalid OOHDNR form. The deficiency was identified as Immediate Jeopardy (IJ) and was corrected before the survey began. Resident #1 had a complex medical history, including end-stage renal disease (ESRD), pulmonary edema, diabetes, altered mental status, anemia in chronic kidney disease, vascular dialysis catheter, peripheral vascular disease, acquired absence of the right leg below the knee, dependence on renal dialysis, and cognitive communication deficit disorder of the brain. The resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 2. Despite the resident's electronic chart indicating a DNR status, the lack of a valid OOHDNR form led to the administration of CPR, contrary to the resident's and RP's wishes. Interviews with staff revealed that there was confusion and a lack of clarity regarding the resident's code status. LVN A and RN B both believed the resident was a full code due to the absence of a valid OOHDNR form. The Admission/Marketer and ADON/RN/Medical Records D were involved in the process of obtaining the physician's signature for the OOHDNR form, but the form was never completed. The Director of Nursing (DON) confirmed that without a valid OOHDNR form, the resident would remain a full code. This failure to ensure the proper completion and validation of the OOHDNR form resulted in the resident's DNR wishes not being honored.
Removal Plan
- Staff training on OODNR/CPR/change of conditions conducted
- 84 of 84 direct care staff in-serviced regarding Code Status/change of condition
- Nurses, CNAs, and MAs trained on where to find the location of the code status
- Non-clinical staff instructed to refer to charge nurse for assistance with code status
- Staff instructed to notify ADON, DON, and Administrator immediately if code status does not match
- Administrator trained on where to locate a resident's code status in the electronic medical records system
- RN D trained on finding code status in different locations in the chart and verifying OODNR completion
- CNA E trained on checking residents' POC for code status and notifying charge nurse of changes
- ADON/LVN F trained on advanced directives, code status location, and OODNR validation
- MA G trained on code status location in the electronic medical records system and notifying charge nurse if code status does not match
- CNA H trained on checking residents' POC for code status and asking nurse about code status
- ADON/LVN I trained on finding code status in the electronic medical records system and verifying OODNR completion
- LVN J trained on advanced directives, mock CPR, and notifying ADM, DON, ADON if code status does not match
- LVN K trained on finding code status in the electronic medical records system and verifying OODNR completion
- CNA L trained on finding code status on residents' POC and notifying nurse of any changes
- CNA M trained on finding code status on residents' POC and alerting nurse of any changes
- DON trained on finding code status in the electronic medical records system and verifying OODNR completion
- Facility policy on Emergency Procedure- Cardiopulmonary Resuscitation reviewed and updated
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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