Lily Springs Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lampasas, Texas.
- Location
- 901 Central Texas Expwy, Lampasas, Texas 76550
- CMS Provider Number
- 455889
- Inspections on file
- 45
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Lily Springs Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents with cognitive and mental health diagnoses were spoken to in a sharp, condescending manner by an LVN during a supervised smoking break when one resident attempted to share a cigarette and later tried to keep an unfinished cigarette. The LVN loudly prohibited sharing and taking the cigarette, causing visible anger and upset in both residents. In interviews, one resident reported feeling treated like a child and being used to that manner of speech at the facility, while the other stated the LVN always spoke to them that way and believed race was a factor. The LVN cited a rule against sharing cigarettes for infection control but could not recall receiving training on dignity, and facility in-service records showed no recent, specific training on treating residents with dignity and respect despite a policy affirming residents’ rights to dignity and personal choice.
A resident with Alzheimer's disease, COPD, and muscle weakness was left in bed with their call light pad placed out of reach for nearly two hours after care was provided. The resident was unable to call for assistance, and staff interviews confirmed awareness of the requirement to keep call lights accessible. Facility policy also mandated that residents have a means to call for help, but this was not followed in this instance.
A resident with severe cognitive impairment and multiple mental health diagnoses did not receive scheduled showers as documented in her care plan and EMR. Staff interviews and record reviews confirmed missed showers on several dates, despite facility policy requiring assistance with personal hygiene for dependent residents.
A resident with hemiplegia, muscle weakness, and a history of trauma and anger issues was not permitted to have a powered wheelchair, despite reporting difficulty using a manual wheelchair due to shoulder pain. Facility staff cited concerns about the resident's aggressive behaviors and potential safety risks, referencing past incidents of aggression and the need for further evaluation. The resident felt she was being unfairly denied the powered wheelchair, and the facility did not uphold her right to retain and use personal possessions.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of the resident's care needs.
A resident with multiple medical conditions, including morbid obesity and legal blindness, was injured after falling from a bariatric shower chair during transport following a shower. The chair tipped when a CNA pushed it forward after the wheels became crooked, and the resident was not fully settled in the chair. The incident resulted in a right femur fracture and increased anxiety for the resident during shower times.
The facility did not provide sufficient activities to meet residents' interests and support their well-being, especially in the secured unit and on weekends. Observations and interviews showed that residents were often left without structured engagement, with staff unable to consistently provide activities due to interruptions and staffing limitations. The activities offered were limited, and residents and staff reported boredom and lack of stimulation, contrary to the facility's policy for individualized and comprehensive activity programming.
A secured memory care unit housing 14 residents with severe cognitive impairments was inadequately staffed, with only one or two staff members present at times. This resulted in residents being left unsupervised, leading to frequent incidents such as wandering, falls, aggression, and lack of engagement. Staff consistently reported that the staffing levels were insufficient to meet the residents' needs, and incident logs confirmed a high rate of accidents and behavioral issues in the unit.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols during high-contact care activities for two residents, including not donning gowns and not performing proper hand hygiene when changing gloves during peri-care and wound care, despite posted signage and prior training.
A resident with severe cognitive impairment and contracted hands was not provided with an accessible call light device, despite care plan requirements and staff awareness of the need for accommodations. Observations showed the call light was out of reach and no adaptive device was in place, and staff and leadership interviews confirmed the deficiency and its impact on the resident's ability to request assistance.
A resident with multiple health conditions sustained a right femur fracture after falling from a malfunctioning shower chair during transport. The facility did not report the incident to the State Agency as required by policy, and staff interviews revealed confusion about reporting requirements. The event was handled internally and not reported within the mandated timeframe, despite the injury's severity.
A resident with impaired vision and mobility needs sustained a femur fracture after falling from a shower chair, but the facility did not report the incident to the State Agency as required. Staff documented the event internally and notified the family and physician, but did not recognize the need for external reporting, despite facility policy mandating immediate notification for serious injuries.
A resident with severe cognitive impairment and multiple diagnoses had their Ativan discontinued by physician order, but the responsible party was not notified as required by facility policy. Staff interviews confirmed the expectation to notify the responsible party of significant treatment changes, but this did not occur, and documentation of notification was absent.
A facility failed to update a resident's care plan to reflect a change in their Advanced Directive from DNR to full code, resulting in the resident not receiving CPR when they expired. The resident, who had intact cognition and communicated his wishes, was not provided with the care he desired due to a lack of responsibility and communication among staff. This deficiency was identified as an Immediate Jeopardy situation.
A resident with heart failure, diabetes, and hypertension requested a change from DNR to Full Code, but the facility failed to update his records. During a medical emergency, staff followed the outdated DNR status, and CPR was not administered, leading to the resident's death.
A Med Tech administered medications to four residents with an expired license, which was not tracked by the facility. Despite no medication errors occurring, the lapse in licensure compliance could have risked inadequate care. The facility's policy for license verification and tracking was not effectively implemented.
A resident's Advanced Directive was not followed, resulting in the resident not receiving CPR and expiring. The incident was not reported to the State Survey Agency as required. The resident had heart failure, diabetes, and hypertension, and was cognitively intact. The Administrator failed to report the incident, which was against facility policy and state law.
A resident was not administered hospital-ordered antibiotics upon admission to the facility, resulting in a delay of several days before receiving Levofloxacin and Metronidazole. The admitting nurse did not enter the orders, and the error was discovered later by another nurse. The facility's policy on medication reconciliation was not followed, leading to this deficiency.
The facility failed to document flu vaccinations for two residents, resulting in them receiving double doses. The oversight occurred because the flu shots given during a clinic were documented on paper but not uploaded to the electronic system. Interviews with staff and residents confirmed the lack of documentation and the subsequent double administration of the vaccines.
The facility failed to implement an admissions policy requiring inventory sheets for residents' personal belongings, affecting three residents. One resident reported missing items, which were reimbursed, while another alleged missing belongings but was noted to be confused. Staff acknowledged the importance of inventory sheets, but the practice was not followed.
The facility failed to keep the medication room locked and supervised, allowing unauthorized access. Observations showed the room was left unlocked, and interviews with staff confirmed that it should be locked at all times. This breach of policy could lead to medications being accessed by residents, posing a risk to their health.
A resident with Alzheimer's, polyarthritis, and dementia did not have a comprehensive care plan developed within the required timeframe due to the vacancy of the MDS Nurse position. The facility's staff, including the DON and ADM, acknowledged the absence of a comprehensive care plan, which left staff without guidance on providing necessary care.
A medication cart was found unsupervised and unlocked in a hallway, containing various medications and supplies. The responsible MA was not present, and the cart was in a busy area with staff and residents. Interviews with staff, including the MA, LVN, DON, and ADM, confirmed that the cart should have been locked when unattended to prevent unauthorized access and potential resident harm.
A resident with Alzheimer's, polyarthritis, and dementia did not have a comprehensive care plan developed within the required timeframe after admission. The MDS Nurse responsible for care plans had vacated the position, leading to a lapse in care planning. Interviews with staff revealed that without the care plan, there was no guidance for providing necessary care, including ADLs. The facility's policy required a baseline care plan until a comprehensive one was developed, but this was not followed.
A facility failed to implement a comprehensive care plan for a resident, addressing only the risk of wandering while neglecting other significant health concerns such as depression, cognitive impairment, and fall risk. The MDS Nurse did not complete or update the care plan due to unfamiliarity with the documentation system and unclear responsibilities, while the DON did not ensure proper oversight. This deficiency placed the resident at risk of unmet needs.
A resident with dementia exhibited signs of fear and pain during a mechanical lift transfer and incontinent care when two CNAs failed to identify themselves or explain the procedure. The CNAs engaged in personal conversation instead of communicating with the resident, who was unable to verbally communicate but understood when spoken to. The facility's DON had previously emphasized the importance of professional communication with residents.
The facility failed to provide scheduled showers to three residents, leading to a decline in hygiene and feelings of neglect. A cognitively intact male with mobility issues received only one shower in a month, while a female with moderate cognitive impairment and physical disabilities received four showers. Another male with physical disabilities received three showers. Staff interviews revealed a lack of communication and accountability for missed showers.
A resident with limited range of motion did not receive appropriate care as the facility failed to apply a prescribed hand contracture cushion. The resident, with dementia and osteoarthritis, was observed without the cushion, which was meant to prevent further contraction and skin issues. Nursing staff admitted to forgetting to replace the cushion after wound care, and the facility's policy did not emphasize the importance of following physician orders.
A resident in a LTC facility experienced a violation of privacy and consent when placed in a room with electronic monitoring equipment that included audio capabilities, without her consent. The resident's personal property was also searched without permission. Facility staff acknowledged the lack of proper documentation and consent procedures, failing to adhere to policies on resident rights and personal property.
The facility failed to securely store medications, with drugs left unattended on medication and linen carts, and at residents' bedsides. Observations revealed unsecured medications on the 500 and 100 hall carts, and a medication cup with creams on a linen cart. Two residents with impaired cognition had medications improperly stored at their bedsides, contrary to facility policy. Staff interviews confirmed the lapses in following storage protocols, highlighting deficiencies in medication security and adherence to policies.
A resident with multiple health issues, including legal blindness and congestive heart failure, did not receive adequate bathing services as required by the facility's policy. Despite the resident's need for assistance with activities of daily living, the care plan did not address showering, and the resident reported only having three showers since admission. Interviews with the ADON and DON confirmed that wiping a resident's back and legs does not meet the facility's definition of a bath or shower.
The facility failed to ensure a safe environment by allowing unauthorized items on linen carts in two hallways, posing potential risks to residents. Observations revealed items like razors and creams on carts, which should only contain linens, briefs, and gloves. Staff interviews confirmed the oversight and lack of a specific Linen Cart policy contributed to the issue.
Failure to Maintain Resident Dignity During Supervised Smoking Break
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity during a supervised smoking break. A male resident with hypertension, schizophrenia, a history of traumatic brain injury, and mildly impaired cognition (BIMS 12) and a female resident with anxiety disorder, vascular dementia, depression, and severely impaired cognition (BIMS 6) were observed at a smoke break along with other residents. The LVN supervising the smoke break controlled the cigarettes and lighter. When the LVN reached the male resident, she told him she did not have cigarettes for him because staff had not been to the store; he became visibly upset, with a pursed brow, frown, and looking away, but did not speak. Shortly afterward, the female resident attempted to share her cigarette with him. In response, the LVN spoke in a sharp and condescending tone, loudly saying, “No! No! Yall can't be sharing. nuh-uh, no ma'am!” audible to all residents and the surveyor. When the female resident questioned when the rule had changed, the LVN replied, “It's just policy you cannot share. It's been a thing for a while,” and confirmed “Uh huh 100%” when the resident asked if she was serious. The male resident then made an angry facial expression and left the smoking area. The LVN further told the female resident, “No, ma'am, you cannot take that with you,” when she tried to pocket her unfinished cigarette, and held an ashtray out in front of her, after which the resident angrily threw the cigarette butt into the ashtray and left the area. In interviews, the male resident stated he was angry about what happened, felt he had been spoken to as a child, and that it made him feel “shitty,” adding that he was used to being spoken to that way at the facility. The female resident stated the LVN always spoke to them like that, had not reported it as a grievance because she thought it would make things worse, and believed the LVN did not like Black people and that this was why she spoke to them in that manner. She also stated she understood sharing a cigarette could be an infection control problem but had not known it was against the rules. The LVN reported she had been told residents could not share cigarettes due to infection control but could not recall who told her or any training on dignity or enforcing rules while maintaining dignity. Review of in-service records from October 2025 through January 2026 showed no specific in-service on treating residents with dignity and respect, and the facility’s policy on Rights of the Elderly stated residents have the right to be treated with dignity and respect for personal integrity without regard to race or other characteristics and to make their own choices regarding personal affairs, care, benefits, and services.
Call Light Not Kept Within Reach for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, chronic obstructive pulmonary disease, lack of coordination, and muscle weakness was found to have their call light pad placed out of reach while lying in bed. The resident, who had moderate cognitive impairment and required varying levels of assistance with activities of daily living, stated that the CNA must have moved the call pad during care and did not return it to an accessible position. Observations confirmed that the call light remained out of reach for nearly two hours, during which time the resident was unable to call for assistance if needed. Interviews with staff, including a CNA, the ADON, and the ADM, revealed that all were aware of the policy requiring call lights to be within reach and acknowledged it was everyone's responsibility to ensure this. The facility's policy also specified that each resident must have a means to call staff for assistance from their bed, and alternative communication methods should be provided and documented if a resident is unable to use the standard system. Despite these policies and staff awareness, the call light was not returned to the resident's reach, resulting in a failure to provide reasonable accommodation for the resident's needs.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide care and services to assist a resident with activities of daily living, specifically in maintaining personal hygiene through scheduled showers. Record review showed that a female resident with severe cognitive impairment, dementia, generalized anxiety disorder, and major depressive disorder was dependent on staff for bathing and other ADLs. Despite a care plan and EMR documentation specifying a shower schedule, there was no evidence that the resident received showers or baths on several scheduled dates. The resident herself reported not having received a bath in a while, though she could not recall specific dates. Interviews with staff, including a CNA, the ADON, and the administrator, confirmed that the resident did not receive her scheduled showers on the identified dates. Staff acknowledged that missing scheduled baths or showers could result in odor or skin issues, and the facility's policy required staff to assist residents with personal hygiene to prevent such problems. The failure to follow the resident's care plan and shower schedule constituted a deficiency in providing necessary care and services for activities of daily living.
Failure to Allow Resident Use of Powered Wheelchair Due to Behavioral Concerns
Penalty
Summary
The facility failed to maintain a resident's right to retain and use personal possessions by not allowing a resident to have a powered wheelchair. The resident, a female with a history of hemiplegia, muscle weakness, difficulty walking, and other medical conditions, was admitted with intact cognition as evidenced by a BIMS score of 15. Her care plan included interventions for trauma, anger issues, and emotional regulation, and she was receiving therapy and medication management. Despite her expressed need for a powered wheelchair due to shoulder pain and difficulty self-propelling a manual wheelchair, the facility staff repeatedly told her she could not have one. Interviews with facility staff, including the DON, ADON, PsyD, and OTA, revealed concerns about the resident's history of aggression and the potential for her to use a powered wheelchair in a manner that could endanger herself or others. Staff cited incidents where the resident had been aggressive, including bumping into others with her manual wheelchair and being placed on 1:1 supervision for lashing out. The PsyD and OTA expressed concerns about her ability to safely operate a powered wheelchair, referencing her behavioral history and the need for further evaluation by therapy and the IDT before making a decision. The resident reported feeling that she was being denied the powered wheelchair due to perceived prejudice from therapy staff and her history of aggressive behavior. She described an incident where she fell while using a manual wheelchair, resulting in injury and involvement of EMS and law enforcement. The facility's policy on resident rights, which includes the right to a dignified existence and to retain personal possessions, was not upheld in this instance, as the resident was not allowed to have the powered wheelchair she requested.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Provide Safe Supervision and Equipment During Resident Transport Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and safe assistance devices to prevent accidents for a resident with significant medical needs. The resident, a male with a history of morbid obesity, legal blindness, chronic obstructive pulmonary disease, osteoarthritis, and previous right femur and tibia fractures, required extensive assistance for mobility and transfers. Despite these needs, the resident was transported in a bariatric shower chair after a shower, during which the chair tipped and the resident fell, resulting in a right femur fracture. The incident report and interviews revealed that the resident was still wet from the shower, the wheels of the chair became crooked, and the chair was pushed forward at an angle, causing the resident to fall and sustain injury. Interviews with staff indicated that the shower chair was believed to be appropriate for the resident's weight, and maintenance records showed the chair had been inspected and was within its weight limit. However, the incident occurred when the resident adjusted himself in the chair and indicated he was ready to be transported, but was not fully settled. The CNA transporting the resident did not stop to ensure the resident was properly positioned before moving, and when the chair's wheel got stuck while rounding a corner, the CNA pushed the chair forward, leading to the tip and fall. The resident reported immediate pain and gross deformity, and was subsequently hospitalized for a right distal shaft femur fracture. The facility's investigation initially ruled out abuse and neglect, citing that the fall was witnessed, the equipment was within weight limits, and the staff member had not acted improperly according to their policies. However, the investigation was later reopened, and it was found that the facility failed to provide adequate supervision and did not ensure the safe use of assistance devices during resident transport, directly resulting in the resident's injury. The event led to increased anxiety for the resident around shower times and a reduced quality of life.
Failure to Provide Adequate Resident Activities and Engagement
Penalty
Summary
The facility failed to provide activities that met the interests and supported the physical, mental, and psychosocial well-being of all residents, particularly in the secured unit and on weekends. Observations revealed that residents were often left without structured activities, with some wandering the hallways or sitting idly at tables. The activities coordinator (ACT) was frequently the only staff member present to supervise and conduct activities, and was often interrupted to manage behavioral issues, leaving residents without consistent engagement. On weekends, there were no dedicated activities staff, and residents relied on limited options such as coloring, puzzles, or watching TV, with no formal activities provided. Interviews with staff and residents confirmed the lack of meaningful activities, especially during weekends and evenings. Residents described feeling bored and under-stimulated, with some expressing that all they did was smoke or play games they retrieved themselves. Staff members, including CNAs and LVNs, reported difficulty in providing activities due to staffing shortages and competing responsibilities, such as supervising residents or managing behaviors. The ACT and other staff noted that interruptions and lack of support made it challenging to keep residents engaged throughout the day. A review of the activities calendar showed that while some activities were scheduled, they were limited in scope and frequency, particularly on weekends. The facility's policy required a comprehensive activity program tailored to individual needs and interests, including social, physical, creative, and religious activities, offered at convenient times, including evenings and weekends. However, the observed and reported practices did not align with these requirements, resulting in unmet needs for resident engagement and well-being.
Insufficient Staffing in Secured Memory Care Unit Leads to Increased Incidents
Penalty
Summary
The facility failed to provide sufficient staffing with the necessary competencies and skills to meet the behavioral health needs of all 14 residents in the secured memory care unit. Observations revealed that at various times, only one or two staff members were present to supervise and care for residents with severe cognitive impairments, including Alzheimer's disease and dementia. Staff were frequently occupied with individual resident care tasks, leaving other residents unsupervised, which led to situations where residents wandered, entered other residents' rooms, or engaged in unsafe behaviors such as pushing wheelchairs or fighting over snacks. Staff interviews consistently indicated that the staffing levels were inadequate to provide the required supervision and care, especially given the residents' high needs for assistance with activities of daily living (ADLs) and behavioral management. Incident logs showed a disproportionate number of accidents and behavioral incidents in the secured unit compared to the rest of the facility. Of the total incidents recorded since the beginning of the year, 40% involved the 14 residents in the secured unit, who made up only 22% of the facility's population. These incidents included physical aggression, exit-seeking, bruises, and both witnessed and unwitnessed falls. Staff reported that many falls and incidents occurred when they were busy assisting other residents, and that the lack of supervision contributed to increased wandering and aggression among residents. The activity staff, who were intended to provide engagement, were frequently interrupted to address behavioral issues due to the lack of available nursing staff. Interviews with staff, including CNAs, LPNs, the activity director, and the psychiatric physician's assistant, all highlighted the challenges posed by insufficient staffing. Staff expressed concerns about resident safety, the inability to provide adequate supervision, and the increased workload leading to burnout. The facility's own policy required staffing levels to be based on resident needs and care plans, but the increase in resident numbers in the secured unit was not matched by an increase in staff. Overnight shifts were particularly understaffed, with only one CNA assigned to the secured unit and two nurses for the entire facility. The deficiency was further corroborated by the experiences of responsible parties and staff who reported frequent falls, increased aggression, and a lack of engagement for residents due to inadequate supervision.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during care provided to two residents. Certified Nursing Assistants (CNAs) did not consistently perform hand hygiene when changing gloves during peri-care and wound care. Specifically, during Foley catheter care for a resident with a stage 4 sacral pressure ulcer and other significant medical conditions, the CNA and Assistant Director of Nursing (ADON) did not don gowns as required by Enhanced Barrier Precautions signage. The CNA also changed gloves without performing hand hygiene, and soiled wipes were observed in a trash bag at the foot of the bed, with some wipes touching the resident's top sheet and the resident's feet coming into contact with the soiled wipes. During wound care for the same resident, the Licensed Vocational Nurse (LVN) and Registered Nurse (RN) donned gowns and gloves as required, but the LVN removed gloves and handled a wound dressing with bare hands before sanitizing and re-gloving. For another resident with colon cancer and a neuromuscular bladder dysfunction, two CNAs provided peri-care without donning gowns, despite Enhanced Barrier Precautions signage. One CNA was observed applying hand sanitizer in a haphazard manner while holding a glove, and then donning the glove without proper hand hygiene. Interviews with the CNA, ADON, and Director of Nursing (DON) confirmed that staff were aware of the requirements for hand hygiene and the use of gowns and gloves during high-contact care activities for residents on Enhanced Barrier Precautions. Facility policies and CDC guidance were reviewed, indicating that hand hygiene and proper use of personal protective equipment (PPE) are required during high-contact care activities, and that supplies should be readily accessible. In-service records showed that the involved CNA had received training on infection control and Enhanced Barrier Precautions prior to the observed deficiencies.
Failure to Provide Accessible Call Light Device for Resident with Contractures
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the needs and preferences of a resident with severe cognitive impairment and multiple physical disabilities, including contractures of the hands and wrists. The resident required extensive assistance with all activities of daily living and had a care plan specifying that the call light should be within reach and that staff should encourage its use for assistance. Despite this, observations on multiple occasions revealed that the call light button was out of reach, either lying on the floor or clipped to the side of the bed, making it inaccessible due to the resident's contracted hands. There was no evidence of an alternative call light device, such as a call light pad button, being provided during these observations. Interviews with staff confirmed that the resident would benefit from a call light pad button device placed on the chest, as the original call light system was not feasible for the resident's physical limitations. Staff acknowledged that the resident had not previously used the original call light system and that the lack of an appropriate device could prevent the resident from requesting assistance. The responsible party also indicated that a call light pad button would be easier for the resident to use, given the contractures. Facility leadership, including the DON and Administrator, stated that staff are responsible for ensuring call light devices are within reach and appropriate for each resident's needs. They confirmed that the original call light device was not suitable for this resident and that the care plan required individualized accommodations. Facility policies reviewed also required that adaptive devices be provided and documented for residents unable to use standard call systems, but these accommodations were not in place at the time of the observations.
Failure to Report Major Injury and Implement Abuse Reporting Policy
Penalty
Summary
The facility failed to develop and implement abuse reporting policies as required, specifically in the case of one resident who experienced a significant injury. The resident, a male with multiple medical conditions including legal blindness, morbid obesity, and a history of fractures, fell out of a shower chair while being transported back to his room after a shower. The incident resulted in a right femur fracture, and the resident was subsequently hospitalized. Documentation indicated that the shower chair's wheels malfunctioned, contributing to the fall, and the resident reported hearing a loud pop and experiencing immediate pain and inability to bear weight. Despite the severity of the injury, the facility did not report the incident to the State Agency as required by their abuse prohibition policy. Interviews with staff revealed confusion and lack of clarity regarding what constitutes a reportable event, with some staff believing that any fracture should be reported, while others deferred to internal investigations that ruled out abuse or neglect. The incident was not reported within the required two-hour window, and the facility's abuse coordinator and administration determined in-house that the event was not suspicious and did not meet their criteria for neglect or abuse, despite the major injury. Further review showed that the facility's policy required reporting all allegations and substantiated occurrences of abuse, neglect, or misappropriation, especially those resulting in serious bodily injury, to the state agency immediately or within two hours. However, the incident involving the resident's fall and fracture was not reported as mandated. The lack of reporting was confirmed through interviews and record reviews, and a complaint was later filed by the resident alleging neglect due to the injury.
Failure to Timely Report Serious Injury Following Resident Fall
Penalty
Summary
The facility failed to ensure that all allegations involving abuse, neglect, or serious bodily injuries were reported immediately, but not later than 24 hours after the allegation was made. Specifically, an incident occurred in which a male resident with a history of impaired vision, right femur and tibia fractures, and osteoarthritis fell out of a shower chair while being transported back to his room. The incident resulted in a right distal shaft femur fracture, which was confirmed by hospital records. The resident required extensive assistance for mobility and had been receiving physical therapy following the injury. Despite the severity of the injury and the requirement to report such incidents to the State Agency, the facility did not submit a report regarding the fall and resulting fracture. The incident was documented internally, and the resident's family and medical provider were notified. However, the event was not reported to the State Agency as required by facility policy and state regulations. The omission was confirmed through interviews with facility staff, including the Abuse Coordinator, DON, and other nursing staff, who indicated that they either did not believe the incident met the criteria for reporting or were unaware of the reporting requirements. The facility's own Abuse Prohibition Policy mandates immediate reporting of all allegations and substantiated occurrences of abuse, neglect, or serious bodily injury to the state agency. In this case, the incident was not reported, and the failure to do so was attributed to the staff's interpretation of the event as non-suspicious and not indicative of neglect or abuse. The lack of timely reporting was further highlighted when a complaint was later filed by the resident, prompting an investigation.
Failure to Notify Responsible Party of Medication Discontinuation
Penalty
Summary
The facility failed to immediately notify a resident's responsible party (RP) when there was a significant change in treatment, specifically the discontinuation of the medication Ativan, as ordered by the physician. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 7, and diagnoses including anxiety disorder, major depressive disorder, and primary hypertension. Documentation review showed that Ativan was discontinued, but there was no record of the RP being notified of this change. The RP later confirmed in an interview that she was not informed about the discontinuation and would have wanted to know, especially as she lived out of state. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that it was the facility's expectation and policy to notify the RP of such significant changes, but this did not occur. The ADON acknowledged the oversight, and both the DON and ADM reiterated that the RP would not have known about the medication change without being contacted. The facility's policy requires notification of the family or legal representative and physician when there is a significant change in the resident's status or a need to alter treatment, which was not followed in this instance.
Failure to Update Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes that met the resident's medical, nursing, and mental and psychosocial needs. The deficiency was identified when the facility did not update the resident's care plan to reflect a change in the resident's Advanced Directive from Do Not Resuscitate (DNR) to full code. This oversight resulted in the resident not receiving CPR when they expired at the facility. The resident, a male with diagnoses including heart failure, diabetes, and hypertension, had a BIMS score indicating intact cognition and was able to communicate his needs and wishes. Despite expressing a desire to change his code status to full code during a care plan meeting, this change was not documented in the care plan. Interviews with facility staff, including the Social Worker (SW), MDS Coordinator, and Director of Nursing (DON), revealed that the responsibility for updating the care plan was not clearly assigned, leading to the resident's wishes not being followed. The facility's policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, but this was not adhered to in this case. The failure to update the care plan with the resident's code status change was attributed to a lack of communication and responsibility among the staff, as the previous MDS Coordinator, who was responsible for the update, was no longer at the facility. This deficiency was determined to be an Immediate Jeopardy situation, indicating a serious risk to resident safety.
Removal Plan
- A comprehensive review of all residents was conducted to verify code status and to ensure care plan status reflects resident current choices by DON, ADON, and Corporate Clinical Specialists.
- An Ad Hoc QAPI was held to include Medical Director, DON, Administrator and Corporate Clinical Specialist.
- A care plan training session was successfully conducted by Corporate Clinical Specialist with the interdisciplinary team, focusing on the detailed process of updating code status within the care plan, as well as providing clear instructions on how to effectively implement and modify any necessary changes.
- The above information will be included in new hire orientation, by the Administrator.
- The DON/designee will ensure advance directive care plans are updated immediately following a status change and will conduct audits of advance directive care plans to ensure accuracy in electronic medical records (E.M.R.) weekly. After, the DON/designee will follow the above process twice a month, then monthly thereafter.
- The facility QA Committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
Failure to Update Code Status Leads to Resident's Death
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident had requested a change in his code status from DNR (do not resuscitate) to Full Code, but the facility did not update his records to reflect this change. As a result, when the resident experienced a medical emergency and became non-responsive, CPR was not administered, and he subsequently expired. The resident was a male with diagnoses including heart failure, diabetes, and hypertension. He had a BIMS score indicating intact cognition and was able to communicate his needs and wishes. Despite his request to change his code status to Full Code during a care plan meeting, the facility's records and the nurse's station binder still reflected a DNR status. This discrepancy led to the failure to provide life-saving measures when the resident fell back in his bed and became non-responsive while talking to EMS. Interviews with facility staff revealed that the responsibility for updating the resident's code status was not fulfilled. The MDS Coordinator, who was responsible for making the change, did not update the records, and the nursing staff followed the outdated DNR status in the electronic medical records. This oversight resulted in the resident's wishes not being honored, and no CPR was performed, contributing to the resident's death.
Removal Plan
- A comprehensive review of all residents was conducted by DON, ADON, and Corporate Clinical Specialists to verify code status, medical orders, care plan, and DNR documentation.
- Care plans were checked to ensure alignment with advance directive documentation by DON, ADON, and Corporate Clinical Specialists.
- Advance directive binders at the nurses' station were cross-checked, with necessary adjustments made to DNR documentation by DON, ADON, and Corporate Clinical Specialists. DON/Designee will keep binders updated on an ongoing basis. All staff were in-serviced on binders kept at the nursing station.
- An Ad Hoc QAPI was held to include Medical Director, DON, Administrator, and Corporate Clinical Specialist.
- Inservice DON and ADON was completed by Corporate Clinical Specialist on the following: How to document, identify and update code status on residents. CCS/DON/Nursing Administration will in-service licensed staff on the following: How to document, identify and update code status on residents. Competency was validated by verbal quizzes. Any staff that were not in-serviced will not be able to work the floor until training and competency is validated by DON/Designee.
- Inservice was provided to all staff on how to identify code status by nursing admin. Competency validated by verbal quizzes.
- The above information will be included in new hire orientation by Administrator.
- The Administrator/designee will conduct audits of advance directive documentation to ensure accuracy in electronic medical records (E.M.R.) weekly. After 4 weeks, the Adm/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter.
- DON/designee will perform quarterly mock code drills for 1 year to ensure staff can effectively identify code status and respond correctly to emergencies.
- The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
Expired Med Tech License Leads to Deficiency
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with applicable state laws, specifically concerning medication administration for four residents. Med Tech M administered medications to these residents while her Med Tech license was expired. This lapse in licensure compliance occurred over a period of eight days, during which Med Tech M was unaware of her expired status and continued to provide medications to residents. The residents involved had various medical conditions, including heart failure, diabetes, hypertension, chronic respiratory failure, COPD, and depression. Despite the expired license, there were no recorded medication errors during the period Med Tech M administered medications. However, the facility's failure to ensure that Med Tech M's license was current could have placed residents at risk for inadequate care and services. Interviews with facility staff revealed that the responsibility for tracking license renewals was not clearly managed. The HRR admitted to not tracking licenses prior to the incident, and the ADM confirmed that Med Tech M was removed from medication administration duties once the expired license was discovered. The facility's policy required a system for license verification and tracking, which was not effectively implemented, leading to this deficiency.
Failure to Report Incident of Unhonored Advanced Directive
Penalty
Summary
The facility failed to report an incident involving a resident whose Advanced Directive was not followed, resulting in the resident not receiving CPR and subsequently expiring. The incident was not reported to the State Survey Agency as required by regulations. The resident, a male with diagnoses including heart failure, diabetes, and hypertension, was admitted to the facility and had a BIMS score indicating intact cognition. On the day of the incident, the resident experienced chest pain and shortness of breath, and despite being placed on oxygen and receiving aspirin, he became non-responsive and was pronounced dead shortly after EMS arrived. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the ADM was responsible for reporting the incident but failed to do so. The facility's policy required such incidents to be reported within 24 hours, but this was not adhered to. The ADM acknowledged the expectation to report the incident and admitted that the state reportable was not sent, which could lead to further neglect of residents. The facility's failure to report the incident as required by state law and facility policy constitutes a deficiency in ensuring the safety and well-being of its residents.
Failure to Administer Hospital-Ordered Medications on Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the accurate acquiring, receiving, dispensing, and administering of medications. A resident was discharged from the hospital with orders for Levofloxacin and Metronidazole to treat infections. However, these medications were not documented as ordered upon the resident's admission to the facility, resulting in a delay in administration. The resident did not receive the first dose of Levofloxacin until nine days after admission and the first dose of Metronidazole eight days after admission. Interviews with facility staff revealed that the admitting nurse, LVN J, did not recall entering the antibiotic orders upon the resident's admission. LVN K later discovered the omission and initiated the orders after consulting with the nurse practitioner (NP). The NP confirmed that the resident did not receive the antibiotics as ordered upon admission and noted that the hospital physician was attempting to determine the most effective antibiotic for the resident's lung lesions. The NP could not ascertain if the delay in receiving antibiotics had any adverse effects on the resident. The facility's Director of Nursing (DON) and Administrator (ADM) both stated that it was expected for all hospital discharge orders to be entered into the system at the time of admission. The facility's policy on medication reconciliation for new admissions and readmissions was not followed, leading to the deficiency. The report highlights the failure to ensure that the resident received the necessary medications promptly, which could have impacted the resident's recovery and well-being.
Failure to Document Flu Vaccinations Leads to Double Dosing
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure that each resident was offered influenza and pneumococcal immunizations as required. Specifically, the facility did not document the administration of flu vaccines for two residents, leading to them receiving double vaccinations. This oversight was identified during a review of records and interviews with staff and residents. Resident #3, a female with moderate cognitive impairment and multiple diagnoses including hypertension and diabetes, received a flu shot on two consecutive days in November 2024. The facility's records did not reflect any prior documentation of the flu shot being administered before these dates. Similarly, Resident #4, a female with intact cognitive function and diagnoses including heart failure and COPD, also received a flu shot twice, with no prior documentation of the first administration. Interviews with the residents indicated they did not recall receiving two shots, and no adverse reactions were reported. Interviews with facility staff, including the RN who administered the vaccines and the current DON, revealed that the flu shots given during a clinic in October 2024 were documented on paper but not uploaded to the facility's electronic system, PCC. This lack of documentation led to the double administration of the flu vaccines. The ADM confirmed that the previous DON, who assisted with the clinic, was no longer employed at the facility, and attempts to contact the previous MDS Coordinator and DON were unsuccessful.
Failure to Implement Admissions Policy for Personal Property Inventory
Penalty
Summary
The facility failed to implement an admissions policy that did not require residents to waive potential facility liability for the loss of personal property. This deficiency was identified for three residents who did not have completed inventory sheets for their personal belongings upon admission. The absence of these inventory sheets could place residents at risk of not having their personal property replaced in the event of damage or loss. The facility's undated admission packet indicated that residents or their representatives should complete and sign an inventory form listing personal belongings at the time of admission, but this was not done for the residents reviewed. Interviews and record reviews revealed that Resident #1, Resident #2, and Resident #3 did not have completed inventory sheets in their electronic medical records. Resident #1 had filed a grievance about missing personal items, which the facility reimbursed. Resident #3 alleged that his belongings were missing, but the facility's social worker stated that he was confused and did not arrive with the items he claimed were missing. The social worker and an LVN both acknowledged the importance of completing inventory sheets to track residents' belongings, but noted that this practice was not being followed. The facility did not provide a policy on admissions or inventory sheets when requested.
Medication Room Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and that only authorized personnel had access to the keys for the medication room. On the date of the survey, the medication room was observed to be unlocked and unsupervised, with residents passing by in their wheelchairs. This situation was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged that the room was usually locked when not in use and that authorized staff, such as nurses and medication aides, had access to it. Further observations and interviews revealed that the ADON herself left the medication room unlocked when she exited, and both RN A and LVN B confirmed that the medication room should be locked at all times to prevent unauthorized access. The facility's medication labeling and storage policy, revised in February 2023, mandates that compartments containing medications and biologicals must be locked when not in use. The failure to adhere to this policy could lead to medications going missing or being ingested by residents, posing a risk to their health and safety.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, which was identified during a survey. The resident, a male with Alzheimer's disease, polyarthritis, and dementia, was admitted to the facility and had a severely impaired cognition with a BIMS score of 3. Despite the requirement for a comprehensive care plan to be completed within 21 days of admission, only a baseline care plan was documented, and no comprehensive care plan was developed. This oversight was confirmed through interviews with facility staff, including an LVN and the DON, who acknowledged the absence of a comprehensive care plan. The deficiency was attributed to the vacancy of the MDS Nurse position, which was responsible for completing care plans. The DON and ADM both stated that the expectation was for all residents to have a baseline care plan completed within 48 hours and a comprehensive care plan within 21 days. The lack of a comprehensive care plan left staff without guidance on how to provide necessary care for the resident, including ambulation, eating, walking, and ADLs. The facility's policy required the baseline care plan to be used until a comprehensive assessment and interdisciplinary person-centered care plan were developed, which did not occur in this case.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, making them inaccessible to unauthorized staff, visitors, and residents. This deficiency was observed when Med Cart #1 was found unsupervised and unlocked in the hallway near the nurses' station. The cart contained prescription and over-the-counter medications, ointments, glucometer supplies, insulin pens, and insulin syringes. The medication aide (MA) responsible for the cart was not within eyesight, and another staff member had to shout for the MA to return and lock the cart. This incident occurred in a busy area with numerous staff and residents present. Interviews with the MA, LVN, DON, and ADM revealed a consensus that the medication cart should have been locked whenever the staff member was not directly in front of it. The MA acknowledged the lapse in protocol, despite having recently attended an in-service on med-cart safety. The LVN, DON, and ADM all identified significant risks associated with the unlocked cart, including the potential for residents to access medications they are not prescribed, leading to allergic reactions or overdose. The expectation from all interviewed staff was clear: medication carts must be locked when unattended to prevent unauthorized access and ensure resident safety.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, which is a deficiency in their care planning process. The resident, a male with Alzheimer's disease, polyarthritis, and dementia, was admitted to the facility and had a severely impaired cognition with a BIMS score of 3. Despite the requirement for a comprehensive care plan to be completed within 21 days of admission, only a baseline care plan was completed, and no comprehensive care plan was developed. This oversight was identified during a record review and interviews with facility staff. Interviews with the LVN, DON, and ADM revealed that the MDS Nurse, who was responsible for completing care plans, had vacated the position two weeks prior, leading to the lapse in care plan development. The staff acknowledged that without a comprehensive care plan, there was no guidance for providing necessary care to the resident, including ambulation, eating, walking, and ADLs. The facility's policy required a baseline care plan to be used until a comprehensive assessment and care plan were developed, but this was not adhered to, resulting in a lack of direction for the resident's care.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. The care plan was not completed upon the resident's admission and was not updated to reflect changes in the resident's care needs, such as falls, medications, cognition, and other health concerns. This oversight placed the resident at risk of not having their individualized needs met in a timely manner, potentially affecting their physical and psychosocial well-being. The resident, an elderly male, was admitted with multiple diagnoses, including recurrent major depressive disorder, age-related cognitive decline, difficulty walking, joint pain, insomnia, urinary tract infection, and essential hypertension. Despite these conditions, the care plan only addressed the resident's risk of wandering due to confusion and wandering behavior. The comprehensive MDS assessment indicated severe cognitive impairment and frequent feelings of depression, yet these were not adequately addressed in the care plan. Interviews with facility staff revealed that the MDS Nurse, responsible for completing and updating care plans, was not fulfilling these duties due to a lack of understanding of the Point Click Care system and unclear job responsibilities. The Director of Nursing admitted to not ensuring that care plans were completed as needed, assuming the MDS Nurse was capable due to prior experience. This lack of oversight and communication contributed to the deficiency in providing a comprehensive care plan for the resident.
Failure to Communicate with Resident During Care
Penalty
Summary
The facility failed to treat a resident with respect and dignity during a mechanical lift transfer and incontinent care. Two CNAs did not identify themselves or explain the procedure to the resident, who exhibited nonverbal signs of fear and pain, such as widened eyes, an open mouth, and facial grimacing. The resident, who had unspecified dementia and was dependent on a hoyer lift for transfers, was not engaged by the CNAs during the procedure. Instead, the CNAs conversed with each other about personal matters, neglecting to communicate with the resident. The resident's family member expressed frustration over the staff's lack of communication, noting that the resident understood when spoken to despite her inability to communicate verbally. The facility's Director of Nursing (DON) stated that staff are expected to communicate professionally with residents, focusing solely on their care. An in-service conducted by the DON prior to the incident emphasized the importance of acknowledging, introducing, and explaining procedures to residents. However, during the observed incident, the CNAs failed to adhere to these guidelines, resulting in the resident's distress.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain good hygiene, nutrition, grooming, and personal and oral hygiene. Specifically, the facility did not provide showers to three residents in compliance with their shower schedules. This deficiency was observed in three out of five residents reviewed for ADLs, potentially placing them at risk of a decline in hygiene and other related issues. Resident #2, a cognitively intact male with intellectual disabilities and mobility issues, was supposed to receive showers on Mondays, Wednesdays, and Fridays. However, records showed he only received one shower over a month-long period. During an interview, he expressed feeling neglected and having to wash up using the sink in his room. Similarly, Resident #3, a female with moderate cognitive impairment and physical disabilities, was also supposed to receive showers three times a week but only received four showers in a month. She reported feeling unclean and unable to remember her last shower. Resident #4, a cognitively intact male with physical disabilities, also did not receive showers as scheduled, receiving only three showers in a month. He expressed frustration and a sense of neglect due to the lack of assistance with his care. Interviews with staff revealed that shower aides were responsible for giving showers, but if they were absent, other aides were supposed to step in. However, there was a lack of communication and accountability, leading to missed showers. The Director of Nursing acknowledged the issue and the potential negative outcomes of not receiving regular showers.
Failure to Apply Hand Contracture Cushion
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically by not applying a hand contracture cushion as prescribed. The resident, an elderly female with unspecified dementia, generalized muscle weakness, and osteoarthritis, was observed without the necessary hand cushion during a transfer. The cushion was intended to prevent further contraction and skin irritation or wounds on her contracted left hand. The resident's care plan and physician's orders included the use of a hand contracture cushion to be applied every Monday, Wednesday, and Friday, but this was not adhered to. During interviews, it was revealed that the responsibility for ensuring the cushion was in place fell to the nursing staff. A nurse admitted to removing the cushion for wound care and forgetting to replace it. The Director of Nursing confirmed the importance of following physician orders to prevent further contraction or skin issues. The facility's policy on physician orders did not address the importance of adherence, contributing to the oversight.
Failure to Ensure Resident Privacy and Consent for Monitoring
Penalty
Summary
The facility failed to uphold the resident rights of a resident, specifically regarding privacy and consent for electronic monitoring. The resident, who had intact cognition and was dependent on staff for all activities of daily living, was placed in a room with another resident who had electronic monitoring equipment installed. The monitoring equipment included audio capabilities, and the resident did not consent to this monitoring. The resident became aware of the audio feature after a private conversation was overheard and reported by the roommate's family, leading to feelings of distress and a lack of privacy. Additionally, the facility did not obtain the necessary consent from the resident before searching her personal property. The resident reported an incident where a registered nurse searched her drawer without permission, looking for vape pens to store in the medication room. This unauthorized search further contributed to the resident's sense of violated privacy and lack of control over her personal space. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator (ADM), revealed a lack of proper documentation and consent procedures for electronic monitoring. The staff acknowledged the importance of obtaining consent and maintaining privacy but failed to implement these practices effectively. The facility's policies on resident rights and personal property were not adhered to, resulting in a deficiency in respecting and supporting the resident's rights to privacy and dignity.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and only accessible to authorized personnel. Observations revealed that medication carts on the 500 and 100 halls were not properly secured, with medications left unattended on top of the carts. Additionally, a medication cup containing three types of unidentified cream was found unattended on a linen cart in the 500 hall. These lapses in security were noted during a period when multiple staff and residents passed by the unsecured medications. Further deficiencies were observed in the storage of medications at residents' bedsides. A medication cup with three types of cream was found on the over-the-bed table of a resident with moderately impaired cognition and multiple health conditions, including cancer and heart failure. The facility's policy did not allow for medications to be stored at the bedside unless in their original containers, and there was no physician order permitting bedside storage for this resident. Another resident, also with moderately impaired cognition and various health issues, had eye drops left on her nightstand, which she did not self-administer. The facility's policy required medications to be stored in the medication room or carts, not at the bedside. Interviews with facility staff, including the Corp RN, LVN, ADON, DON, and ADM, confirmed that the facility's policies were not followed. Staff acknowledged that medications should be locked and secured, and that leaving them unattended could lead to misuse or adverse reactions. The facility's policies on medication storage and administration did not adequately address the issue of bedside storage, contributing to the observed deficiencies.
Failure to Provide Adequate Bathing Services
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living independently, received the necessary services to maintain good grooming and personal hygiene. The resident, a male with multiple diagnoses including legal blindness, hypertension, and congestive heart failure, was observed to have received inadequate showering services. Despite the facility's policy requiring regular bathing, the resident reported having only three showers since admission, with some instances of only having his back and legs wiped down, which was not considered a full bath or shower by the facility's standards. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed discrepancies in the understanding and implementation of the facility's bathing policy. The ADON and DON both acknowledged that wiping a resident's back and legs does not constitute a bath or shower. The facility's policy, revised in March 2018, mandates that residents unable to perform ADLs independently should receive appropriate care to maintain personal hygiene. However, the resident's care plan did not address showering, and the facility's records showed inconsistencies in documenting the resident's bathing schedule.
Linen Cart Safety Violation
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in two of its resident hallways, Hall 1 and secured Hall 6. During observations, it was noted that the linen carts in these areas contained items that posed potential risks to residents, including a non-aerosol MedLine odor eliminator spray, MedLine Remedy Antifungal Ointment, Coloplast Hydrophilic Wound Dressing, MedLine Remedy Cleansing Foam, MedLine Soothe and Cool Barrier ointment, and opened packages of disposable razors. These items were not supposed to be on the linen carts, which should only contain linens, briefs, and gloves. The presence of these items was identified as a potential hazard, as residents could access them, leading to possible accidents or injuries. Interviews with facility staff, including a CNA, RN, ADON, and DON, revealed that there was a lack of adherence to the facility's expectations regarding the contents of the linen carts. The CNA and RN acknowledged that the carts should only contain specific items and identified the potential harm of having unauthorized items on the carts. The ADON and DON confirmed that razors and external use creams should not be on the carts and emphasized that it is the responsibility of CNAs, charge nurses, and administrative staff to ensure compliance. The facility lacked a specific Linen Cart policy, and the existing Sharps Disposal Policy did not address the storage and safety of personal use razors, contributing to the oversight.
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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