Longview Hill Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Longview, Texas.
- Location
- 3201 N Fourth St, Longview, Texas 75605
- CMS Provider Number
- 455684
- Inspections on file
- 63
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Longview Hill Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents at risk for pressure injuries did not receive required Braden Scale and weekly skin assessments as outlined in facility policy. One resident with multiple comorbidities and severe cognitive impairment had no documented Braden reassessments for many months and no weekly skin checks for several weeks before a small buttock wound was noted and the resident was sent to the hospital, where a POA stage 2 pressure injury and moisture-related maceration were documented. Another resident with diabetes, dementia, and protein-calorie malnutrition had a Braden score indicating risk but no further Braden assessments for over two years, although later wound and skin checks showed no pressure injuries. The DON and Administrator acknowledged that quarterly Braden and weekly skin assessments were expected and attributed the lack of documentation to an electronic charting glitch.
A resident with severe cognitive impairment and multiple neurologic conditions had an MPOA authorized to access all medical information. After several lab tests, including a UA for a UTI, the MPOA verbally requested the UA results from staff but was told by an LVN and medical records personnel that no information could be released without a completed written authorization form processed through corporate legal. Despite the MPOA’s status and verbal requests, staff followed a facility policy requiring written requests and legal department review, and no lab results were provided within the required timeframes, resulting in a failure to honor the resident’s right to timely access to medical records.
A facility failed to thoroughly investigate an abuse allegation after a resident's sitter was overheard reporting abuse to EMS. The Administrator did not interview the resident, her representative, or the caregiver who made the allegation, and only the CNA who overheard the conversation was interviewed. The investigation was incomplete as required interviews were not conducted.
A nurse administered another resident's evening medications, including a drug to which the recipient had a documented allergy, resulting in symptoms such as drowsiness and altered mental status. The nurse did not verify the correct patient or check for allergies before administration, and subsequent monitoring and documentation were incomplete. The resident's condition worsened, requiring hospitalization, and staff provided inconsistent information regarding the incident and follow-up.
The facility failed to notify physicians of significant changes in two residents' conditions, leading to life-threatening situations. One resident missed several doses of IV antibiotics due to a dislodged PICC line, and the physician was not informed until the resident's condition worsened. Another resident's surgical wound deteriorated, showing signs of infection, but the physician was not notified, resulting in a hospital admission for sepsis. The facility did not follow its policy on notification of changes, causing delayed medical interventions.
Two residents in a LTC facility experienced severe health consequences due to the facility's failure to provide timely medical interventions. One resident did not receive IV antibiotics for pneumonia due to a dislodged PICC line, while another resident's surgical wound deteriorated without proper care. The facility's lack of communication with medical providers and inconsistent care practices led to an Immediate Jeopardy situation.
The facility failed to ensure proper insulin management for several residents, with insulin being used past the 28-day expiration period. This affected multiple residents with diabetes, as insulin was administered either expired or without proper timing relative to meals. The LVN was unaware of these issues, highlighting a lapse in adherence to medication administration policies.
The facility's kitchen failed to meet food safety standards, with undated and unsealed food items found in storage and dietary staff not wearing hair restraints properly. The dietician and dietary manager acknowledged the importance of proper labeling, sealing, and hair restraint to prevent foodborne illness. The administrator confirmed oversight responsibilities, and facility policies required compliance with these standards.
The facility failed to develop comprehensive care plans for residents, neglecting to address critical medical and behavioral needs. A resident's care plan did not include her behavioral symptoms, COPD diagnosis, and antiplatelet medication use. Another resident's plan omitted her antiplatelet medication, pressure ulcer risk, and dehydration diagnosis. A third resident's need for dentures was not included, affecting her nutritional intake and safety. Additionally, a resident at high risk for falls lacked a care plan addressing this risk, despite a history of falls.
The facility failed to ensure that the drug regimens of three residents were free from unnecessary antibiotics. A resident received Cephalexin for a suspected UTI without lab confirmation, another was given Macrobid despite negative urine analysis, and a third received Rocephin and Levaquin without clear indications. The facility's antibiotic stewardship program was not properly followed, leading to unnecessary medication administration.
The facility failed to ensure proper monitoring of psychotropic medications for three residents, leading to potential unnecessary medication use. A resident's Wellbutrin dosage was increased without documented behaviors to justify it, another resident received Depakote without behavior or side effect monitoring, and a third resident was prescribed Trazodone without side effect monitoring. Staff interviews revealed inconsistencies in documentation responsibilities.
The facility failed to provide palatable and properly tempered food for several residents, who reported the meals as bland and sometimes cold. Observations confirmed the food's lack of flavor and incorrect temperatures. Dietary staff acknowledged past complaints and the importance of serving appetizing meals, but the facility did not provide a test tray policy when requested.
The facility failed to ensure informed consent for antipsychotic medications for three residents, as required forms were incomplete, lacking details on clinical indications, dosage, and side effects. This deficiency involved residents with schizophrenia, anxiety, and depressive disorders, who were prescribed medications like Abilify, Risperdal, and Quetiapine. Interviews with staff revealed a lack of clarity in responsibility for completing these forms, which are essential for residents to make informed treatment decisions.
A resident's room was found in an unclean state, with dust, dirt, and debris on the floors, a refrigerator door splattered with dried substances, and a dresser smeared with a creamy substance. The resident, an elderly female with multiple health conditions, required assistance with daily activities. Interviews with staff revealed lapses in cleaning practices, despite a five-step cleaning process being in place. The facility lacked a specific policy for maintaining a homelike environment.
A facility failed to accurately document a resident's use of Quetiapine Fumarate, an antipsychotic medication, in the MDS assessment. The resident, who was cognitively intact, was receiving the medication daily for depressive episodes, but this was not reflected in the MDS. The MDS coordinator admitted the oversight, and the facility lacked a specific policy on assessment accuracy, relying on the RAI Manual instead.
A resident with major depressive disorder was inaccurately assessed in their PASRR Level I screening, which failed to reflect their mental illness. The MDS Nurse initially misunderstood the qualification criteria, but later acknowledged the error. The facility lacked a PASRR policy, contributing to the oversight.
Three residents in an LTC facility did not receive necessary assistance with personal hygiene, specifically facial hair removal, despite being unable to perform these tasks independently. One resident with multiple sclerosis was embarrassed by her facial hair, another with severe cognitive impairment was unaware of her chin hair, and a third resident's requests for assistance were unmet. Staff interviews revealed a lack of proactive care and adherence to facility policies.
A resident with severe cognitive impairment was left unsupervised during a mechanical lift transfer, posing a risk of injury. Two CNAs failed to ensure the resident's safety by not raising the side assist rail and walking away, leaving the resident swaying close to the bed's edge. The facility's policy requiring two staff members for such transfers was not followed, as confirmed by staff interviews.
A resident with dementia and malnutrition experienced significant weight loss due to the facility's failure to implement the dietician's recommendations to increase Med Pass frequency. Despite multiple communications, the nursing staff did not obtain the necessary orders, delaying the resident's nutritional support.
A facility failed to ensure the timely refill of Wellbutrin for a resident with major depressive disorder, resulting in missed doses on three occasions. The resident, who also had dementia and anxiety, relied on this medication for managing her condition. Staff interviews revealed a breakdown in the medication refill process, despite protocols in place to prevent such occurrences. The facility's policy required medications to be administered as ordered, but this was not followed, leading to the deficiency.
The facility failed to securely store medications, with prescription ointments improperly stored in a resident's room, medications left unattended on a resident's bedside table, and an unlocked medication cart. Staff interviews revealed a lack of awareness and adherence to facility policies regarding medication storage and supervision.
A resident's personal refrigerator was found to be unsanitary, with spoiled milk and a dark substance covering the interior. The resident, who has severe cognitive impairment, reported that no one cleans his refrigerator, and consuming food from it has caused him distress. Staff interviews revealed inconsistent monitoring and cleaning practices, contrary to facility policy, posing a risk of foodborne illness.
A LTC facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents. An LVN did not use enhanced barrier precautions during gastrostomy tube feeding for a resident, and two CNAs failed to follow proper infection control procedures during incontinent care for another resident. These lapses in protocol were acknowledged by the facility's administration and could lead to cross-contamination and infections.
The facility failed to maintain the dignity of two residents by not explaining care procedures and not providing scheduled smoke breaks. One resident, with severe cognitive impairment, was transferred without explanation, causing distress. Another resident, with moderate cognitive impairment, was not consistently offered smoke breaks, affecting her quality of life.
A resident with severe cognitive impairment was roughly handled by two CNAs during a mechanical lift transfer and incontinent care. The CNAs failed to communicate with the resident, left her unattended near the edge of the bed, and did not use a draw sheet, leading to potential skin tears and distress. Facility staff acknowledged the care was too swift and rough, not aligning with training and policies.
A facility failed to provide a timely 30-day discharge notice to a resident and their representative. The resident, with severe cognitive impairment and multiple health issues, was discharged without a formal notice due to issues with the payor source. Staff interviews revealed confusion about discharge notice requirements, and the responsible Business Office Manager was on medical leave.
The facility failed to re-evaluate PRN orders for psychotropic medications every fourteen days for two residents, leading to a deficiency in medication management. Both residents, with severe cognitive impairments, received Lorazepam without documented physician re-evaluation. Staff interviews revealed a lack of awareness and adherence to the policy, highlighting potential risks such as overmedication and chemical restraint. The facility's policy mandates re-evaluation every fourteen days, which was not followed, resulting in this deficiency.
The facility failed to maintain a seven-day food supply and did not follow planned menus due to delayed grocery deliveries and budget constraints. The Dietary Manager did not notify the dietician of menu substitutions, leading to meals that did not meet nutritional guidelines. Staff interviews revealed a lack of communication and oversight regarding food supply and menu adherence.
Failure to Complete Required Braden and Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and monitoring consistent with its own policies and professional standards for two residents at risk for pressure injuries. For one resident with heart failure, muscle weakness, diabetes, severe cognitive impairment, and identified risk for pressure ulcers, the care plan noted risk factors including fragile skin, incontinence, impaired mobility, and nutritional and hydration risk, with an intervention to identify and document potential causative factors. A Braden Scale assessment documented a score of 21, indicating no risk, but no further Braden assessments were documented for this resident from early June of one year through late February of the following year. A weekly skin check documented no skin issues in late January, and there were no further weekly skin assessments documented from that date through the resident’s discharge to the hospital in late February, despite facility policy requiring weekly full-body skin assessments and quarterly Braden assessments. For this same resident, a wound care NP completed an "At Risk Skin Assessment" in early February, documenting no new skin abnormalities and no active wounds, while noting the resident remained at increased risk due to age, history of falls, and reduced mobility, and recommending continued skin surveillance at routine intervals. Later in February, a change of condition note by an LVN documented a small wound on the buttock, and a subsequent progress note the same day recorded that the resident had a small wound to the buttock and black, tarry stool, after which EMS was called and the resident was sent to the hospital. A hospital wound care nurse note the next day documented that on admission the resident had a Braden score of 14 (moderate risk), required maximum assistance for turning and repositioning, was incontinent of stool, and was saturated in urine with a dry Foley bag. The hospital note identified a POA stage 2 pressure injury to the left buttock with specific measurements and characteristics, macerated tissue to the bilateral buttocks concerning for a moisture component, and pale pink intact scar tissue on the right buttock. The second resident was an older adult with diabetes, dementia, and protein-calorie malnutrition, with severe cognitive impairment and identified risk for developing pressure ulcers. The care plan documented diabetes and bowel incontinence related to cognitive decline. A Braden Scale assessment showed a score of 16, indicating risk for pressure injury, but there were no further Braden assessments documented for this resident for more than two years, despite the facility’s policy requiring quarterly Braden assessments and weekly skin assessments. A wound evaluation by a wound care NP in late February documented a diabetic wound on the right first toe but did not identify any pressure injuries, and a skin check shortly thereafter did not indicate any new skin issues. During interviews, the DON confirmed that Braden assessments were expected quarterly and skin assessments weekly, acknowledged that the last Braden and skin assessments for the first resident and the last Braden for the second resident were significantly outdated, and stated that failure to complete these assessments could result in unrecognized skin problems and lack of appropriate interventions. The Administrator and DON both attributed the missing assessments to a perceived glitch in the electronic charting system that was not triggering the required Braden and skin assessments.
Failure to Provide MPOA Timely Access to Resident Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s medical power of attorney (MPOA) had timely access to the resident’s medical records, specifically urinalysis (UA) lab results, as required by resident rights regulations. The resident was an older male with a history of cerebral infarction affecting the right middle cerebral artery, dementia without behavioral disturbance, hemiplegia and hemiparesis of the left non-dominant side, cognitive communication deficit, and seizures. His care plan documented impaired cognitive function and dementia, with interventions that included communicating with family/caregivers regarding the resident’s capabilities and needs. A quarterly MDS showed severe cognitive impairment with a BIMS score of 0/15, unclear speech, and dependence or maximal assistance for most ADLs, indicating that the resident relied on his MPOA to act on his behalf. The resident’s medical power of attorney document, dated 1/6/23, appointed a family member as the Agent under Texas law and explicitly authorized the Agent, as the resident’s HIPAA personal representative, to request, receive, and review all medical and hospital records and other protected health information. In December 2025, multiple laboratory specimens were collected for the resident, including on 12/24/25, when a UA related to a UTI was obtained. The MPOA verbally requested the resident’s UA lab results from facility staff, including from the medical records staff and an LVN. According to interviews, the LVN reported she had been instructed not to provide any medical information directly and to direct all such requests to medical records via a release form, regardless of whether the request was for a verbal explanation or a hard copy of records. The MPOA stated she was denied verbal results by the LVN and never received the lab results. The medical records staff member confirmed that the MPOA verbally requested the UA results in December 2025 and that she provided a medical records release form, explaining that facility policy required completion of the form before any records could be released. She stated she did not receive the completed form and therefore did not provide the requested documents. A subsequent letter from a family member to medical records requested an explanation for the denial of the resident’s recent test results, and the company’s legal department responded that, under 45 C.F.R. § 164.524(b)(1), they could require written requests and that no written request from the MPOA had been received. The facility’s Release of Medical and Billing Records Policy required a fully completed authorization form and routing all requests through the legal department before releasing any information. As a result of these practices and requirements, the resident’s MPOA was not given access to the resident’s UA lab results within 24 hours of request, and copies were not provided within two working days, constituting a failure to honor the resident’s right to access records as specified in the regulations.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a female resident with dementia and moderately impaired cognition, who required assistance with activities of daily living and had a sitter present. On the day of the resident's discharge, a sitter was overheard telling EMS personnel that the resident had been abused and that hospice staff were aware. This verbal allegation was reported to the charge nurse and escalated to the Administrator. Despite the report, the Administrator did not interview the resident, her representative, or the caregiver who made the allegation. The Administrator stated that he did not investigate further because the resident had already left the building and was unsure if he had contact information for the sitter. The only interview conducted was with the CNA who overheard the conversation. The DON attempted to call the family member once after the allegation but did not reach them, and no one attempted to contact the caregiver directly. Facility policy requires immediate and thorough investigation of abuse allegations, including identifying and interviewing all involved persons, such as the alleged victim, perpetrator, witnesses, and others with knowledge of the incident. In this case, the investigation was incomplete as key individuals were not interviewed, and the investigation was concluded as unconfirmed without gathering all necessary information.
Significant Medication Error and Failure to Prevent Administration of Allergic Medication
Penalty
Summary
A significant medication error occurred when a nurse administered the entire evening medication regimen intended for one resident to another resident. The affected resident had a documented allergy to one of the medications, Trazodone, with a known reaction of altered mental status. The nurse failed to verify the correct resident and medication prior to administration, resulting in the resident receiving multiple medications not prescribed to him, including anti-seizure drugs, diabetes medication, and Trazodone. The nurse did not recall checking for allergies before administering the medications and could not specify which medications were given at the time of the incident. Following the administration of the incorrect medications, the resident exhibited symptoms such as drowsiness, slurred speech, and altered mental status. Neurological assessments and vital sign monitoring were inconsistently performed and documented, with several checks missing vital sign data. The nurse and other staff members involved did not consistently follow the facility's protocol for incident reporting, documentation, and investigation. The incident report did not list the specific medications administered, and there was confusion among staff regarding the resident's allergies and the medications involved in the error. Interviews with staff and the resident's representative revealed that the resident's condition deteriorated following the medication error, leading to hospitalization and a stay in the ICU. The nurse, DON, and other staff members provided inconsistent accounts of the events, the medications administered, and the actions taken in response to the error. The facility failed to ensure that medications were administered as ordered, that allergies were checked, and that appropriate monitoring and documentation occurred after the error, resulting in an Immediate Jeopardy situation.
Failure to Notify Physicians of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to consult with the physician when there was a significant change in the physical status of two residents, which was life-threatening. For one resident, the facility did not notify the physician when the resident's PICC line was dislodged, preventing the administration of IV antibiotics for pneumonia. The resident missed several doses of the medication, and the physician was not informed of the situation or the resident's worsening condition until days later, resulting in the resident being transferred to the hospital with pneumonia. Another resident experienced a deterioration in a surgical wound, which was not communicated to the physician. The resident's wound showed signs of infection, including increased drainage and pain, but the facility staff did not notify the physician of these changes. The resident was later admitted to the hospital with a diagnosis of sepsis and an infection at the amputation site. The facility's failure to follow its policy on notification of changes with significant health issues led to life-threatening consequences for these residents. The report highlights the lack of communication and documentation regarding changes in the residents' conditions, which resulted in delayed medical interventions.
Removal Plan
- The Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be evaluated, the physician will be notified. The evaluation will be documented in the resident's clinical record.
- The Director of Nursing /Designee initiated reeducation with Licensed Nurses on the following topics: Documentation in Medical Record, Medication Administration, Notification of Changes Policy to include changes in medication administration, wound care and abnormal radiology results.
- When a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record.
- Licensed Nurses will give shift report from the PCC generated 24 hour report.
- Licensed Nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results.
- Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training.
- The Director of Nursing / designee will review the 24-hour report, the PCC Skin and Wound Module and the PCC Results Module in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative.
- The Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed.
- The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition.
- The Weekend Supervisor will review the 24-hour report in PCC as well as the Results Module (Lab and Radiology) to ensure that Medical Providers are notified of results.
- An Ad Hoc QAPI Meeting was conducted by the Administrator, with the Medical Director, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F580 Notification of Changes and plan to correct.
Failure to Provide Timely Medical Interventions
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for two residents, leading to life-threatening consequences. One resident, who had a history of pneumonia, osteomyelitis, and quadriplegia, did not receive IV antibiotics for pneumonia due to a dislodged PICC line. The facility was aware of the dislodged line but failed to replace it or notify the physician promptly, resulting in the resident missing several doses of antibiotics. The resident's condition worsened, and he was eventually diagnosed with pneumonia and admitted to the hospital. Another resident with a surgical wound from a below-the-knee amputation experienced a deterioration in his wound condition. The facility failed to provide consistent wound care and did not notify the physician of the wound's worsening state. The resident was admitted to the hospital with sepsis and an infection at the amputation site. The facility's lack of timely medical intervention and communication with medical providers contributed to the resident's deteriorating condition. The deficiencies identified in the facility's care practices resulted in an Immediate Jeopardy situation, as the failures posed a risk of more than minimal harm to the residents. The facility's inability to ensure timely medical interventions and proper communication with medical providers led to severe health consequences for the residents involved.
Removal Plan
- The Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be evaluated, the physician will be notified. The evaluation will be documented in the resident's clinical record.
- The Director of Nursing /Designee initiated reeducation with Licensed Nurses on the following topics: Documentation in Medical Record, Medication Administration, Notification of Changes Policy to include changes in medication administration, wound care and abnormal radiology results.
- When a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record.
- Licensed Nurses will give shift report from the PCC generated 24 hour report. (PCC generated from clinical documentation).
- Licensed Nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results.
- Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training.
- The Director of Nursing / designee will review the 24- hour report, the PCC Skin and Wound Module and the PCC Results Module in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative.
- The Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed.
- The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition.
- The Weekend Supervisor will review the 24-hour report in PCC as well as the Results Module (Lab and Radiology) to ensure that Medical Providers are notified of results.
- An Ad Hoc QAPI Meeting was conducted by the Administrator, with the Medical Director, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning Quality of Care and plan to correct.
Failure in Insulin Management and Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the accurate dispensing and administering of insulin to residents. This deficiency was observed in five out of six residents reviewed for medication administration. The issue primarily involved the use of insulin that was past the 28-day labeled precautionary instructions, which could potentially affect the effectiveness of the medication in controlling diabetic symptoms. Resident #3, a male with diabetes mellitus, was found to have been administered Novolog insulin that was opened 31 days prior, exceeding the recommended 28-day usage period. The LVN initially attempted to administer this expired insulin but was stopped and had difficulty locating a new supply. Similarly, Resident #4, a female with type 2 diabetes mellitus, had Humalog insulin that was opened 32 days prior. She received her insulin injection after finishing her meal, contrary to the prescribed timing before meals. Resident #5 had both Novolog and Lantus insulin that were opened 41 and 40 days prior, respectively, both exceeding the 28-day usage period. Resident #6's Lantus insulin did not have an opened date recorded, although there was a designated space for it. Resident #7's Novolog insulin was also past the 28-day usage period. The LVN responsible for administering these medications was not aware of the expiration issue, indicating a lack of proper oversight and adherence to medication administration policies.
Food Safety and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Specifically, food items were not properly sealed and dated, with two undated containers of instant mashed potatoes found in dry storage and an unsealed box of biscuits in the freezer. Additionally, dietary staff did not wear hair restraints appropriately, as evidenced by an employee's hair being visible outside of the hairnet during meal preparation. These lapses were confirmed through interviews with the dietician, dietary manager, and the staff member involved, all of whom acknowledged the importance of proper food labeling, sealing, and hair restraint to prevent food contamination. The dietician and dietary manager both stated that food items should be labeled with receive and open dates, and sealed if opened, to prevent bacterial growth and potential foodborne illness. The dietary manager also noted that she conducted weekly walkthroughs to ensure compliance with these standards and provided regular training to staff. The administrator confirmed that the dietary manager was responsible for ensuring proper food storage and cleanliness in the kitchen, and that she conducted random walkthroughs to monitor compliance. The facility's policies on food storage and employee sanitation were reviewed, indicating requirements for labeling, dating, and proper hair restraint use.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #17's care plan did not include her verbal and other behavioral symptoms, the diagnosis of COPD, and the use of an antiplatelet medication. Despite having a moderate cognitive impairment and experiencing behavioral symptoms, these issues were not addressed in her care plan, which could have provided necessary interventions to manage her condition effectively. Resident #110's care plan was also incomplete, as it did not address her use of an antiplatelet medication, her risk for pressure ulcers, and her diagnosis of dehydration. This resident had severe cognitive impairment and was at risk for developing pressure ulcers, yet these critical aspects were not included in her care plan. The lack of a comprehensive care plan could lead to inadequate management of her medical conditions and increased risk of complications. Additionally, Resident #21's care plan failed to include her need for dentures, which was crucial for her nutritional intake and to prevent choking and swallowing difficulties. Observations revealed that she often ate without her dentures, which were left soaking in dirty water. Furthermore, Resident #79, who was at high risk for falls, did not have a care plan addressing this risk, despite having a history of falls and related injuries. The absence of a fall risk care plan could result in insufficient preventive measures being in place to protect her from further falls.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that the drug regimens of three residents were free from unnecessary medications, specifically antibiotics, which were administered without appropriate lab work or indications for use. Resident #66 received Cephalexin for a suspected UTI without a culture to confirm the infection. Despite the absence of lab work, the resident was administered the full course of antibiotics, as noted in the Medication Administration Record (MAR) and progress notes. Resident #71 was prescribed Macrobid for a suspected UTI, even though a urine analysis showed no pathogens. The resident received the full course of antibiotics, as documented in the MAR, despite the negative lab results. The facility's Infection Control Log and progress notes indicated that the antibiotics were continued based on the family's suspicion of a UTI, rather than clinical evidence. Resident #78 was administered Rocephin and Levaquin for a suspected infection without a clear indication of use. The resident's progress notes and lab results did not support the presence of an infection that required antibiotic treatment. The facility's Infection Control Log incorrectly logged the infection as a UTI, and the antibiotics were administered without meeting the McGreers criteria for infection treatment. Interviews with facility staff revealed a lack of adherence to the antibiotic stewardship program, resulting in the unnecessary administration of antibiotics.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens of three residents were free from unnecessary psychotropic drugs due to inadequate behavior monitoring and diagnosis. Resident #17's Wellbutrin dosage was increased without documented behaviors to justify the change. The resident, who had a history of dementia, anxiety, and major depressive disorder, was noted to have moderate cognitive impairment and exhibited behavioral symptoms. However, the facility's records did not indicate any behaviors related to depression that would warrant the increase in medication. Resident #23, who had severe cognitive impairment and a history of dementia, anxiety disorder, and insomnia, was prescribed Depakote for agitation and anxiety. The facility failed to conduct behavior and side effect monitoring for this anticonvulsant medication. Despite receiving multiple doses of Depakote, there was no documentation of behavior or side effect monitoring, which is crucial for assessing the necessity and effectiveness of the medication. Resident #110, diagnosed with cerebral infarction, dementia, insomnia, and anxiety disorder, was prescribed Trazodone for insomnia. The facility did not perform side effect monitoring for the antidepressant, as indicated in the resident's medical records. Interviews with facility staff revealed that nurses were responsible for ordering and documenting behavior and side effect monitoring, but this was not consistently done, leading to potential unnecessary medication use.
Facility Fails to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for seven residents. Multiple residents expressed dissatisfaction with the taste and temperature of the food, describing it as bland and sometimes served cold. During interviews, residents consistently reported that the food lacked flavor and was not enjoyable, with specific complaints about the frequent serving of baked fish or chicken with plain white rice. Observations by the Dietary Manager and surveyors confirmed that the food was bland, and some items were not served at the correct temperature, such as cold baked apple slices that were intended to be warm. Interviews with the facility's dietary staff, including the Dietician and Dietary Manager, revealed awareness of food complaints and acknowledged the importance of serving palatable and appropriately tempered meals for residents' nutritional status and overall wellbeing. The Dietary Manager admitted to past food complaints and emphasized the responsibility of dietary staff to ensure food quality. The Administrator also acknowledged resident complaints about food taste and temperature, stating that the kitchen staff and facility staff were responsible for ensuring food quality. Despite daily management rounds to monitor food complaints, the facility did not provide a policy on test trays when requested.
Incomplete Consent Forms for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the use of antipsychotic medications. For three residents, the facility did not complete the required HHSC Form 3713, which is necessary for obtaining informed consent for antipsychotic or neuroleptic medication treatment. The forms lacked critical information such as clinical indications for use, dosage, frequency, and potential side effects, risks, or benefits of the medications. Resident #68, who had diagnoses of schizophrenia and anxiety disorder, was prescribed Abilify and Risperdal. However, the consent forms for these medications were incomplete, missing essential details about the treatment. Despite the resident's representative believing that the facility had discussed the medications' side effects and benefits, the documentation did not reflect this. Similarly, Resident #79, with diagnoses of depressive episodes and anxiety disorder, was taking Quetiapine but was unaware of the reasons for its use or its side effects, as the consent form was also incomplete. Resident #108, who had multiple diagnoses including seizures and depressive disorder, was prescribed Quetiapine. The consent form for this medication was incomplete, lacking information on the clinical indications, dosage, and potential side effects. Interviews with facility staff, including the LVN, ADON, and DON, revealed a lack of clarity and responsibility in ensuring the completion of these forms. The facility's policy and state regulations require that residents or their representatives be fully informed about the medications, but the failure to complete the forms accurately meant that residents could not make informed decisions about their treatment.
Failure to Maintain a Clean and Homelike Environment for a Resident
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident, as observed during multiple inspections. The resident's room was found to have floors covered in dust, dirt, and debris, including white paper and large brown crumbs. Additionally, the resident's personal refrigerator door was splattered with dried white substances, and the bathroom counter had a sticky pinkish dried liquid. The dresser was smeared with a white creamy substance, and the closet contained clean clothing on the floor. The chair in the room had brownish stains. The resident involved was an elderly female with a history of cerebrovascular disease, hypertension, hyperlipidemia, stroke, and dysphagia. She was moderately cognitively impaired and required assistance with daily activities such as toileting, dressing, and bathing. Despite her cognitive status, the resident was understood by others and could understand others, as indicated by her BIMS score of 11. The care plan did not mention her use of dentures for eating, although she required assistance with them. Interviews with facility staff revealed that the housekeeper responsible for cleaning the resident's room had missed several areas, including the sides and front of the dresser and the refrigerator door. The housekeeper acknowledged the importance of maintaining a clean environment for residents, as it is their home. The Environmental Services Supervisor outlined a five-step cleaning process but emphasized that maintaining cleanliness was a group effort. The Director of Nursing and the Administrator both expressed expectations for clean and homelike resident rooms to prevent infection spread, but the facility lacked a specific policy for a homelike environment.
Inaccurate MDS Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the medication regimen of a resident, specifically the administration of Quetiapine Fumarate, an antipsychotic medication. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, had multiple diagnoses including depressive episodes and anxiety disorder. Despite having an active order for Quetiapine Fumarate, which was administered daily, the MDS assessment did not indicate the use of this antipsychotic medication in the relevant section. This oversight was acknowledged by the MDS coordinator responsible for the assessment, who admitted it was an error on her part. Interviews with the MDS coordinators and the Administrator (ADM) revealed that the facility did not have a specific policy on the accuracy of assessments, relying instead on the Resident Assessment Instrument (RAI) Manual. The ADM and MDS coordinators stated that the MDS assessment is primarily a tool for data gathering and payment, and they did not believe the inaccuracy would affect the resident's care. However, the RAI Manual specifies that all high-risk drug class medications should be coded according to their pharmacological classification, which was not done in this case.
Inaccurate PASRR Level I Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the mental health status of a resident diagnosed with major depressive disorder. The resident's PASRR Level I screening incorrectly indicated no mental illness, despite a diagnosis of major depressive disorder, which was confirmed by the MDS Nurse and the Director of Nurses as qualifying for a positive PASRR Level I. This oversight was identified during a review of the resident's records, which showed the resident had been diagnosed with major depressive disorder and was using psychotropic medication. Interviews with facility staff revealed a lack of understanding and proper procedure regarding PASRR evaluations. The MDS Nurse initially believed that major depressive disorder did not automatically qualify a resident for a positive PASRR Level I, but later acknowledged the error after consulting with the local mental health authority. The Director of Nurses confirmed that residents with qualifying mental illness diagnoses should receive a Level II evaluation. The facility lacked a policy regarding PASRR, as noted in an email from the Administrator, which contributed to the deficiency.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to ensure that three residents received necessary assistance with personal hygiene, specifically in the removal of facial hair, which is part of their activities of daily living (ADLs). Resident #5, a female with multiple sclerosis and moderate cognitive impairment, was observed with approximately 1-inch gray facial hairs on her chin and sides of her mouth. Despite being dependent on staff for personal hygiene, she was not offered assistance with facial hair removal, leading to embarrassment and a desire for help. Staff interviews revealed that assistance was not provided because it was not requested, highlighting a lack of proactive care. Resident #46, who has severe cognitive impairment and requires supervision for ADLs, was observed with small white hairs on her chin. Although she claimed to manage her own facial hair, she was unaware of its presence and expressed an intention to address it. Staff interviews indicated that facial shaving should occur during showers, but it was not noticed or addressed by the staff, suggesting a gap in supervision and assistance. Resident #51, with severe cognitive impairment, was observed with patches of white-gray chin hair. Despite requesting assistance for hair removal, she reported that aides often claimed they lacked time or would return later, which did not happen. Staff interviews confirmed that facial hair removal should be part of the bathing routine, but it was not consistently offered or performed. The facility's policy mandates assistance with ADLs, including grooming, for residents unable to perform these tasks independently, which was not adhered to in these cases.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during a mechanical lift transfer for a resident, leading to a potential risk of injury. The incident involved a resident with severe cognitive impairment and functional limitations, who was dependent on staff for transfers and other activities of daily living. During a transfer using a Hoyer lift, two CNAs left the resident unsupervised at the bedside, failing to raise the side assist rail, which resulted in the resident swaying dangerously close to the edge of the bed. The resident, who had diagnoses including dementia and muscle wasting, was observed in a video where the CNAs did not communicate with her during the transfer process. The CNAs walked away from the resident for approximately 15 seconds without ensuring her safety, leaving her at risk of falling. The facility's policy required two staff members to assist with mechanical lift transfers to ensure the resident's safety, which was not adhered to in this instance. Interviews with the facility's staff, including the ADON, DON, and the CNAs involved, revealed that the transfer was not conducted according to the facility's standards. The staff acknowledged the risk posed by the lack of supervision, with one CNA expressing regret upon realizing the resident almost fell. The facility's policy emphasized the importance of a team approach to prevent falls, which was not followed during this incident.
Failure to Implement Dietary Recommendations for Resident
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as Resident #23, who was at risk for malnutrition and weight loss. Resident #23, an 86-year-old female with dementia, protein-calorie malnutrition, and dysphagia, experienced significant weight loss over several months. Despite the dietician's recommendations to increase the frequency of Med Pass 2.0 from three times a day (TID) to four times a day (QID) to address her declining appetite and nutritional needs, the facility did not implement these recommendations in a timely manner. The dietician made recommendations on multiple occasions, specifically on 11/15/24, 12/06/24, and 12/13/24, to increase the Med Pass frequency to QID. However, the facility's nursing staff did not follow through with obtaining the necessary orders from the physician or nurse practitioner, even though the dietician's recommendations were communicated via email to the administrative staff. The facility's policy required that such recommendations be implemented within 72 hours, but this was not adhered to, resulting in a delay in addressing the resident's nutritional needs. Interviews with facility staff, including the LVN, DON, and ADM, revealed a lack of awareness and follow-up on the dietician's recommendations. The dietician, who had recently been granted order writing privileges, eventually entered the order herself after noticing the facility's inaction. The failure to implement the dietary recommendations placed Resident #23 at risk for further weight loss and nutritional decline, as the Med Pass was intended to supplement her calorie intake and support her nutritional health.
Failure to Ensure Timely Medication Refill for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident, specifically concerning the availability of Wellbutrin SR Oral Tablet Extended Release 200mg. This medication was not available for administration on three separate occasions, which were documented as 10/13/24, 10/14/24, and 11/04/24. The resident, a female with a history of dementia, anxiety, major depressive disorder, and cognitive communication deficit, was dependent on this medication for managing her major depressive disorder. Interviews with facility staff revealed a breakdown in the medication refill process. Licensed Vocational Nurse (LVN) N, who had been with the facility for almost four years, explained that Medication Aides (MAs) were responsible for notifying nurses when a medication needed refilling. The facility had a system in place where the MAs would alert the nurses when the blister pack was running low, specifically when only seven days of medication remained. However, there was a delay in refilling the medication, which could have been due to insurance issues or medication changes, although the pharmacy was noted to be quick in refilling orders once placed. Further interviews with the Director of Nursing (DON) and the Administrator (ADM) highlighted expectations for timely medication refills, emphasizing the importance of ordering before the blister pack reached the blue section, indicating low supply. Despite these protocols, the resident missed doses of Wellbutrin, which could have led to episodes of crying or anxiety due to the lack of medication. The facility's Medication Administration policy required medications to be administered as ordered by the physician, but this was not adhered to in this instance, leading to the deficiency.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to securely store medications and biologicals, as evidenced by the improper storage of prescription medications for two residents and an unlocked medication cart. For Resident #10, Nystop powder and Venelex ointment were found in the resident's room without proper labeling or storage, contrary to facility policy. Interviews with staff revealed a lack of awareness regarding the prohibition of storing prescription ointments or creams in resident rooms, and the absence of an order for Nystop powder for Resident #10 was noted. Resident #39 was found with a cup containing approximately 10 medications left unattended on his bedside table. The resident reported that staff had left the medications there, and he had forgotten to take them. Facility policy dictates that medications should not be left with residents unsupervised, and staff are responsible for ensuring residents take their medications or return them if refused. Additionally, a medication cart on Hall 200 was observed unlocked and unattended, posing a risk of unauthorized access to medications. The staff member responsible for the cart admitted to leaving it unlocked while attending to another task. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that medication carts should always be locked when not in use to prevent unauthorized access and potential harm.
Failure to Maintain Sanitary Conditions in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of food items in a resident's personal refrigerator, specifically for a resident with severe cognitive impairment and multiple diagnoses, including Paranoid Schizophrenia, Dysphagia, and Dementia. During observations, the resident's refrigerator was found to be covered in a dark substance, and a glass of milk inside was growing a white fuzzy substance, indicating spoilage. The resident reported that no one cleans his refrigerator and that consuming food from it has caused him gastrointestinal distress. Interviews with staff revealed that there was a lack of consistent monitoring and cleaning of residents' personal refrigerators. A CNA admitted to occasionally discarding items but had never cleaned the resident's refrigerator. The Director of Nurses stated that staff are required to check and clean residents' refrigerators, but this was not done in this case. The facility's policy mandates weekly cleaning and discarding of non-compliant foods, but this was not adhered to, leading to the potential risk of foodborne illness for the resident.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not adhere to enhanced barrier precautions while performing gastrostomy tube feeding for a resident. The LVN failed to don a gown, which is required for residents with gastric feeding tubes to prevent cross-contamination and protect both the resident and staff. This oversight was acknowledged by the LVN, who admitted to forgetting to wear the gown and noted the absence of a sign indicating the need for enhanced barrier precautions. In the second incident, two Certified Nursing Assistants (CNAs) did not follow proper infection control procedures during incontinent care for another resident. The CNAs failed to change their gloves and perform hand hygiene between handling soiled and clean items, and they touched clean surfaces with soiled gloves. This improper technique was captured on video and confirmed by the facility's Assistant Director of Nursing (ADON) and Director of Nursing (DON) as not adhering to the facility's policy, which could lead to cross-contamination and potential infections. Both incidents highlight lapses in following established infection control protocols, despite the staff having been recently in-serviced on these procedures. The facility's infection preventionist and other administrative staff acknowledged the importance of adhering to these protocols to prevent the spread of infections and protect residents' health.
Failure to Uphold Resident Dignity and Smoking Rights
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents, leading to deficiencies in their care. For one resident, the facility did not ensure that CNAs explained the procedures before initiating a transfer and providing incontinent care. The resident, who had severe cognitive impairment and was dependent on staff for assistance, was transferred using a mechanical lift without any explanation from the CNAs. The resident's muttering and increased shakiness in her voice indicated distress, yet the CNAs did not communicate with her during the process, leaving her feeling insecure and agitated. In another instance, the facility failed to provide scheduled smoke breaks for a resident residing in the memory care unit. The resident, who had moderate cognitive impairment and was a current tobacco user, was not consistently offered the opportunity to smoke at the scheduled times. Despite having a smoking schedule, the facility did not actively ask the resident if she wanted to smoke, relying instead on the resident to express the desire to smoke. This lack of initiative from the staff led to the resident missing scheduled smoke breaks, which could have been used as an intervention to help with her behaviors. Interviews with staff and family members revealed that the resident's smoking habits were not adequately supported by the facility. The resident's family member expressed concern that the resident did not get to smoke enough, and staff acknowledged that the resident's memory issues prevented her from remembering the smoking schedule. The facility's failure to ensure that the resident was taken to smoke at the scheduled times compromised her right to smoke and potentially affected her quality of life.
Rough Handling of Resident During Transfer and Care
Penalty
Summary
The facility failed to protect a resident from abuse during a mechanical lift transfer and incontinent care. The incident involved two CNAs who roughly handled the resident, failing to communicate with her during the process. The resident, who had severe cognitive impairment and was dependent on staff for assistance, was not informed about the actions being taken, which led to increased agitation and distress. The resident, an elderly female with dementia and other health issues, was observed in a video being transferred to her bed using a Hoyer lift by the CNAs. The CNAs did not explain their actions to the resident, who was placed near the edge of the bed without the side assist rail being raised. The CNAs left the resident unattended for a brief period, during which she swayed dangerously close to the edge. Upon returning, the CNAs continued to handle the resident roughly, pulling her gown and brief without unfastening it, causing her distress. Interviews with facility staff, including the ADON, DON, and Administrator, revealed that the care provided was considered too swift and rough, potentially leading to skin tears and soreness. The staff acknowledged that the CNAs should have used a draw sheet to prevent injury and that the actions observed in the video were concerning. The CNAs involved had received training on abuse and neglect, but their actions during the incident did not align with the facility's policies and expectations for resident care.
Failure to Provide Timely Discharge Notice
Penalty
Summary
The facility failed to provide timely notification to a resident and their representative regarding a discharge. The resident, an elderly female with multiple health issues including acute respiratory failure, congestive heart failure, and severe cognitive impairment, was discharged without a 30-day written notice. The facility did not complete a discharge summary or provide a written notice to the resident's representative, which is required by policy. The resident was admitted to the facility for skilled nursing and therapy evaluation but faced issues with the payor source due to not meeting the 3-midnight hospital stay requirement. This resulted in the resident being discharged home after only a short stay, with the family being informed by phone rather than through a formal written notice. The facility arranged for a home health agency to provide services after the respite care period ended, but the lack of a formal discharge notice was a significant oversight. Interviews with facility staff revealed confusion and a lack of awareness regarding the discharge notice requirements. The Admission Coordinator, Social Worker, and MDS Coordinator all provided conflicting information about the necessity of a discharge notice, citing the resident's short stay and lack of a payor source as reasons for not issuing one. The Administrator acknowledged the oversight but noted that the Business Office Manager, who was responsible for discharge notices, was on medical leave at the time.
Failure to Re-evaluate PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to fourteen days for two residents, leading to a deficiency in medication management. Resident #1 had a PRN order for Lorazepam, a psychotropic medication, which was not re-evaluated by a physician for more than fourteen days. The resident, who had severe cognitive impairment and a history of dementia and anxiety, received the medication multiple times over several months without documented physician re-evaluation. Similarly, Resident #2, who also had severe cognitive impairment and a history of dementia, had a PRN order for Lorazepam that was not re-evaluated within the required timeframe. Interviews with facility staff revealed a lack of awareness and adherence to the policy requiring re-evaluation of PRN psychotropic medications every fourteen days. LVN A acknowledged the absence of re-evaluation documentation, while LVN B and LVN C expressed differing views on the necessity of re-evaluation based on resident stability. The ADON and DON confirmed the oversight, noting the potential risks of not re-evaluating such medications, including overmedication and the use of chemical restraints. The facility's Medication Management Policy and Procedure mandates ongoing monitoring and re-evaluation of PRN psychotropic medications every fourteen days, with documentation of the physician's rationale if the order is to be extended. However, this policy was not followed for the two residents in question, resulting in a failure to ensure safe and appropriate medication use. The deficiency highlights the need for consistent adherence to established protocols to prevent potential adverse consequences for residents.
Inadequate Food Supply and Menu Substitutions
Penalty
Summary
The facility failed to ensure that menus and nutritional adequacy met the nutritional needs of residents in accordance with established national guidelines. This deficiency was observed during two meals where the planned menu was not followed due to a lack of ingredients. The Dietary Manager (DM) reported that the grocery delivery was delayed due to the Labor Day holiday, and the corporate office did not approve the grocery order on time due to budget constraints. As a result, the facility did not have the necessary ingredients to prepare the meals as planned, leading to substitutions that were not reviewed by a dietician. During the period from 09/01/2024 to 09/03/2024, the facility did not maintain a seven-day supply of food, as required by their emergency and disaster planning policy. Observations of the facility's pantry, cooler, and freezer revealed insufficient food supplies to meet the needs of the 123 residents for seven days. The DM admitted that the current food supply was inadequate and that there was no separate area for emergency food supplies. The lack of adequate food supply led to meal substitutions that were not nutritionally equivalent to the planned menu items. Interviews with staff, including the DM, cooks, and the Administrator, highlighted a lack of communication and oversight regarding the food supply and menu substitutions. The DM did not follow the procedure for notifying the dietician of menu substitutions, and the dietician was unaware of the low food supply. The Administrator was not informed of the food supply issues until they became critical, and although petty cash was available for emergency purchases, it was not utilized effectively to address the shortage. The facility's failure to maintain an adequate food supply and follow the planned menu could potentially lead to inadequate nutrition for the residents.
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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