Los Arcos Del Norte Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 11169 Sean Haggerty, El Paso, Texas 79934
- CMS Provider Number
- 676283
- Inspections on file
- 38
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Los Arcos Del Norte Care Center during CMS and state inspections, most recent first.
The facility did not promote or facilitate resident self-determination by failing to support resident choice, resulting in a deficiency related to resident autonomy.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
The facility did not adequately protect resident-identifiable information or failed to maintain medical records according to professional standards, as identified by surveyors.
Several residents with complex needs, including chronic hygiene refusal, wandering into other residents' rooms, and sexually inappropriate behaviors, did not have these issues addressed in their care plans. Despite staff awareness and documentation of these behaviors, the care plans lacked measurable objectives, time frames, and specific interventions, leaving staff without clear guidance to address the residents' needs.
The facility did not document two separate incidents involving two residents—one alleging verbal mistreatment by a staff member and another reporting theft of money—in their medical records, despite both events being reported to the state and investigated. Facility leadership confirmed that nursing staff were responsible for documenting these incidents, in accordance with facility policy and professional standards.
A resident with a chronic skin condition and moderate cognitive impairment alleged mistreatment during a shower, but staff failed to perform or document a timely skin assessment as required by facility policy. Interviews confirmed that the assessment was either delayed or not documented, and the incident was not properly recorded in the medical record, resulting in a failure to follow abuse prevention procedures.
Two residents experienced deficiencies in their living environment: one was moved to a new room without notification or consent, resulting in damage to her personal property, while another, with severe cognitive impairment, resided in a room lacking any personal items or homelike features. Staff interviews and record reviews confirmed that facility policies regarding resident notification, involvement, and room personalization were not followed.
Surveyors found that several medication and treatment carts contained bottles of Betadine Iodine, Chlorhexidine Gluconate, and Pro-stat liquid medication with dried drippings on their sides. Staff, including LVNs and the DON, acknowledged that bottles should be cleaned after each use, but some medications were noted as difficult to keep clean. The facility's policy lacked specific instructions on maintaining bottle cleanliness.
During a meal service, surveyors observed that food trays were transported and stored on mobile racks covered with plastic bags instead of insulated carts, resulting in several hot food items being served below the required temperature. The DON and Dietary Manager confirmed the use of plastic bags to keep food warm and acknowledged resident complaints about cold food. Test tray sampling showed that some food items did not meet the facility's policy for safe food temperatures.
Surveyors found that kitchen staff did not consistently use beard restraints or hairnets, and failed to properly seal, label, and date opened food items in both storage and preparation areas. The deep fryer was left uncovered and unclean, and multiple food containers were not stored according to professional standards, despite staff training on these procedures.
A facility with 124 beds failed to employ a qualified full-time social worker, as the only social worker present continued to provide services with an expired license. Leadership and HR were aware of the expired status, and no other full-time social worker was available to provide oversight or coverage, resulting in noncompliance with licensure requirements.
The facility did not ensure that direct care staff, including an Interim Administrator, DON, Med Aide, ADON, and LVNs, completed mandatory training on effective communication, as training records were missing or incomplete and could not be provided during the survey.
A review found that several staff members, including administrative and clinical personnel, lacked documentation of required training on resident rights and facility responsibilities. Interviews revealed that new staff and leadership were unaware of where training records were kept, and efforts to locate or compile these records were unsuccessful. The facility was unable to provide evidence of completed training for multiple employees.
The facility did not provide or document required annual or new hire training on abuse, neglect, exploitation, and dementia care for several staff members, including the Interim Administrator, DON, ADON, Med Aide, RN, LVN, and Social Worker. Multiple staff were unable to locate or produce training records when requested by surveyors, and policies regarding required staff training were not provided.
The facility did not provide or document required training on its QAPI program for multiple staff members, including administrative, nursing, social work, maintenance, and dietary personnel. Training records were missing or could not be located, and staff responsible for maintaining these records were unaware of their location or existence. This resulted in a deficiency due to staff being uninformed about the facility's quality assurance and performance improvement efforts.
The facility did not provide or document required infection prevention and control training for multiple staff members, including administrative, nursing, maintenance, social work, and dietary personnel. Key staff and corporate representatives were unable to locate or produce training records or related policies when requested by surveyors.
The facility did not ensure that required staff, including administrative, nursing, and support personnel, received and had documentation of compliance and ethics training. Multiple staff members and temporary leadership were unable to locate or provide the necessary training records during the survey, resulting in a deficiency for lack of documented mandatory training.
The facility did not maintain or provide documentation of required behavioral health training for multiple staff members, including administrative, nursing, social work, maintenance, and dietary personnel. Despite efforts by new and temporary staff to locate the records, the facility was unable to demonstrate that the necessary training had been completed.
Two residents with severe cognitive impairment and a history of falls were found without access to their call lights, as the devices were observed on the floor and out of reach. Despite care plans and facility policy requiring call lights to be kept within reach, staff did not ensure this, as confirmed by interviews with a CNA, ADON, and DON.
A resident with multiple chronic conditions, including the need for peritoneal dialysis, did not have dialysis care addressed in her comprehensive care plan. Although dialysis was ordered and documented, staff interviews revealed it was omitted from the care plan due to MDS processes, with reliance on verbal communication and order sets instead. Facility leadership confirmed that dialysis should have been included in the care plan to ensure all staff were informed of the resident's needs.
Two residents who were unable to perform ADLs independently did not receive necessary nail care, resulting in long, untrimmed, and unclean fingernails. Despite care plans and facility policy requiring assistance with personal hygiene, staff did not consistently provide or document nail care, and one resident was not offered nail trimming since admission.
A resident who was fully dependent for ADLs and had significant dental and medical needs did not receive necessary assistance in obtaining routine dental care. Despite requests for dental services and a history of oral health issues, there was confusion among staff regarding responsibility for scheduling and monitoring dental appointments, and no clear documentation or follow-up to ensure the resident received routine dental services as required by facility policy.
A CNA failed to perform hand hygiene after removing soiled gloves and before donning new gloves while providing perineal care to a resident with severe cognitive impairment and incontinence. This lapse was observed during care and confirmed by interviews with the CNA, DON, and ADON, all of whom acknowledged that facility policy and standard procedures require hand hygiene at these steps.
The facility failed to maintain a clean and safe environment, with trash and biohazard materials found on floors across all hallways. Staff interviews revealed inconsistencies in responsibilities for trash disposal, contributing to the deficiency. The presence of trash and biohazard materials, such as bloody gauze, posed an infection risk, contrary to the facility's policy for a dignified environment.
A resident with dementia and a history of falls did not have a Bed Rail Assessment or orders for bed rail use, leading to a deficiency in care. The resident reported using the bed rails independently and experienced an incident where their wrist hit the rail, resulting in swelling and pain. Facility staff confirmed the absence of necessary assessments and orders, acknowledging the risk of entrapment. The facility's policy requires evaluations for bed rail use, which were not conducted in this case.
A facility failed to accurately reflect a resident's use of bed rails in the MDS assessment. The resident, diagnosed with dementia and a history of falls, was observed using bed rails, but this was not documented in the MDS. Interviews with staff revealed a lack of awareness about the necessity of coding bed rail use, potentially risking inadequate care.
A facility failed to implement a comprehensive care plan for a resident's use of bed rails, despite the resident's history of dementia and falls. The care plan did not include the use of bed rails, which was observed to pose a risk when the resident's wrist hit the rail. Interviews with staff revealed that the care plan should have included this information to ensure proper care and safety, as per the facility's policy.
A facility failed to ensure a safe environment by not engaging the brakes on a mechanical lift during a resident transfer, despite staff training on proper procedures. The resident, with severe cognitive impairment and mobility issues, required extensive assistance. The facility's policy emphasized safety checks, which were not followed, leading to a potential risk of injury.
A resident did not receive their prescribed Cilostazol medication due to unavailability, as noted in the MAR. The facility failed to document or report the issue to the physician, despite the resident's history of hypertension and strokes. Staff interviews revealed a lack of recollection and follow-up actions regarding the medication's unavailability.
The facility failed to document a resident's transfer request and included an error in another resident's care plan regarding eyeglasses. The DON and BOM did not record the transfer request, and an LVN admitted to mistakenly documenting eyeglass use. These lapses in documentation could lead to misleading information affecting resident care.
A facility licensed for 124 beds failed to employ a full-time social worker since early August, leading to management staff, including the DON, handling social worker duties. This resulted in grievances not being properly addressed and a resident's transfer request not being followed up, as confirmed by the Administrator. The position had been posted online, but remained unfilled, increasing workloads for existing staff.
The facility failed to notify the State LTC Ombudsman of a resident's discharge, as required. The Ombudsman had not received a discharge list for several months, and the new social worker was unaware of the responsibility. Interviews revealed confusion among staff about who should send the notices, despite the facility's policy stating it should be done at the same time as notifying the resident.
The facility failed to ensure that a high-risk resident's fall mat was positioned bedside while the resident was in bed. The resident, with a history of falls and multiple diagnoses, was found without the fall mat in place, contrary to the care plan and facility policy. Staff interviews confirmed the oversight and the requirement for the mat to be in place to prevent injuries.
The facility failed to post an oxygen sign outside a resident's room, who required oxygen therapy for acute respiratory failure with hypoxia. This oversight was confirmed by the RN and DON, who acknowledged the necessity of the sign to inform staff and visitors and prevent fire hazards.
A resident with multiple diagnoses and a high fall risk was inaccurately documented as low risk for falls by a nurse, despite previous assessments and the care plan indicating otherwise. The DON confirmed the error and acknowledged the potential impact on the resident's treatment.
The facility failed to conduct neurological checks for two residents after they experienced falls, despite facility policies requiring such checks for unwitnessed falls or suspected head injuries. This deficiency placed the residents at risk of undetected head injuries and other complications.
A facility failed to use a Hoyer lift for a resident requiring a two-person transfer, leading to an incident where the resident slipped and nearly fell. The CNA attempted the transfer alone, against the care plan and facility policy, placing the resident at risk of injury.
A facility failed to maintain an infection control program, as a resident's catheter drainage bag was observed lying on the floor multiple times. Despite policies and care plans instructing proper storage, staff interviews confirmed the lapse in protocol, posing a risk of infection.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. The report identifies a deficiency related to the lack of support for resident autonomy, specifically in the area of enabling residents to make their own choices regarding their care and daily life. No further details about specific actions, inactions, or events, nor information about individual residents or their medical history, are provided in the report.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that either resident information was not properly protected or medical records were not kept as required by professional guidelines. No additional details about specific residents, their medical history, or the exact nature of the records or information involved are provided in the report.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents, as required by regulation. For one resident with a chronic skin condition and moderate cognitive impairment, there was a documented pattern of refusing showers, resulting in poor hygiene, strong body odor, and extremely dry skin. Despite repeated refusals and family reports of long-standing hygiene issues, the care plan did not address the resident's refusal of showers or outline interventions to address this behavior. Staff interviews confirmed awareness of the issue, but no care plan was in place to guide consistent care or document effective strategies. Another resident with Alzheimer's disease and depression exhibited wandering behaviors, specifically entering other residents' rooms and rummaging through their belongings, which led to altercations with other residents. Although the care plan addressed wandering in general, it did not specifically address the behavior of entering other residents' rooms. Staff and leadership interviews confirmed that this was a known, ongoing behavior, but it was not reflected in the care plan, leaving staff without clear guidance on how to manage or prevent these incidents. Two additional residents displayed sexually inappropriate behaviors, including exposing themselves and inappropriate physical contact with other residents. In both cases, these behaviors were not included in the residents' care plans, despite being documented in progress notes and incident reports. Staff interviews revealed that these were new or ongoing behaviors that had not been care planned, and the lack of documentation meant that staff were not fully informed or prepared to address these behaviors. The facility's own policy required that care plans include refusals, behaviors, and interventions, but this was not followed for these residents.
Failure to Document Resident Incidents in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, as required by accepted professional standards. For one resident, who had a history of depression and dementia but demonstrated little to no cognitive impairment, an incident occurred in which the resident alleged that a staff member called her 'evil' during an activity. Although the incident was reported to the state, investigated, and statements were collected from staff and other residents, there was no documentation of the incident in the resident's medical chart. Both the Director of Nursing (DON) and the Administrator confirmed that this incident should have been documented by nursing staff, as it pertained to the resident's care and behavior needs. In a separate case, another resident with moderate cognitive impairment and a diagnosis of metabolic encephalopathy versus TIA reported that $40 was stolen from his wallet while he was napping. The incident was reported to the state, the resident's room and wallet were searched with his permission, and the family and local police were notified. Despite these actions, there was no documentation of the incident in the resident's medical record. Interviews with the Assistant Director of Nursing (ADON), a Licensed Vocational Nurse (LVN), the DON, and the Administrator all confirmed that the incident was not documented as required. The facility's own documentation guidelines require that all individuals who document in the medical record follow good clinical record practice. The lack of documentation for these incidents was acknowledged by facility leadership, who stated that nurses are responsible for documenting such events to ensure continuity of care. The omission of these records could result in inaccurate resident records and impact the provision of needed services due to documentation errors.
Failure to Implement Abuse Prevention Policy and Timely Skin Assessment
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Specifically, after an incident in which a resident alleged mistreatment during a shower, the facility did not perform or document a timely skin assessment as required by its abuse policy. The policy mandates that an immediate assessment and documentation in the medical record occur upon discovery of alleged abuse, but this was not completed following the resident's allegation. The resident involved had a history of chronic skin conditions and was moderately cognitively impaired. She had refused showers previously and required a two-person assist for bathing. On the day of the incident, two CNAs assisted with her shower, during which the resident became upset and alleged that she had been scrubbed too hard and that both hot and cold water were used. Staff interviews confirmed that no skin assessment was documented on the day of the incident, and the only available assessment was completed two days later without specifying its relation to the allegation. Interviews with nursing staff and administration revealed that the required documentation and assessment were not completed at the time of the incident. The DON and ADON acknowledged that the lack of immediate assessment and documentation was a failure to provide adequate care and ensure continuity. The facility's own policy was not followed, as the assessment and documentation were either delayed or omitted, placing residents at risk for abuse and neglect.
Failure to Ensure Resident Rights and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for two residents, resulting in deficiencies related to resident rights and environmental standards. One resident, a cognitively intact female with diagnoses including toxic liver disease and muscle wasting, was moved to a different room without her consent or prior notification. During this unannounced transfer, her personal portable closet was broken by facility staff and not replaced, despite her requests. The resident expressed that her rights were violated by not being included in the decision-making process regarding her room change and by having her belongings handled without her presence. Multiple staff interviews confirmed that the resident was not notified or involved in the transfer, and the facility's own grievance summary documented her formal complaint about the incident. Another resident, a male with severe cognitive impairment due to dementia and Alzheimer's disease, was found to be living in a room that lacked any personal items or homelike touches. Observations revealed that his room was empty except for snacks on the nightstand, with bare walls and no evidence of personalization. Interviews with staff indicated that they were unaware of the lack of personal items in his room, and the social worker acknowledged that the resident carried family photos in his pockets but had not facilitated displaying them in his room. The facility's policy required that resident rooms be arranged to preserve dignity and contribute to a positive self-image, but this was not followed in this case. Both deficiencies were substantiated through observations, interviews, and record reviews, including care plans and facility policies. The failures included not protecting a resident's personal property during a room transfer, not notifying or involving the resident in the process, and not ensuring that another resident's room was personalized to create a homelike environment. These actions and inactions were directly linked to the facility's failure to honor residents' rights to a safe, clean, comfortable, and homelike environment, as required by regulation and facility policy.
Medication Storage and Cleanliness Deficiency
Penalty
Summary
Surveyors observed that the facility failed to maintain proper storage and cleanliness of medication bottles in three out of four medication and treatment carts. Specifically, bottles of Betadine Iodine, Chlorhexidine Gluconate solution, and Pro-stat liquid medication were found with dried drippings running down their sides in the 100, 200, and 300 hall carts. These observations were made during multiple checks of the medication carts. Staff interviews confirmed that medication bottles should be cleaned after each use to prevent cross contamination, but it was acknowledged that some medications, such as iodine and pro-stat, are difficult to keep clean due to their properties. The Director of Nursing and regional nurse both stated that staff were trained to clean bottles after each use, but there was uncertainty about when the last training occurred. Review of the facility's Medication Management Program policy revealed no specific instructions regarding the requirement to keep bottles clean and free of dried drippings. The deficiency was identified through direct observation, staff interviews, and policy review, with no mention of specific residents affected or their medical conditions at the time.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature during a meal observation. Surveyors observed that meal trays were transported and stored on mobile Sheet Pan Racks covered with clear plastic trash bags, rather than insulated or heated carts. When questioned, the DON did not provide an explanation for how the food was kept warm. The Dietary Manager confirmed that the racks were covered with plastic bags in an attempt to keep the food hot, and acknowledged that the facility only had two insulated meal carts and two metal meal carts available. She also noted that residents in certain halls had complained about cold food, and that the temperature of the food could be affected by the timing of meal tray distribution by CNAs. Test tray sampling revealed that several hot food items were below the required temperature at the point of service, with mashed potatoes on the regular diet tray measured at 123°F and pot roast on the pureed diet tray at 125.9°F, both below the facility's policy requirement of maintaining hot foods at 135°F or higher. The Dietary Manager confirmed that some of the food temperatures were cold and stated that food below the required temperature would be reheated before serving. The facility's policy on safe food handling requires that hot foods be maintained at 135°F or higher and cold foods at 40°F or below at the point of service, which was not consistently achieved during the observed meal service.
Failure to Follow Food Safety Standards in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and service practices that did not comply with professional standards for food safety. Kitchen staff, including one with a short beard, were seen serving and preparing food without required beard restraints, and the Dietary Manager was present in the kitchen without a hairnet. The deep fryer was left uncovered, contained burnt oil, and had food particles around the basket. Several opened food containers in both the food preparation area and dry storage room were not properly sealed, and multiple opened food items in the refrigerator and dry storage were not labeled or dated as required. Interviews with the Dietary Manager and kitchen staff confirmed that staff had been trained on the importance of using hairnets, beard restraints, and proper food storage procedures, including sealing, labeling, and dating opened food items. Despite this training, staff did not consistently follow these protocols, as evidenced by repeated observations of improper food handling and storage. These actions were not in accordance with the facility's own policies and the 2022 Food Code requirements.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, licensed for 124 beds, failed to employ a qualified full-time social worker as required for facilities of its size. Record review and staff interviews revealed that the only social worker present, Social Worker L, had an expired license and continued to provide social services, including updating and participating in resident care plans. The HR/Payroll Coordinator confirmed that Social Worker L's temporary permit had expired and that the other social worker, Social Worker M, was not a full-time employee and did not provide regular oversight. Social Worker L stated she was the only social worker in the building and was unsure when Social Worker M would be present. Further interviews indicated that facility leadership, including the national director of social services, regional vice president, and previous administrator, were aware of Social Worker L's expired license. Social Worker L continued to work despite knowing her license was expired, citing a lack of other social workers and believing that Human Resources was responsible for monitoring licensure status. The facility's policy required adherence to licensure and educational standards, but these were not met, as Social Worker L provided services without a current license and without full-time qualified coverage.
Failure to Provide and Document Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory training on effective communication for direct care staff, as evidenced by the absence of completed training records for seven staff members, including the Interim Administrator, Interim DON, Med Aide, ADON, and two LVNs. During interviews and record reviews, it was revealed that the HR/Payroll Coordinator, who was new to her role, did not maintain training records in personnel files and was unaware of their location. The ADON, also recently hired, was unable to locate the required training records and had not provided them to the state surveyor as requested. The Corporate Regulatory Specialist, temporarily assigned to the facility, was similarly unaware of the records' whereabouts and was unable to produce them after follow-up attempts. A review of the User Learning Records confirmed that the identified staff members had not completed training on effective communication. Additionally, policies regarding required staff training were requested by the surveyor but were not provided before the survey exit. The lack of documentation and completion of effective communication training for direct care staff constituted the deficiency identified during the survey.
Failure to Ensure Staff Education on Resident Rights and Facility Responsibilities
Penalty
Summary
The facility failed to ensure that all staff members were educated on resident rights and the responsibilities of the facility to properly care for its residents. During interviews and record reviews, it was found that eight out of twelve employees reviewed, including the Interim Administrator, Interim DON, Med Aide, ADON, two LVNs, a Social Worker, and another staff member, did not have documentation of having received the required training on resident rights and facility responsibilities. The HR/Payroll Coordinator, who was new to her role, was unable to locate the training records and was unaware of who maintained them. The ADON, also recently hired, did not know where the training records were kept and was unable to provide them upon request. Further interviews with the Corporate Regulatory Specialist revealed that the training records could not be found, and attempts to compile them were unsuccessful. The facility was unable to provide policies regarding required staff training before the survey exit. A review of the User Learning Records confirmed the absence of documentation for the required training for the identified staff members, some of whom had been recently hired or re-hired. This lack of documentation indicated that the facility did not ensure all staff received the necessary education on resident rights and facility responsibilities.
Failure to Provide and Document Required Abuse and Dementia Training for Staff
Penalty
Summary
The facility failed to provide required annual or new hire training on abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention for eight out of twelve employees reviewed. These employees included the Interim Administrator, Interim DON, Med Aide, RN, ADON, Social Worker, and others. During interviews and record reviews, it was revealed that the HR/Payroll Coordinator, who was new to her role, did not maintain training records in the personnel files and was unaware of their location. The ADON, also recently hired, was unable to locate the training records and did not know where they were kept. The Corporate Regulatory Specialist, temporarily assigned to the facility, was similarly unaware of the records' location and attempted to follow up with the ADON and corporate office. Despite multiple attempts by facility staff to locate the required training documentation, they were unable to provide evidence that the selected employees had completed the necessary abuse, neglect, exploitation, and dementia care training. The User Learning Records provided did not contain documentation for the required trainings for the identified staff members. Additionally, policies regarding required staff training were requested by surveyors but were not received before the survey exit.
Failure to Provide and Document Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training to all staff on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program. During interviews and record reviews, it was found that training records for 12 employees, including administrative, nursing, social work, maintenance, and dietary staff, were either missing or could not be located. The HR/Payroll Coordinator, who was new to her role, was unaware of where the training records were kept and did not maintain them in the personnel files. The ADON, also recently hired, was unable to find or provide the requested training documentation. The Corporate Regulatory Specialist, temporarily assigned to the facility, was similarly unaware of the location of these records and attempted to follow up with the ADON and corporate office without success. Despite repeated requests from the state surveyor, the facility was unable to produce documentation showing that the selected staff had received training on the QAPI program. The User Learning Records provided did not include evidence of QAPI training for the identified employees. Additionally, policies regarding required staff training were requested but not received before the survey exit. The lack of documented QAPI training for these staff members constituted a deficiency, as it left staff uninformed about the facility's quality control efforts.
Failure to Provide and Document Mandatory Infection Control Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on infection prevention and control standards, policies, and procedures for 11 of 12 staff members reviewed. During interviews and record reviews, it was revealed that the HR/Payroll Coordinator, who was new to her role, did not maintain training records in the personnel files and was unaware of their location. The ADON, also recently hired, was unable to locate the required training records and was still searching for them during the survey. The Corporate Regulatory Specialist, temporarily assigned to the facility, was also unaware of the location of these records and attempted to follow up with both the ADON and the corporate office. Despite multiple attempts by facility staff to locate the training documentation, the records for the required infection prevention and control training could not be produced for the Interim Administrator, Interim DON, Med Aide, RN, ADON, LVNs, Maintenance, Social Worker, and Dietary Manager. Policies regarding required staff training were requested by surveyors but were not received before the survey exit. The lack of documentation indicated that the facility did not ensure the required infection prevention and control training was provided to the identified staff members.
Failure to Provide and Document Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that all required staff received training in compliance and ethics, as evidenced by the absence of training documentation for eight out of twelve staff members reviewed. These staff included the Interim Administrator, Interim DON, Med Aide, ADON, two LVNs, a cook, and a social worker. During interviews and record reviews, it was revealed that the HR/Payroll Coordinator, who was new to her role, did not maintain training records in the personnel files and was unaware of their location. The ADON, also recently hired, was unable to locate the training records and was still searching for them during the survey. The Corporate Regulatory Specialist, temporarily assigned to the facility, was similarly unaware of where the records were kept and was unable to provide them upon request. Despite multiple attempts by facility staff to locate the required training records, they were unable to produce documentation confirming that the identified staff had completed the mandatory compliance and ethics training. The facility also failed to provide policies regarding required staff training before the survey exit. The User Learning Records reviewed did not show evidence of ethics training for the staff in question, confirming the deficiency in staff training documentation.
Failure to Maintain Behavioral Health Training Records for Staff
Penalty
Summary
The facility failed to maintain a training program to ensure that staff received behavioral health training as required. During interviews and record reviews, it was found that training records for 12 staff members, including the Interim Administrator, Interim DON, Med Aide, RN, ADON, LVNs, Social Workers, Maintenance, and the Dietary Manager, could not be located or provided for review. The HR/Payroll Coordinator, who was new to her role, was unaware of where the training records were kept and did not maintain them in personnel files. The ADON, also recently hired, was unable to locate the records and was still searching for them during the survey. The Corporate Regulatory Specialist, temporarily filling in, was also unaware of the location of the training records and attempted to follow up but was unsuccessful in obtaining the required documentation. Despite multiple attempts by facility staff to locate or compile the necessary training records, the facility was unable to provide documentation that behavioral health training had been completed for the selected employees. Policies regarding required staff training were requested by surveyors but were not received before the survey exit. The lack of documentation and inability to demonstrate compliance with behavioral health training requirements constituted the deficiency cited in the report.
Failure to Ensure Call Light Accessibility for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that two residents had access to their call lights. For one resident with severe cognitive impairment, a history of falls, muscle weakness, and decreased vision, the call light was observed lying on the floor at the foot of the bed and out of reach. The resident's care plan specifically required the call light to be kept in a consistent and repetitive place to promote usage. For another resident, also with severe cognitive impairment, generalized muscle weakness, and a history of falls, the call light was found on the floor by the head of the bed and similarly out of reach, despite care plan interventions directing staff to always keep the call light within reach. Interviews with staff, including a CNA, ADON, and DON, confirmed that all staff members are responsible for ensuring call lights are within reach of residents. The facility's policy also requires staff to place the call light within the resident's reach when leaving the room. These observations and interviews demonstrate that staff did not follow established protocols and care plan interventions, resulting in the call lights being inaccessible to the residents at the time of observation.
Failure to Include Dialysis in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting dialysis care for one resident. The resident, an elderly female with diagnoses including arteriovenous fistula, atherosclerotic heart disease, and hypertension, had physician orders for peritoneal dialysis three times weekly. Despite these orders and documentation of dialysis in the Minimum Data Set (MDS), the resident's comprehensive care plan did not include dialysis or related care instructions. Interviews with facility staff, including the DON, MDS nurse, and regional nurse, confirmed that dialysis should have been included in the care plan to inform staff of the necessary care. The MDS nurse indicated that dialysis was not included because it did not trigger a care area in the MDS, and believed that nurses would follow the orders and communicate relevant information to CNAs. However, both the DON and regional nurse acknowledged that the omission meant the care plan did not fully guide staff in meeting the resident's needs as required by facility policy.
Failure to Provide Required Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary nail care for two residents who were unable to perform activities of daily living independently. One resident, with diagnoses including cerebral infarction, hemiplegia, and muscle weakness, required substantial assistance with personal hygiene and had impairments in mobility and upper body strength. Despite these needs, the resident was observed with long fingernails containing dirt and reported not being offered nail trimming since admission. The care plan included assistance with grooming and hygiene, but this intervention was not carried out as required. Another resident, with generalized muscle weakness, cognitive decline, and aphasia, also required assistance with self-care and had an order for weekly nail checks. This resident was observed with long fingernails, and there was no care plan addressing personal hygiene. Staff interviews revealed that nail care was scheduled weekly but could be provided as needed, and that refusals were to be documented. However, there was no evidence that nail care was consistently offered or refusals properly documented. Facility policy required necessary care for residents unable to perform ADLs, but this was not followed, resulting in the deficiency.
Failure to Provide Routine Dental Services to Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance to a resident who required dental care. The resident, a female with quadriplegia, dysphagia, and a disorder of tooth development, was dependent on staff for all activities of daily living, including oral care. Her care plan indicated that staff should provide oral care assistance according to her abilities. Despite this, records showed that her last dental visit was for an emergency exam after losing a crown, during which it was noted that her oral hygiene needed improvement and she required a deep cleaning in a hospital setting. The resident reported sensitivity and bleeding during oral care, and she had requested dental services from both nursing staff and the previous administrator since her last dental visit. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for monitoring and scheduling dental appointments. The CNA stated that oral care was performed by CNAs and nursing staff, and that residents either went out for dental services or were seen by a dentist in the facility, with the last visit occurring several months prior. The DON and social worker both indicated that social services were responsible for monitoring dental appointments, but neither was certain about the frequency of dental visits or the process for monitoring effectiveness and dentist availability. The social worker also stated she had not received any reported concerns or requests for dental appointments, and that such requests would be discussed in meetings, but she was unsure how the process was tracked. Facility policy required staff to provide a list of dental care providers upon admission and to assist with scheduling appointments and transportation as needed. However, interviews and record reviews indicated that the resident's requests for dental care were not effectively addressed, and there was no clear documentation or follow-up to ensure routine dental services were provided. This lack of coordination and follow-through resulted in the resident not receiving the routine dental care she required.
Failure to Perform Hand Hygiene During Perineal Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene during perineal care for a female resident with severe cognitive impairment, dementia, and generalized muscle weakness. The resident required extensive assistance with toileting and was dependent on staff for activities of daily living. During an observed episode of perineal care, the CNA disposed of dirty wipes and gloves and then put on new gloves to place clean briefs on the resident without performing hand hygiene in between these steps. Interviews with facility staff, including the CNA, Director of Nursing (DON), and Assistant Director of Nursing (ADON), confirmed that hand hygiene should be performed after removing soiled gloves and before donning new gloves and handling clean briefs. The facility's policy and referenced nursing procedures also required hand hygiene at these points. The failure to follow these procedures was observed directly and acknowledged by staff as not in accordance with infection prevention and control protocols.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents across all four hallways reviewed for infection control. Observations revealed trash, including medical gloves, food, and paper, scattered on the floors of various rooms and hallways. Notably, bloody gauze was found on the floor in hall 400, which was acknowledged as an infection control issue by LVN I. The Interim-DON confirmed that biohazard materials should be disposed of by nursing staff, followed by disinfection by housekeeping. Interviews with staff, including the Interim-DON, Manager of Housekeeping, and RN E, highlighted a lack of clarity and consistency in responsibilities for trash and biohazard disposal. The Manager of Housekeeping stated that his team was responsible for non-fluid trash during their working hours, while nursing staff were responsible for biohazard materials. However, outside of housekeeping hours, nursing staff were expected to manage all trash and spills. This inconsistency in roles and responsibilities contributed to the observed deficiencies. The facility's policy on maintaining a clean and dignified environment was not adhered to, as evidenced by the presence of trash and biohazard materials on the floors. Staff interviews consistently pointed out the risk of infection due to the failure to promptly and properly dispose of trash and biohazard materials. The report indicates that the facility's environment did not meet the standards set by their own policy, potentially compromising resident safety and comfort.
Failure to Assess Bed Rail Risk for Resident
Penalty
Summary
The facility failed to assess a resident for the risk of entrapment from a bed rail prior to its installation, which is a deficiency in the care provided. The resident, who was diagnosed with dementia and had a history of falls, did not have a Bed Rail Assessment completed to ensure the appropriateness of the bed rails for their needs. Additionally, there were no orders for the use of bed rails documented in the resident's records, and the use of bed rails was not included in the resident's care plan. The deficiency was identified through observation, interviews, and record reviews. The resident reported using the bed rails to get up independently and mentioned an incident where their wrist hit the bed rail, causing swelling and pain. This incident led to a medical evaluation, which revealed a fracture. Interviews with facility staff, including the Interim-DON, EX-DON, and Nurse Assessment Coordinator, confirmed that there were no orders or assessments for the bed rail use, and the staff acknowledged the necessity of such assessments to prevent risks like entrapment. The facility's policy on bed rails and side rails requires an evaluation for the risk of entrapment before installation and mandates that qualified staff assess the need for bed rails based on specific criteria. However, the policy was not followed in this case, as evidenced by the lack of assessment and orders for the resident's bed rail use. The failure to adhere to these procedures could place residents at risk of injury from inappropriate or unnecessary enablers.
Inaccurate MDS Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident regarding the use of bed rails. Specifically, the quarterly MDS for a resident did not indicate the use of bed rails, despite observations and interviews confirming their presence. The resident, who was diagnosed with dementia and had a history of falls, was observed using bed rails during a demonstration of his ability to turn in bed. However, the MDS assessment did not include this information in Section P, which covers restraints and alarms. Interviews with facility staff, including the Interim Director of Nursing (DON), the former DON, and the Nurse Assessment Coordinator, revealed a lack of awareness and understanding regarding the necessity of coding bed rail use in the MDS assessment. The Interim DON and the Nurse Assessment Coordinator were unsure of the risks associated with not coding the bed rail use, while the former DON acknowledged that the resident should have been coded for bed rail use. This oversight in the MDS assessment could potentially place residents at risk of not receiving adequate care.
Failure to Implement Comprehensive Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident's use of bed rails, which are considered enablers. This deficiency was identified during a review of the resident's records, which showed that the care plan did not include the use of bed rails, despite the resident having a history of dementia and falls. The resident was observed demonstrating how his wrist hit the bed rail while turning in bed, indicating the need for a care plan that addresses the use of bed rails. Interviews with facility staff, including the Interim-DON, EX-DON, and Nurse Assessment Coordinator, revealed that the care plan should have included the use of bed rails to ensure proper care and safety for the resident. The staff acknowledged that the absence of this information in the care plan could pose a risk, as it would leave the nursing staff unaware of how to properly care for the resident. The facility's policy requires the development of a comprehensive care plan that meets professional standards of quality, which was not adhered to in this case.
Failure to Engage Brakes on Mechanical Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents for a resident requiring mechanical lift assistance. During an observation, two CNAs were seen using a mechanical lift to transfer a resident without engaging the brakes, causing the lift to move slightly. This oversight occurred despite the CNAs having received training on proper mechanical lift procedures, which included securing the brakes to prevent movement during transfers. The resident involved was an elderly male with severe cognitive impairment and multiple mobility-related diagnoses, including muscle wasting and paralytic gait, necessitating extensive assistance for bed mobility and transfers. The facility's policy on mechanical lifts emphasized performing safety checks and ensuring the stability of equipment before lifting, which was not adhered to in this instance. Interviews with the CNAs and the former Director of Nursing confirmed the lapse in following established safety protocols, highlighting a failure in maintaining a hazard-free environment for residents requiring mechanical lift transfers.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of Cilostazol, a vasodilator medication prescribed for essential primary hypertension. The medication was not administered on a specific date due to its unavailability, as noted in the Medication Administration Record (MAR). The medication was ordered to be given twice daily, but the facility did not have it on hand, and there was no documentation of any follow-up actions taken to address the unavailability. Interviews with staff revealed a lack of recollection regarding the specific resident and the actions taken when the medication was unavailable. The resident involved was an elderly female with a history of diabetes, hypertension, and strokes, which could increase the risk of complications from missed doses of blood pressure medication. The facility's policies required that medications be administered as ordered and that any issues with medication availability be documented and reported to the physician. However, there was no evidence that the physician was notified or that alternative measures were taken to ensure the resident received the necessary medication. This deficiency in pharmaceutical services could potentially place residents at risk for medical complications due to missed doses.
Deficiencies in Resident Documentation and Care Planning
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation. For one resident, the facility did not document the resident's request to transfer to another facility. Despite the resident's cognitive intactness and clear communication of her desire to transfer, the request was not recorded in her progress notes. The Director of Nursing (DON) acknowledged the oversight, stating that the request should have been documented, and the Business Office Manager (BOM) was involved in the transfer process but did not document the request either. This lack of documentation could lead to missing or misleading information affecting resident care. Another resident's care plan contained an error regarding the use of eyeglasses. The care plan inaccurately stated that the resident should be wearing eyeglasses, although the resident did not use them. The Licensed Vocational Nurse (LVN) responsible for the care plan admitted to the mistake and acknowledged that the inaccurate information could be misleading. The DON confirmed that nurses are trained to modify care plans based on resident needs and that the care plan must be accurate to ensure appropriate care. The facility's policies on discharge planning and documentation guidelines emphasize the importance of accurate and complete documentation. The failure to document the transfer request and the incorrect care plan entry highlight lapses in adhering to these policies. The Administrator reiterated the expectation for accurate documentation to prevent gaps in information that could impact resident care.
Facility Lacks Full-Time Social Worker, Affecting Resident Services
Penalty
Summary
The facility, licensed for 124 beds, failed to employ a qualified social worker on a full-time basis since August 5, 2024. This deficiency was identified through interviews and record reviews, revealing that the Director of Nursing (DON) and other management staff were handling the social worker's duties. The absence of a social worker led to issues such as grievances not being properly addressed and discharge planning being inadequately managed. Resident #1's family member reported a grievance that was not handled by a social worker, and Resident #6 experienced a failed transfer request due to the lack of follow-up by the facility staff. The Administrator, who was newly hired on July 29, 2024, confirmed that the social worker's last day was August 2, 2024, and that the position had been posted online since July 8, 2024. Despite the ongoing recruitment process, the facility had not yet filled the position, resulting in increased workloads for existing management staff. The Administrator acknowledged the challenge of not having a social worker available for residents and families, and a potential candidate was scheduled for an interview on August 26, 2024.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide timely notification to the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of a resident. Specifically, the facility did not send a written notice of transfer or discharge for a resident who was discharged home. This oversight was identified during a review of the resident's records and communication with the Ombudsman, who confirmed that they had not received any notification about the resident's discharge. The Ombudsman also noted that they had not received a monthly discharge list from the facility for several months, which is a requirement. Interviews with facility staff revealed a lack of clarity regarding the responsibility for sending discharge notices to the Ombudsman. The social worker, who was newly hired, was unaware of the requirement, and the Director of Nursing (DON) believed it was the social worker's responsibility. The Administrator also stated that the social worker should be responsible for contacting the Ombudsman. The facility's policy, dated March 2021, clearly states that a copy of the notice should be sent to the Ombudsman at the same time it is provided to the resident and their representative.
Failure to Ensure Fall Mat Placement for High-Risk Resident
Penalty
Summary
The facility failed to ensure that Resident #7's fall mat was positioned bedside while the resident was lying in bed. This failure was observed during an interview and observation on 05/22/2024, where Resident #7 was found lying in bed with the fall mat folded and leaning against an unoccupied bed in the room. Resident #7, a [AGE] year-old male with diagnoses including unsteadiness on feet, hypotension, dementia, and other conditions, had a history of falls and was assessed as high risk for falls. The resident's care plan included the use of a fall mat to reduce the severity of injuries if the resident fell from the bed. However, the mat was not in place as required, which could place the resident at risk of falls and injuries. During interviews, LVN I and the DON confirmed that Resident #7 was a high-risk fall patient and that the fall mat should be in place anytime the resident was in bed. LVN I was observed placing the mat on the floor next to Resident #7's bed after it was found folded and leaning against another bed. Both LVN I and the DON acknowledged that staff members responsible for checking on residents should ensure that fall prevention measures, including the use of fall mats, are in place. The facility's policy on Fall Management also indicated that individualized interventions should be reassessed and revised as needed to manage falls, but this was not adhered to in Resident #7's case.
Failure to Post Oxygen Sign for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care was provided with appropriate care consistent with professional standards. Specifically, the facility did not post an oxygen sign outside the resident's room, which is necessary to inform staff and visitors of the presence of oxygen and to prevent fire hazards. The resident, an elderly female with severe cognitive impairment and a diagnosis of acute respiratory failure with hypoxia, was observed using oxygen therapy without the required signage. This oversight was confirmed during interviews with the RN and the DON, both of whom acknowledged the necessity of the sign and the responsibility of the Charge Nurse to ensure it was posted. The resident's care plan and physician orders indicated the need for intermittent oxygen therapy at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%. Despite these documented needs, the absence of the oxygen sign was noted during an observation. The facility's policy on oxygen administration also mandates the placement of an oxygen precautions sign if required, which was not adhered to in this case. This failure could potentially expose residents on oxygen therapy to fire hazards if staff and visitors are unaware of the oxygen presence.
Inaccurate Nursing Documentation for Fall Risk Assessment
Penalty
Summary
The facility failed to ensure accurate nursing documentation for a resident, leading to potential errors in treatment. The resident, a male with multiple diagnoses including unsteadiness on feet, acute embolism, hypotension, dementia, anxiety, insomnia, and bipolar disorder, was assessed as having a high risk for falls. However, a fall risk assessment completed by a nurse inaccurately documented the resident as low risk for falls with no history of falls, despite the resident's care plan and previous assessments indicating a high fall risk. During an interview, the Director of Nursing (DON) confirmed that the resident was indeed a high fall risk and had experienced falls in the facility. The DON acknowledged the incorrect assessment and expressed uncertainty about why the nurse documented the resident as low risk. The facility's policy on fall management requires accurate fall risk evaluations to identify appropriate preventative interventions, which was not adhered to in this case.
Failure to Conduct Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not conduct neurological checks for two residents after they experienced falls. Resident #3, a male diagnosed with dementia, anxiety, muscle weakness, lack of coordination, and epilepsy, had a fall on 02/25/24. Despite the fall being unwitnessed, no neurological checks were performed as per the facility's protocol. The Director of Nursing (DON) confirmed that neurological checks should have been conducted for unwitnessed falls or suspected head injuries, but this was not done for Resident #3. Similarly, Resident #5, a male diagnosed with dementia, cataracts, osteoporosis, and seizures, experienced a fall on 03/13/24. The resident was found on the floor in the dining area and expressed pain, but no neurological checks were completed as required by the facility's policy. Interviews with the Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN) confirmed that neurological checks should be performed for unwitnessed falls or head injuries to prevent potential complications such as subdural hematoma. The facility's policies on neurological checks and fall management clearly state that neurological evaluations should be performed for residents who sustain unwitnessed falls, regardless of their cognitive status. However, the facility failed to adhere to these policies for both Resident #3 and Resident #5, thereby placing them at risk of undetected head injuries and other complications. This failure to conduct necessary neurological checks represents a significant deficiency in the care provided to these residents.
Failure to Use Hoyer Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure that Resident #1's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, the facility did not use the Hoyer lift to transfer Resident #1, who required a two-person Hoyer lift transfer due to her medical conditions, including quadriplegia, dementia, and chronic pain. Instead, CNA B attempted to transfer Resident #1 alone, which led to an incident where Resident #1 slipped and nearly fell while being moved to a shower chair. Resident #1's medical records indicated that she was dependent on facility staff for all activities of daily living and required a two-person Hoyer lift for transfers. Despite this, CNA B attempted a one-person transfer, which was against the care plan and facility policy. During the transfer, the shower chair moved, causing Resident #1 to slip. CNA B then called for assistance from LVN A, who helped complete the transfer. Resident #1 reported hitting her head and experiencing pain, although no injuries were noted upon assessment. Interviews with facility staff, including CNA B, LVN A, the DON, and the DOR, confirmed that Resident #1 was a two-person Hoyer lift transfer and that CNA B had not followed the proper procedure. CNA B admitted to not thinking clearly and attempting the transfer alone, which was inappropriate given Resident #1's condition. The facility's policies on fall management and mechanical lifts were not adhered to, leading to the incident and placing Resident #1 at risk of injury.
Improper Handling of Catheter Drainage Bag
Penalty
Summary
The facility failed to establish and maintain an infection control program, as evidenced by the improper handling of a catheter drainage collection bag for one resident. Resident #4, who has a history of hepatitis C and chronic kidney disease, was observed with their catheter drainage collection bag lying flat on the floor next to their bed on multiple occasions. The resident's care plan specifically instructed that the collection bag should be stored inside a protective pouch and not allowed to touch the floor. However, these instructions were not followed, as observed on two separate occasions on the same day. The resident was unable to provide details about the situation due to their condition of being rarely/never understood, as noted in their quarterly MDS assessment. Interviews with the facility staff, including an LVN and the DON, confirmed that the drainage collection bag should never be left on the floor due to the risk of infection. Both staff members acknowledged that it is the responsibility of CNAs and nurses to ensure the proper positioning of the drainage bag. The facility's infection control policy and urinary catheter maintenance policy both emphasize the importance of not placing the drainage bag on the floor to reduce the risk of contamination and catheter-associated urinary tract infections (CAUTI). Despite these policies, the deficiency was observed, indicating a lapse in adherence to established infection control protocols.
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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