Lytle Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Lytle, Texas.
- Location
- 15366 Oak St, Lytle, Texas 78052
- CMS Provider Number
- 675295
- Inspections on file
- 34
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Lytle Nursing Home during CMS and state inspections, most recent first.
The facility did not have a grievance policy or process in place, failed to maintain a Grievance Log, and did not provide written forms or feedback for grievances. Grievances were handled informally, and concerns raised in Resident Council meetings were not systematically addressed or communicated back to residents.
A resident with a nephrostomy tube experienced multiple hospitalizations due to the facility's failure to ensure timely medical intervention. The resident's surgery to remove a kidney stone was canceled due to an insurance issue that the facility did not properly address. Despite the resident's severe cognitive impairment, the facility did not follow up with the physician or reschedule the surgery, leading to an Immediate Jeopardy situation.
A resident with a nephrostomy tube experienced multiple hospitalizations due to complications, yet the facility failed to notify the physician or medical director. The resident's scheduled surgery to remove a kidney stone was canceled due to an insurance issue, which the facility did not resolve. The Director of Nursing was aware of the issue but did not take action, and the Medical Director was not informed, leading to a deficiency in care.
The facility failed to report alleged abuse and injuries within the required timeframe for three residents. A resident with severe cognitive impairment was found with a dislocated arm, but the necessary investigation report was not completed. Another resident with severe cognitive impairment suffered a fracture from a fall, and the facility's report lacked staff or resident interviews. A third resident with severe intellectual disabilities sustained a hematoma from an unwitnessed fall, which was not reported within the required two-hour window.
The facility did not update the comprehensive care plans for two residents to reflect their current conditions. One resident's care plan lacked documentation of a left hand contracture, while another's did not include Hospice services, oxygen therapy, and wound care. The facility's policy mandates quarterly updates, which were not followed.
The facility failed to ensure physicians reviewed residents' care programs, including medications and treatments, at each visit. Seven residents lacked evidence of MD visits or progress notes, with only NP notes available, which were not co-signed by an MD. This deficiency could risk residents not receiving appropriate care.
A facility failed to maintain accurate medical records for three residents, leading to deficiencies in documentation. One resident's refusal to attend medical appointments was not documented, another's nephrostomy care and medication consent forms were incomplete, and a third resident's fall and hospital transfer were not recorded. The DON acknowledged these documentation failures, which could affect resident care.
A facility failed to maintain proper infection control during nephrostomy care for a resident with a history of brain injury and hydronephrosis. An LVN did not follow sterile technique or hand hygiene protocols, contaminating supplies and equipment. The facility's policies on sterile procedures and standard precautions were not adhered to, increasing the risk of infection.
The facility failed to maintain a clean and sanitary environment in the B Hallway shower room, which had a strong sulfur odor, black spots, a hole in the floor, and a missing trim plate. The DON expressed concern about infection risks for residents using the shower, especially those prone to infection. The Administrator admitted to not having seen the shower room during rounds, despite acknowledging the risk of wound contamination. The facility's policy on daily bathroom cleaning was not followed, potentially placing residents at risk.
A facility failed to complete a timely comprehensive assessment for a newly admitted resident with severe cognitive impairment and intellectual disabilities. The MDS Coordinator did not conduct the assessment within the required 14 days, delaying the development of a comprehensive care plan. Observations noted the resident's unsteady gait and need for staff assistance, highlighting the importance of timely assessments.
A facility failed to accurately document a resident's limited range of motion due to a left hand contracture in their MDS assessments. The resident, who also used a wheelchair for mobility, was not properly coded in assessments for two periods. The MDS Coordinator acknowledged the oversight and the importance of accurate documentation to ensure necessary care and services.
A facility failed to refer a resident for a PASARR evaluation despite the resident having bipolar disorder and anxiety. The initial PASARR Level 1 screening did not reflect these diagnoses, leading to a lack of follow-up. The resident was on medications for these conditions, and the care plan noted risks for anxiety, depression, and psychotic behaviors.
A resident with severe cognitive impairment and a stage 2 pressure ulcer on her left great toe did not receive proper wound care due to inadequate hand hygiene and failure to cleanse the wound before applying skin prep. The LVN did not change gloves or sanitize hands between treating different wound sites, and inconsistencies in wound care orders were noted. The facility's policy lacked specific wound care procedures, contributing to the deficiency.
A resident with severe cognitive impairment and multiple health conditions did not receive proper respiratory care due to the facility's failure to maintain the oxygen concentrator. The resident's care plan lacked interventions for oxygen therapy, and the filter on the concentrator was found covered with lint. Nursing staff were unaware of how to clean the filter, and the DON admitted there were no specific orders for its maintenance.
The facility failed to ensure physician-signed admission orders for two residents, relying instead on orders signed by a Nurse Practitioner. One resident, with severe asthma and Alzheimer's, was readmitted under hospice care and later expired. Another resident, with severe cognitive impairment, required full assistance with daily activities. Interviews revealed the physician had not signed any orders, contrary to facility policy requiring physician supervision and order signing.
Two LVNs at the facility demonstrated deficiencies in nursing competency and equipment handling. LVN A failed to follow sterile procedures during nephrostomy care, using contaminated equipment and not wearing sterile gloves, which risked infection for a resident with a nephrostomy tube. LVN H lacked knowledge on calibrating glucometers, leading to potential inaccuracies in blood glucose readings and insulin administration. The DON acknowledged these deficiencies, highlighting a failure to adhere to facility policies.
A resident with moderate cognitive impairment was administered Depakote for mood disorder without obtaining consent from their family representative. The consent form lacked the medication classification, and the resident, unable to make informed decisions, signed it themselves. The DON acknowledged the oversight, and the family representative was unaware of the medication's administration.
The facility failed to ensure proper storage and labeling of drugs and biologicals, with issues found in the nurse supply room's refrigerator and the C hall medication cart. The refrigerator contained staff food and expired items, while the medication cart had loose pills and expired medications. The crash cart also contained expired items. These deficiencies were due to non-compliance with facility policies on food storage and medication labeling.
A resident with a history of cerebrovascular issues and missing teeth was not provided a mechanical soft diet as prescribed, leading to potential risks of aspiration or choking. Observations showed the resident eating regular textured food, contrary to physician orders. Staff interviews revealed communication lapses and improper meal ticket checks, contributing to the dietary error.
The facility lacked a Quality Assurance and Performance Improvement (QAPI) plan, policies, and procedures, affecting the quality of care for all residents. The DON confirmed the absence of a QAPI Program and Performance Improvement Projects (PIPs), with no written plan or procedures. Monthly meetings with department heads and the MD occurred, but direct care staff were not involved, and no root cause analyses were conducted.
The facility did not ensure the survey results binder was accessible to residents and families for four out of seven survey days. Residents were unaware of its location, and the ADM could not find it in the lobby. The ADON later provided the binder, which was on her desk, containing outdated results from 2022. Facility policy requires the binder to be in a common area.
The facility failed to conduct and document a comprehensive facility-wide assessment for the past three years, with the last assessment completed in 2021. The Administrator acknowledged that no assessment had been conducted since his arrival in September 2023. A notebook in the Administrator's office contained outdated assessments from 2019, 2020, and 2021, but no updates had been made since then, potentially placing residents at risk.
The facility failed to provide the required minimum of 80 square feet per resident in four double occupancy rooms, with space per resident ranging from 70.97 to 79.62 square feet. The Administrator acknowledged the deficiency and sought a room size waiver, but one bed needed to be de-licensed as it did not meet waiver requirements.
Failure to Establish and Implement Grievance Policy and Process
Penalty
Summary
The facility failed to establish and implement a grievance process to ensure the prompt resolution of all grievances related to residents' rights. Record review revealed the absence of a Grievance Log, and interviews confirmed that grievances were handled informally as they arose, without documentation or a formal tracking system. The DON stated that there was no written form available for residents or families to submit concerns or grievances, nor was there a process to provide written feedback regarding the resolution of such grievances. Additionally, concerns voiced during Resident Council meetings were relayed to administration by the Activity Director through written notes, but there was no established process for communicating responses or resolutions back to the residents. When asked, the DON confirmed that the facility did not have a written grievance policy in place. These failures affected all residents, as there was no formal mechanism to ensure their grievances were addressed and resolved in a timely manner.
Failure to Ensure Timely Medical Intervention for Resident with Nephrostomy Tube
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the removal of a nephrostomy tube. The resident, who had a history of kidney stones and a nephrostomy tube, was scheduled for surgery to remove a kidney stone. However, the surgery was canceled due to an insurance issue that the facility did not properly follow up on. The facility did not reschedule the surgery or follow up with the resident's physician, resulting in the resident experiencing multiple hospitalizations due to complications from the nephrostomy tube. The resident, who had a history of traumatic brain injury, cerebral infarction, and other medical conditions, was documented to have severe cognitive impairment and was unable to make decisions. Despite this, the facility did not take appropriate steps to ensure the resident's medical needs were met. The resident's nephrostomy tube required frequent replacement, and hospital records indicated that long-term percutaneous drainage was not feasible. The facility's failure to address the insurance issue and reschedule the surgery led to the identification of an Immediate Jeopardy situation. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's medical care. The Director of Nursing (DON) admitted to being aware of the insurance issue but did not take action to resolve it, citing being busy with other tasks. The Medical Director was not informed of the issues with the referral process and stated that he could have facilitated the necessary arrangements if he had been aware. The facility's deficient practices placed the resident at risk of delayed medical intervention, pain, and a decline in health.
Failure to Notify Physician of Resident's Significant Change in Condition
Penalty
Summary
The facility failed to immediately consult with the resident's physician when there was a significant change in the resident's status, specifically for a resident with a nephrostomy tube due to kidney stones. The resident was sent to the hospital emergency room on at least 15 occasions for complications related to the nephrostomy tube, yet the facility did not notify the physician or medical director. This lack of communication denied the physician the opportunity to intervene and potentially prevent further complications. The resident, who had a history of hypertension secondary to renal disorders and hydronephrosis with ureteropelvic junction obstruction, was scheduled for surgery to remove a kidney stone. However, the surgery was canceled due to an insurance issue, as the facility did not follow up on the insurance requirements. The facility also failed to reschedule the surgery or follow up with the resident's physician, leaving the resident at risk for continued complications from the nephrostomy tube. Interviews with staff revealed that the Director of Nursing (DON) was aware of the insurance issue but had not taken action to resolve it, citing being busy with other tasks. The Medical Director was not informed of the issues with the insurance referral and stated he could have intervened if he had been notified. The facility's policies required physician notification for changes in the resident's condition, but these were not followed, contributing to the deficiency.
Failure to Timely Report Alleged Abuse and Injuries
Penalty
Summary
The facility failed to report alleged violations involving abuse, including injuries of unknown source, within the required timeframe for three residents. Resident #7, who had severe cognitive impairment and was receiving hospice services, was found with a dislocated arm. The facility did not complete the necessary Provider Investigation Report (PIR) within five days, and the Administrator (ADM) was unfamiliar with the required form. Despite conducting interviews and an in-service on abuse and neglect, the ADM could not locate the investigation file. Resident #48, with severe cognitive impairment and a history of falls, suffered a fracture after pulling on a tablecloth and falling. The facility's internal report included a description of the incident and a TULIP report, but lacked documented staff or resident interviews. The ADM was unaware of the requirement to submit the Provider Investigation Report Form 3613 A within five days of the incident. Resident #200, who had severe intellectual disabilities and was at high risk for falls, sustained a hematoma from an unwitnessed fall. The DON questioned the reportability of the incident, and the ADM acknowledged the failure to report it within the required two-hour window. The facility's abuse policy mandates reporting the results of all investigations to the State Survey Agency within five working days, which was not adhered to in these cases.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team to reflect their current conditions. Resident #4's care plan was not updated to include her left hand contracture, despite observations confirming the condition. The MDS Coordinator acknowledged the omission, emphasizing the importance of capturing all health needs in the care plan. Similarly, Resident #7's care plan did not reflect her current status of receiving Hospice services, oxygen therapy, and wound care for a Stage 2 pressure ulcer on her left great toe. The DON confirmed that the care plan was outdated and did not address these critical care areas. The facility's policy requires that care plans be reviewed and updated at least quarterly, in conjunction with the required MDS assessments, but this was not adhered to in these cases.
Lack of Physician Oversight and Documentation in Resident Care
Penalty
Summary
The facility failed to ensure that physicians reviewed the residents' total program of care, including medication and treatments, at each visit. This deficiency was observed in seven residents, where physician visits and progress notes were either missing or not properly documented. The facility relied on nurse practitioners (NPs) to conduct visits and sign orders, but these were not co-signed by a medical doctor (MD), as required. This lack of oversight and documentation could potentially place residents at risk for not receiving appropriate care. For Resident #4, there was no evidence of any visits or physician progress notes from the MD since her admission. The records provided only included notes from the NP, which were not co-signed by the MD. Similarly, Resident #7's records showed no evidence of MD visits or progress notes, with only NP notes available. Resident #15's records also lacked MD signatures on physician orders, and there were no MD progress notes since his admission. Resident #17, Resident #40, Resident #45, and Resident #200 all had similar issues, with no evidence of MD visits or progress notes. The MD admitted to attending monthly meetings at the facility but did not provide documentation of individual resident visits. The facility's policy required the MD to conduct initial visits for new admissions within 30 days and subsequent visits every 30 to 60 days, but this was not adhered to, leading to the deficiency.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in documentation and communication. For one resident, the facility did not document his refusal to attend medical appointments, despite his cognitive impairment and the need for follow-up care after a throat mass removal. The Director of Nursing (DON) acknowledged that the resident's refusal should have been documented in the nursing notes, but it was not, potentially affecting the resident's care and follow-up treatment. Another resident's medical records were incomplete regarding nephrostomy care and medication consent forms. The resident had a nephrostomy tube due to kidney stone obstruction, and the facility's Treatment Administration Record (TAR) and Medication Administration Record (MAR) were missing documentation for several dates in March and April. The DON admitted that nursing staff were performing the care but not documenting it, despite previous in-service training on the importance of documentation. Additionally, the consent forms for psychoactive medications were incomplete, lacking signatures and dates, which the resident's representative signed without full awareness of the contents. The third resident's records lacked documentation of a fall and subsequent hospital transfer. The resident, who had severe cognitive impairment and was at high risk for falls, was sent to the hospital after a fall, but there were no progress notes or transfer forms completed. The DON confirmed that the nursing staff failed to document the incident, the reason for the transfer, and the hospital to which the resident was sent, contrary to the facility's policy on charting and documentation.
Infection Control Deficiency in Nephrostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper care practices observed during nephrostomy care for Resident #45. The resident, who had a history of diffuse traumatic brain injury, cerebral infarction, and hydronephrosis with ureteropelvic junction obstruction, required careful monitoring and care of a nephrostomy tube. However, during a dressing change, LVN A did not adhere to proper sterile technique and hand hygiene protocols, which are critical to preventing infection. During the procedure, LVN A contaminated the supplies and failed to sanitize the scissors before use. She handled various items with bare hands, touched her scrubs, and reached into her pockets, which compromised the sterility of the equipment. Additionally, LVN A did not wash her hands in the resident's room before starting the wound care and touched the resident's room door with gloved hands, further increasing the risk of cross-contamination. The facility's policy on nephrostomy tube care and standard precautions clearly outlined the need for sterile technique and proper hand hygiene. However, LVN A's actions deviated from these guidelines, as she did not sanitize equipment before use and failed to maintain a sterile field. The Director of Nursing acknowledged these lapses, noting the increased risk of infection due to the direct connection of the nephrostomy tube to the resident's kidney.
Unsanitary Conditions in Resident Shower Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in one of the three resident shower rooms observed, specifically the B Hallway shower room. During an observation, the shower room was found to have a strong sulfur odor, black spots on the floor and shower wall, a half-foot hole in the shower floor filled with white cloudy water, and a missing trim plate around the shower faucet. The Director of Nursing (DON) acknowledged the condition of the shower room and expressed concern about the risk of infection for residents using the shower, particularly those prone to infection or with uncovered feet. The facility's policy on bathroom maintenance, which requires daily cleaning and sanitation, was not adhered to, as evidenced by the unsanitary conditions observed in the B Hallway shower room. The Administrator admitted to not having seen the shower room during rounds because it was always in use, despite acknowledging the risk of wound contamination for residents using the shower. The facility's failure to maintain the shower room in a clean and sanitary manner could potentially place residents at risk for an unsafe and unsanitary environment.
Failure to Complete Timely Comprehensive Assessment
Penalty
Summary
The facility failed to conduct an initial comprehensive assessment of a resident's functional capacity, including needs, strengths, goals, life history, and preferences, within the required timeframe. Specifically, the MDS Coordinator did not complete the comprehensive assessment for a resident within 14 days of admission, as required by the facility's policy. This oversight was identified during a review of the resident's records, which showed no indication of the initial MDS being completed from the time of admission until over a month later. The resident in question was admitted with diagnoses including Fragile X Chromosome and severe intellectual disabilities, requiring assistance with all activities of daily living and being at high risk for falls. Observations noted the resident's severe cognitive impairment and unsteady gait, with staff needing to redirect her back to her room. Interviews with the MDS Coordinator and the DON confirmed the lapse in completing the assessment, which was crucial for developing a comprehensive care plan to address the resident's needs.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding the resident's limited range of motion due to a left hand contracture. The MDS Coordinator did not code this condition in the resident's assessments for two periods, on 6/2/23 and 2/15/24. This oversight could potentially affect the care and services provided to the resident. The resident, who was admitted with diagnoses including hypertension and Alzheimer's disease, was observed with a left hand contracture and used a wheelchair for mobility, neither of which were accurately documented in the assessments. Interviews with the MDS Coordinator confirmed the omission of the resident's left hand contracture and wheelchair use in the assessments. The coordinator acknowledged the importance of capturing all health needs in the MDS assessments to ensure appropriate care and services are provided. Despite being asked for a policy on the accuracy of MDS assessments, the facility did not provide one by the exit date of the survey.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident for a PASARR evaluation upon a significant change in status assessment, despite the resident having diagnoses of bipolar disorder and anxiety. The resident's initial PASARR Level 1 screening did not reflect these mental health diagnoses, and as a result, a follow-up evaluation was not initiated. The resident was admitted with multiple diagnoses, including traumatic brain injury, cerebral infarction, and anxiety disorder, but bipolar disorder was not documented on the face sheet. Further review of the resident's medical records revealed that the resident was being treated with medications for anxiety and bipolar disorder, including sertraline, Depakote, and Seroquel. The resident's care plan indicated risks for anxiety, depression, and psychotic behaviors, with corresponding medications prescribed. An interview with the MDS Coordinator confirmed that the initial PASARR evaluation did not indicate a mental illness, and a new PASARR Level 1 was not submitted until the deficiency was identified.
Inadequate Wound Care and Hand Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in wound management. The resident, who had severe cognitive impairment and was receiving hospice services, had a stage 2 pressure ulcer on her left great toe. The Licensed Vocational Nurse (LVN) responsible for the resident's care did not follow proper wound care procedures, including inadequate hand hygiene and failure to cleanse the wound with normal saline before applying skin prep. The LVN also did not change gloves or sanitize hands between treating different wound sites, which could contribute to infection. The resident's medical records revealed inconsistencies in wound care orders and documentation. The LVN followed a telephone order that did not align with the hospice nurse's progress notes, which specified a different wound care regimen. Additionally, the LVN did not measure or describe the wounds on the resident's left foot and heel, which is essential for tracking healing progress. Interviews with the LVN and the Director of Nursing (DON) highlighted a lack of adherence to standard wound care practices, including the need for hand hygiene and proper wound cleansing. The facility's policy on pressure ulcer prevention did not address specific wound care procedures or hand hygiene, contributing to the deficiency. The DON acknowledged that the LVN should have sought clarification on the wound care orders and communicated with the hospice nurse to ensure accurate treatment. The failure to follow professional standards of practice in wound care could lead to infection and hinder the healing process for residents with pressure ulcers.
Failure to Maintain Oxygen Concentrator for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as observed in the case of a resident with severe cognitive impairment and multiple health conditions, including congestive heart failure and hypertension. The resident's care plan did not include interventions for oxygen therapy, and the physician orders lacked instructions for maintaining the oxygen concentrator. During observations, the resident was found receiving oxygen at a higher rate than prescribed, and the filter on the oxygen concentrator was covered with lint, indicating it had not been cleaned. Interviews with nursing staff revealed a lack of knowledge and responsibility regarding the maintenance of the oxygen concentrator. An LVN admitted to not knowing how to clean the filter and did not check it during rounds. The DON acknowledged that nursing staff should check and clean the filters regularly, but there were no specific physician orders for this task. The DON also noted that the filter's condition suggested it had not been cleaned as frequently as claimed, potentially leading to respiratory issues for the resident.
Failure to Obtain Physician-Signed Admission Orders
Penalty
Summary
The facility failed to ensure that a physician was notified and provided orders for the immediate care and needs of two residents. For Resident #49, the admission orders were signed by a Nurse Practitioner (NP) instead of the attending physician, who was listed as the Medical Director. The resident, an elderly female with a history of a femur fracture, Alzheimer's disease, and severe asthma, was readmitted from the hospital under hospice care and later expired. Similarly, Resident #200, who had severe cognitive impairment and required assistance with all activities of daily living, had her admission orders signed by an NP rather than the attending physician. Interviews with the Director of Nursing (DON) and the Medical Director revealed that the physician had not signed any of the residents' orders, relying instead on standing orders and lab orders upon admission. The facility's policy stated that the medical care of each resident should be under the supervision of a licensed physician, who is responsible for signing orders and overseeing the resident's care plan. This oversight in obtaining physician-signed orders for the residents' immediate care needs was identified as a deficiency by the surveyors.
Deficiencies in Nursing Competency and Equipment Handling
Penalty
Summary
The facility failed to ensure that two licensed vocational nurses (LVNs) possessed the necessary competencies and skills to provide safe and effective care to residents. LVN A did not adhere to the facility's policy for nephrostomy care, which required the use of sterile gloves and equipment. During an observation, LVN A used contaminated equipment, did not use sterile gloves, and contaminated her hands while providing care to a resident with a nephrostomy tube. This resident had a complex medical history, including a traumatic brain injury, cerebral infarction, and hydronephrosis, and was at risk of infection due to the direct connection of the nephrostomy tube to the kidney. In another instance, LVN H demonstrated a lack of knowledge regarding the calibration of glucometers, which are essential for accurately measuring residents' blood glucose levels. LVN H was observed using glucometers that were not properly calibrated, and she admitted to not having calibrated a glucometer in a long time. During an attempt to calibrate the device, LVN H made errors, resulting in an inaccurate reading. This deficiency could lead to incorrect insulin administration, posing a risk of hypoglycemia to residents. The Director of Nursing (DON) acknowledged the deficiencies in both cases, noting that LVN A should have sanitized equipment and washed her hands before wound care, and that LVN H should have ensured the glucometers were calibrated correctly. The facility's policies on nephrostomy tube care and glucose monitoring were not followed, compromising resident safety and care quality.
Failure to Obtain Consent for Depakote Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Depakote for mood disorder. The nursing staff did not obtain consent from the resident's family representative, who served as the responsible party, for the use of Depakote. Additionally, the medication classification was not indicated on the consent form. This oversight was identified during a review of the resident's records, which showed that the resident, who had moderate cognitive impairment and was receiving hospice services, had signed the consent form themselves, despite being unable to make informed decisions. Interviews conducted during the survey revealed that the Director of Nursing acknowledged the oversight, stating that the nurse should have obtained the responsible party's consent and signature. The resident's family representative confirmed that the nursing staff had not discussed the administration of Depakote with her, and she was not familiar with the medication. The resident was observed to be alert but confused, engaging in limited conversation, which further highlighted the need for proper consent procedures to be followed.
Improper Storage and Labeling of Drugs and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as well as maintaining appropriate access controls. During an observation, it was found that the nurse supply room's patient nourishment refrigerator contained staff food, expired products, unlabeled, and unsealed food items. The refrigerator, intended for resident use only, was improperly used by staff, and lacked a thermometer in the freezer section. Additionally, the crash cart in the nursing supply room contained expired saline and alcohol prep pads, which were not removed by the night shift responsible for checking the cart. Furthermore, the C hall medication cart was found to contain loose pills and expired medications. An LVN was unaware of the origin of the loose pills and improperly disposed of one by throwing it in the trash. The DON acknowledged that the refrigerator should only contain resident supplements and that loose pills pose a concern as they could lead to residents not receiving their prescribed medications. The facility's policies on food storage and medication labeling were not adhered to, contributing to these deficiencies.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a therapeutic diet in the appropriate form as prescribed by a physician for a resident observed for therapeutic diets. The resident, a male with a history of acute cerebrovascular insufficiency, major depressive disorder, and hemiplegia, was ordered a mechanical soft diet due to missing teeth and potential swallowing difficulties. However, during an observation, the resident was seen eating a piece of beef brisket, which was not in the mechanical soft form as prescribed. The resident expressed difficulty in chewing due to missing teeth, indicating that the diet provided did not align with the physician's order. Interviews with facility staff revealed a lack of proper communication and verification of the resident's dietary needs. The Director of Nursing (DON) acknowledged that the resident should be on a mechanical soft diet due to a previous medical condition, but there was no documentation of the resident's refusal to attend follow-up medical appointments. The Speech-Language Pathologist (SLP) noted that the resident was observed eating regular textured food without issues, but was under the impression that the resident was prescribed a regular diet. The Dietary Manager (DM) admitted that the meal ticket checks were not conducted properly, leading to the resident receiving an incorrect diet texture, which posed a risk of aspiration or choking.
Lack of QAPI Plan and Procedures in Facility
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. The facility did not have a Quality Assurance and Performance Improvement (QAPI) plan, policies, or procedures in place for systematic analysis and systemic action. This deficiency could potentially affect all residents' overall quality of life and quality of care due to the lack of systems to improve direct care nursing staff performance. During an interview, the Director of Nursing (DON) revealed that while the facility had a Quality Assurance Committee, it did not have a QAPI Program because they did not utilize Performance Improvement Projects (PIPs). The DON stated that there was no written plan, policies, or procedures in place. Meetings were held monthly with all department heads and the Medical Director to discuss effective systems in the facility, but direct care staff were not involved in the process. Additionally, the facility did not complete written comparative analyses to determine root causes or assess the effectiveness of new systems implemented.
Failure to Post Survey Results in Accessible Location
Penalty
Summary
The facility failed to make the results of the most recent survey readily accessible to residents, family members, and legal representatives for four out of seven survey days. This deficiency was identified through observation, interviews, and record reviews. Several residents reported being unaware of the location of the survey results binder. During an interview, the Administrator (ADM) was unable to locate the binder in the lobby, where it was supposed to be available. The Assistant Director of Nursing (ADON) later provided the binder, which was found on her desk, and admitted to not knowing its intended location. Upon review, the binder contained outdated survey results from 2022. The facility's policy, revised in September 2004, mandates that the most recent survey results be maintained in a binder located in a common area frequented by residents, such as the main lobby or resident activity room.
Failure to Update Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment for the past three years, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. The last completed facility assessment was in 2021, and it had not been updated since then. During an interview and record review on May 26, 2024, the Administrator acknowledged that no facility assessment had been conducted since his arrival in September 2023. A notebook found in the Administrator's office contained a basic facility assessment form completed in 2019, 2020, and 2021, but no updates had been made since 2021. This oversight could potentially place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.
Inadequate Living Space in Double Occupancy Rooms
Penalty
Summary
The facility failed to provide adequate living space for residents in four of its double occupancy rooms, specifically Rooms 27, 28, 34, and 35. These rooms did not meet the required minimum of 80 square feet per resident, with measurements showing that the space per resident ranged from 70.97 to 79.62 square feet. This deficiency was identified during an observation by the life safety code on May 21, 2024, which revealed that the rooms were not in compliance with the space requirements. The facility's Bed Classifications form, dated March 20, 2023, confirmed that each of these rooms was intended for two residents. The Room Census List from May 21, 2024, indicated varying occupancy statuses for these rooms, with some beds unoccupied. During an interview, the Administrator acknowledged the deficiency and expressed a desire to continue with a room size waiver, although it was noted that one bed needed to be de-licensed or de-certified as it did not meet the minimum square footage required for a waiver.
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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