Matlock Place Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Texas.
- Location
- 7100 Matlock Rd, Arlington, Texas 76002
- CMS Provider Number
- 676141
- Inspections on file
- 44
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Matlock Place Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of reliving past trauma alleged sexual abuse to her mental health provider, who promptly notified facility staff. Despite facility policy and regulatory requirements, the allegation was not reported to law enforcement or the state agency within the required 2-hour timeframe, as staff believed the claim was related to past trauma. This failure to report constituted a deficiency in abuse reporting procedures.
Multiple residents with respiratory needs did not have their care plans updated to include respiratory treatments, and staff failed to consistently clean, bag, and date respiratory equipment such as nebulizer masks and nasal cannula tubing. Observations found unbagged and undated equipment in use, and staff interviews confirmed lapses in following established protocols for respiratory care.
Staff failed to follow infection control protocols, including Enhanced Barrier Precautions and hand hygiene, during care of three residents. CNAs and an LVN did not consistently perform hand hygiene, change gloves between tasks, or wear required PPE during incontinence care, transfers, and wound care, despite facility policies and recent training.
Staff failed to accurately document respiratory treatments in the MDS assessments for three residents with severe cognitive impairment and complex medical needs. Despite receiving treatments such as nebulizer therapy and oxygen, these interventions were not recorded in the MDS, as confirmed by record reviews, observations, and interviews with facility leadership.
The facility did not include required respiratory treatments in the care plans for several residents with complex medical and cognitive needs, despite physician orders and ongoing administration of these therapies. Care plans addressed other needs but omitted documentation of oxygen therapy, nebulizer treatments, and inhalation medications, as confirmed by record review, staff interviews, and direct observation.
A resident with severe cognitive impairment, total dependence, and multiple chronic wounds did not receive daily physician-ordered wound care, resulting in unchanged, saturated, and foul-smelling dressings. The responsible LVN admitted to missing the treatment and failing to notify the next shift, and the DON was unaware of the lapse until after it occurred. Facility policy required wound care to be provided and documented as ordered, which was not followed in this case.
A CNA transferred a severely cognitively impaired, dependent resident by manually lifting her under the arms instead of using a mechanical lift with two staff as required by her care plan and facility policy. The CNA did not use a gait belt and was unfamiliar with the resident's needs, leading to a deficiency in accident hazard prevention and supervision.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, as observed in the resident's records.
A resident with Alzheimer's disease was prescribed and administered Seroquel, an antipsychotic, without a documented diagnosis to justify its use. The order listed agitation as the indication, but no associating diagnosis was included, and the resident's records did not reflect behaviors warranting antipsychotic therapy. Staff interviews confirmed the omission, and facility policy did not address the need for a diagnosis with psychotropic medication orders.
Three residents with pressure ulcers did not receive wound care as ordered, including missed dressing changes and lack of PRN care. Staff interviews and record reviews revealed breakdowns in communication and responsibility among CNAs, nurses, and the wound care nurse, resulting in untreated wounds and unaddressed missing dressings.
Two residents did not have comprehensive care plans reflecting their current needs: one receiving hospice services and another dependent on enteral tube feeding. Despite staff awareness and physician orders, the care plans lacked documentation of these services, and staff interviews revealed unclear responsibility for updating care plans. This failure to update care plans as required placed the residents at risk of not receiving appropriate care.
Two residents receiving enteral nutrition experienced deficiencies when staff failed to follow physician orders: one resident was given a substitute tube feeding formula without a documented order, and another did not receive the prescribed downtime between feedings. Nursing staff did not document or communicate these deviations as required by facility policy.
Two residents with end-stage renal disease did not receive dialysis care in accordance with professional standards and their care plans. One resident's post-dialysis vital signs and assessments were not documented, and required communication forms were incomplete or missing. For the other resident, there were no physician orders for dialysis or related monitoring, despite staff awareness of the need. These deficiencies occurred despite facility policy requiring such documentation and orders.
Narcotic counts on multiple medication carts did not match the actual number of pills in the blister packs for three residents. An LVN administered narcotic medications but failed to sign the Narcotic Administration Record log or the MAR as required, resulting in discrepancies between documented and actual medication counts. The DON confirmed that staff are expected to document all narcotic administrations, and no training records on narcotic administration were available when requested.
A nurse failed to flush a resident's gastrostomy tube with the prescribed amount of water between each medication and left residual medication in several cups, resulting in incomplete medication administration. The nurse was aware of the correct procedure but did not follow physician orders or facility policy, and had not attended recent g-tube medication training.
Staff failed to serve correct portion sizes for pureed foods during a lunch meal, using incorrect scoop sizes for pureed broccoli and cauliflower, pizza pasta bake, and garlic bread. The Dietary Manager and a staff member became confused about the required portions, resulting in smaller servings than specified by the menu and recipe card. This was confirmed by a sample tray review and interviews, with eight residents identified as being on a pureed diet.
The facility did not ensure that pureed food served during a lunch meal was smooth and pudding-like, as required for residents on pureed diets. The Dietary Manager prepared and served a pureed pizza pasta bake that remained chunky with pieces of pasta, which was confirmed by surveyors and acknowledged by the DM. Eight residents were identified as requiring a pureed diet, and facility policy assigns responsibility for proper preparation to the food service department.
A resident with a stage 4 pressure ulcer and severe cognitive impairment did not have complete wound care documentation for several days, as required by physician orders and facility policy. Staff interviews revealed that wound care was either not documented due to system limitations or was performed by the Weekend Supervisor but not recorded, resulting in incomplete clinical records.
Staff failed to follow infection control protocols during wound and incontinence care for two residents with pressure ulcers and cognitive impairment. A Wound Care Nurse did not change gloves or perform hand hygiene between steps of wound care, and two CNAs did not consistently perform hand hygiene when changing gloves during incontinence care. These lapses occurred despite prior training and facility policies requiring proper infection prevention practices.
A CNA did not receive required annual dementia management training, as shown by missing documentation in personnel records. Interviews with HR, ADON, and DON confirmed that dementia training was not provided during orientation or annual in-services, and the facility could not produce evidence of such training for staff.
A resident with depression and moderate cognitive impairment was temporarily moved to another room without any personal belongings, television, or activities, leaving her in a bare environment. Staff did not provide alternative entertainment or move her items, despite her care plan and facility policy requiring support for a home-like setting. Multiple staff acknowledged the oversight after the fact.
The facility failed to provide adequate PPE for staff entering rooms on droplet precautions, as observed in multiple rooms across three halls. Despite the presence of COVID-19 cases, face shields were missing from PPE bins, leading staff to rely on insufficient protection. Interviews confirmed the absence of necessary PPE, contradicting facility policy and CDC guidelines, thereby risking the spread of infection.
A facility failed to accurately document a resident's medications on their MDS assessments, leading to discrepancies between the resident's actual medication administration and what was recorded. The resident, with multiple complex medical conditions, was prescribed and administered several medications, including antipsychotics and anticonvulsants, which were not accurately reflected in the MDS assessments. The issue was identified through interviews and record reviews, revealing that the staff responsible for the assessments were initially unaware of the inaccuracies.
A resident with dementia was subjected to abuse by a CNA who roughly transferred her from bed to a geri-chair without using a gait belt, resulting in a rough transfer and a slap on the hand. The incident was captured on video by the resident's POA, leading to the CNA's termination. The facility's failure to protect the resident from abuse placed her at risk of harm.
A resident with cognitive impairments was roughly handled during a transfer by a CNA who failed to use a gait belt, as required by facility policy. The CNA attempted to transfer the resident from a bed to a geri-chair without proper equipment, resulting in an unsafe and rough transfer. The incident was captured on video and reported by the resident's POA, leading to the identification of a deficiency in supervision and use of assistance devices.
Two residents in an LTC facility did not receive timely incontinence care, leading to deficiencies in their ADL support. One resident with cognitive impairments was found with a soaked brief, while another resident, who required moderate assistance due to physical limitations, expressed frustration over delayed care. The facility's policy required care every two hours, but lapses in communication and adherence to care plans resulted in extended periods without necessary assistance.
A resident with cirrhosis and hepatic encephalopathy refused her Lactulose medication on three occasions, and the facility failed to notify her physician or document the refusals. This oversight led to a delay in addressing her altered mental status, which was eventually noticed by her family, prompting a hospital evaluation.
A resident with a history of stroke and hemiplegia was left unattended in a shower chair by a CNA, leading to a fall and a right shoulder fracture. The resident's care plan indicated a high risk for falls, and staff were instructed to use a shower bed, but this was not followed. The facility's policy did not address the need for supervision while a resident is in a shower chair, contributing to the incident.
The facility failed to ensure proper labeling and dating of food items stored in the freezer, with multiple bags of food found undated and unlabeled. Additionally, a dark substance from spilled tea was observed frozen at the bottom of the freezer, indicating a lack of immediate cleaning. Interviews confirmed that the facility's food storage policies were not followed.
The facility failed to report a resident's positive urine culture results in a timely manner, leading to a delay in starting antibiotics and implementing contact isolation. The delay was due to a lack of follow-through by the nursing staff, which could have prolonged the resident's infection and increased the risk of spreading the infection to others.
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in multiple resident rooms and a conference room. Despite increased pest control efforts and regular cleaning, the issue persisted, with staff and residents noting ongoing problems. The facility's pest control records indicated multiple visits for various pests, but the program was not effectively implemented.
The facility failed to follow physician orders for weekly weights for a resident, resulting in significant weight fluctuation, and did not obtain necessary physician orders for the use of a hinged knee brace for another resident. These lapses in care and documentation were acknowledged by the DON and ADON.
The facility failed to provide adequate supervision and assistance devices for two residents, resulting in one resident's wheelchair tipping over in a van and another resident being stuck outside in the courtyard due to downed phone lines. Both incidents highlight significant lapses in ensuring resident safety.
The facility failed to follow physician orders for water flushes on a feeding pump for a resident with severe cognitive impairment and multiple medical conditions. Observations revealed discrepancies in the settings, which were not corrected over multiple days. Interviews confirmed that the settings were not verified against the orders, leading to incorrect administration.
The facility failed to implement policies and procedures to prevent neglect, as evidenced by an incident where a resident's wheelchair tilted in a van, causing a fall and minor injuries. The incident was not reported to the State Survey Agency as required by the facility's policy.
The facility failed to report an incident where a resident tilted in her wheelchair while being transported in the facility van. The resident sustained a bruise and mild pain, but the incident was not reported to the State Survey Agency within the required 24-hour timeframe. Interviews revealed that the incident was not considered severe enough to report, despite the facility's policy requiring such reporting.
A resident with severe dementia and schizophrenia was admitted without a proper PASARR Level II evaluation due to an error in the screening process, leading to a lack of necessary specialized services.
A facility failed to update a resident's care plan to include the use of a hinged knee brace following a fall that resulted in a fracture. Despite the resident's intact cognition and the necessity of the knee brace for fracture care, the care plan only addressed fall interventions. Interviews with staff confirmed the omission, which placed the resident at risk of not receiving appropriate care.
The facility failed to provide necessary grooming and personal hygiene services to two residents with cognitive impairments. Both residents expressed a desire to have their facial hair removed, but staff did not address this need. Interviews revealed confusion among staff regarding responsibility for facial hair removal, despite facility policy indicating that such care should be provided.
The facility failed to provide timely lab services for a resident, resulting in a delayed diagnosis and treatment of a urinary tract infection. The lab results were not communicated to the physician for 12 days, leading to a delay in starting antibiotics and placing the resident in isolation. Staff interviews revealed a lack of follow-through and communication, confirmed by the DON.
The facility failed to prepare pureed meals according to the recipe, resulting in food that lacked nutritive value and flavor. Both the Dietary Manager and Cook P deviated from the recipe, leading to flavorless pureed meals that could risk residents' nutrition and appetite.
The facility failed to update the daily nurse staffing information for three consecutive days, as required by policy. Observations confirmed that the postings were outdated, and interviews with the ADON and Administrator revealed that the oversight was due to the ADON forgetting to update the information.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse of residents were reported immediately, but not later than 2 hours after the allegation was made, as required. Specifically, a resident with severe cognitive impairment and a history of reliving past trauma alleged sexual abuse to her Mental Health Habilitator (HAB). The HAB promptly informed the facility's Assistant Director of Nursing (ADON) about the allegation. Despite this, the facility did not report the allegation to law enforcement or the State Agency (SA) within the required 2-hour timeframe. The resident involved had multiple diagnoses, including Bipolar Disorder, Dementia, Down Syndrome, and severe cognitive impairment, and was dependent on staff for personal care. Her care plan noted a history of reliving trauma related to past sexual abuse and included interventions to provide consistency and avoid triggering discussions. On the day of the incident, the resident told her HAB that she had been raped, but was unable to provide specific details. The HAB, concerned due to the lack of prior similar behaviors, reported the allegation to the facility. The ADON and Administrator (ADM) interviewed the resident, who gave inconsistent responses and was unable to provide clear information about the alleged perpetrator or timeframe. The facility staff referenced the resident's care plan history and concluded the allegation was likely related to past trauma. Despite facility policy requiring immediate reporting of all abuse allegations to the Administrator, state agency, and law enforcement, the ADM and DON decided not to report the incident, believing it was a recurrence of past trauma rather than a new event. Interviews with staff confirmed that the expectation was to report all allegations, but in this case, the required notifications were not made. The facility's failure to report the allegation within the mandated timeframe constituted a deficiency in abuse reporting procedures.
Failure to Maintain and Document Proper Respiratory Equipment Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents who required such care, as evidenced by observations, interviews, and record reviews. Specifically, for five residents reviewed for respiratory care, deficiencies were noted including nebulizer masks not being bagged for four residents, and nasal cannula (NC) tubing not being dated for two residents. Additionally, care plans for these residents did not address their respiratory treatments, despite physician orders and ongoing needs for respiratory support. Staff interviews confirmed that the expected protocols for cleaning, bagging, and dating respiratory equipment were not consistently followed. Resident records revealed that these individuals had significant medical conditions such as Alzheimer's disease, vascular dementia, metabolic encephalopathy, and acute respiratory issues with hypoxia. Most were dependent on staff for personal care and required assistance or setup for meals. Despite these needs, care plans often omitted respiratory care interventions, and staff failed to ensure that equipment was properly maintained and stored according to professional standards and facility expectations. Observations included unbagged nebulizer masks left on nightstands and undated NC tubing in use, with some equipment showing visible debris. Interviews with nursing staff, the DON, and the administrator confirmed that the facility's protocol required respiratory equipment to be cleaned, bagged, and dated, and that failure to do so could result in infection. However, staff admitted to missing these steps during rounds, and the facility was unable to provide a respiratory care policy when requested. No interviews were conducted with weekend night shift nurses regarding respiratory equipment protocol.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple staff not adhering to established protocols for Enhanced Barrier Precautions and hand hygiene during care of three residents. In several observed instances, certified nursing assistants (CNAs) and a licensed vocational nurse (LVN) did not perform hand hygiene before or after resident care, did not change gloves between clean and dirty tasks, and failed to don required personal protective equipment (PPE) such as gowns when providing high-contact care to residents on Enhanced Barrier Precautions. These lapses were observed during incontinence care, dressing, mechanical lift transfers, and wound care. One resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was on Enhanced Barrier Precautions due to a chronic eye infection. The assigned CNA did not perform hand hygiene before or after care, failed to wear a gown, and used the same gloves for both soiled and clean tasks, including handling the resident's clothing and wheelchair. Another resident, who was cognitively intact but required substantial assistance and had a colostomy and non-pressure wounds, also did not receive care in accordance with infection control protocols. The CNA providing care did not perform hand hygiene, did not wear a gown, and used the same gloves for incontinence care and handling personal items. Additionally, a CNA was observed leaving the resident's room and handling equipment in the hallway while still wearing PPE, only removing it outside the room. For a third resident, who was severely cognitively impaired, dependent for all care, and at risk for pressure ulcers, the LVN performing wound care did not change gloves or perform hand hygiene between cleaning multiple wounds, only doing so after all wounds were cleaned. The LVN later acknowledged not being aware of the need to change gloves and perform hand hygiene between wounds. Facility policies reviewed indicated that Enhanced Barrier Precautions and hand hygiene are required before and after resident contact, after glove removal, and when moving from soiled to clean tasks, but these protocols were not consistently followed by staff during the observed care.
Failure to Accurately Document Respiratory Treatments in MDS Assessments
Penalty
Summary
Facility staff failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the respiratory treatments being provided to several residents. Specifically, for three residents with significant cognitive impairment and complex medical conditions, the MDS did not document the respiratory treatments that were ordered and administered, such as nebulizer treatments and oxygen therapy. These omissions were identified through record reviews, observations, and interviews, which showed that the residents were receiving respiratory care that was not captured in their MDS assessments. For one resident, records indicated diagnoses of vascular dementia, acute respiratory issues with hypoxia, and atherosclerotic heart disease. The resident was dependent on staff for all activities of daily living and was receiving nebulizer treatments for wheezing, as confirmed by medication administration records and the resident's own statements. However, the MDS did not reflect these respiratory treatments. Similar findings were noted for two other residents with severe cognitive impairment and terminal illnesses, both of whom were dependent on staff and receiving respiratory treatments such as oxygen therapy and inhaled medications, but whose MDS assessments also failed to document these interventions. Interviews with facility leadership, including the DON and Administrator, confirmed that the expectation was for the MDS to accurately reflect all care and treatments provided, and that failure to do so could result in residents missing necessary care. The facility's policy on maintaining MDS assessments did not address the requirement for accuracy in documenting treatments. The MDS coordinator was not available for interview at the time the deficiency was identified.
Failure to Include Respiratory Treatments in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all of the residents' needs, specifically omitting respiratory treatments for five residents reviewed. Despite medical diagnoses such as Alzheimer's disease, vascular dementia, metabolic encephalopathy, and acute respiratory conditions with hypoxia, the care plans for these residents did not include details about their required respiratory therapies, such as oxygen therapy, nebulizer treatments, or inhalation medications. This omission was identified through record reviews, observations, and interviews, which revealed that while physician orders for respiratory treatments existed and residents were receiving these treatments, the care plans did not reflect these interventions. For example, one resident with Alzheimer's disease and acute respiratory issues had active orders for oxygen therapy and nebulizer treatments, but her care plan only addressed her ADL self-care deficit and did not mention respiratory care. Another resident with vascular dementia and acute respiratory needs had a care plan that addressed cognitive impairment but not the use of respiratory treatments, despite having orders for oxygen and nebulizer use. Similar deficiencies were found for other residents with severe cognitive impairment and complex respiratory needs, where care plans failed to document the specific respiratory treatments being provided, even though these treatments were observed or confirmed through interviews. Interviews with staff, including the DON and ADM, confirmed that care plans are expected to reflect all medical orders and treatments, and that it is the responsibility of nursing leadership to ensure care plans are updated to match current care and treatments. The facility's own policy requires the interdisciplinary team to develop comprehensive, person-centered care plans with measurable objectives and timeframes to meet all identified needs, but this was not followed for the residents reviewed, resulting in incomplete documentation of their respiratory care.
Missed Physician-Ordered Wound Care for Resident with Chronic Pressure Ulcers
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, total dependence for activities of daily living, incontinence, and multiple chronic wounds did not receive physician-ordered wound care on a specified date. The resident, who had a history of Alzheimer's disease, malnutrition, abnormal posture, muscle wasting, and was at high risk for pressure ulcers, had orders for daily wound cleansing and dressing changes for multiple wounds on both feet. Documentation and direct observation confirmed that no wound care was provided on the missed date, and the dressings remained unchanged from the previous day. During an interview and observation the following day, the LVN responsible for the resident's care admitted to not performing the wound care, citing a busy shift and failing to communicate the missed treatment to the oncoming shift. The resident was found with saturated, foul-smelling dressings, particularly on the right foot, which was also edematous. The LVN acknowledged awareness of the daily wound care orders and expressed regret for not completing the treatment as required. The DON confirmed that weekend wound care was the responsibility of the assigned nurses and was unaware that the treatment had been missed until after the fact. The wound care physician stated that the wounds were chronic with a poor prognosis, but emphasized the importance of daily dressing changes to prevent odor and further deterioration. Facility policy required wound treatments to be provided as ordered and documented accordingly, which did not occur in this instance.
Failure to Follow Safe Transfer Protocols for Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan and facility policy regarding safe resident transfers. The CNA provided a one-person manual lift by placing his arms under the resident's armpits to transfer her from bed to wheelchair, rather than using a mechanical lift with two staff as required. The resident involved was a female with severe cognitive impairment, dependent on staff for all activities of daily living except eating, and required two-person assistance with transfers due to impaired balance and diagnoses including dementia and multiple sclerosis. The care plan specifically indicated the use of a mechanical lift with two staff for all transfers. During the incident, the CNA did not use a gait belt and was unfamiliar with the resident's care needs, admitting he should have checked the care plan or asked for guidance. Interviews with facility staff, including the physical therapy assistant and the director of nursing, confirmed that the proper procedure for this resident was a mechanical lift with two staff, and that lifting under the arms is prohibited due to risk of injury. Facility policy also mandates the use of appropriate lifting devices and techniques, and manual lifting is to be eliminated when feasible. The failure to follow these protocols resulted in a deficiency related to accident hazards and inadequate supervision.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Antipsychotic Medication Prescribed Without Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident with Alzheimer's disease and no documented psychosis was prescribed and administered Seroquel, an antipsychotic medication, without an appropriate diagnosis to justify its use. The medication order listed 'agitation' as the indication, but did not include a corresponding diagnosis, and the resident's records did not reflect behaviors such as physical or verbal aggression that would typically warrant antipsychotic therapy. The resident was observed to be calm and unable to answer questions, and her medical history included memory problems and inability to make daily decisions, but not psychosis. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) entered the Seroquel order without ensuring a proper diagnosis was included, despite being trained to do so. The Psychiatric Nurse Practitioner (NP) stated he diagnosed the resident with unspecified psychosis after several meetings, but acknowledged the order should have specified the diagnosis. The Director of Nursing (DON) confirmed that orders are checked for accuracy and that the diagnosis should have been included. The facility's policy on psychotropic medication use did not address the requirement for a diagnosis to accompany medication orders. Manufacturer information for Seroquel highlighted increased mortality risks for elderly patients with dementia-related psychosis, and the drug is not approved for such use.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevent new ulcers from developing for three residents with existing wounds. For one resident with a history of neurological conditions, malnutrition, and Alzheimer's disease, the facility did not provide PRN wound care to a right buttocks wound as ordered. Observations revealed the resident was without a dressing on the wound, and interviews with staff indicated a lack of communication and awareness regarding the missing dressing. The wound care nurse and CNA both expected the other to notify or address the missing dressing, and the nurse on duty was unaware of the wound, resulting in the dressing not being replaced as required. Another resident with diabetes and renal insufficiency did not receive daily wound care to a left foot ulcer on two consecutive days. The wound care administration record had blank entries for those days, and the resident reported that her dressings had not been changed as scheduled. The wound care nurse confirmed that the dressing was not changed over the weekend and stated that the charge nurse was responsible for wound care during that time. The DON confirmed that staff were trained to check orders and provide care when the wound care nurse was absent, but the care was not provided as ordered. A third resident with a non-traumatic brain injury and muscle weakness did not receive wound care to a sacrum wound on a scheduled day. The wound care administration record was blank for that day, and the charge nurse responsible was not aware that the wound care nurse was absent. The DON stated that charge nurses were notified in the morning meeting about the wound care nurse's absence, but the wound care was not completed. In all three cases, the facility failed to follow physician orders and professional standards of practice for wound care, as confirmed by record reviews, staff interviews, and direct observations.
Failure to Develop and Implement Comprehensive Care Plans for Hospice and Enteral Feeding
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interview, and record review. One resident, a female with moderate cognitive impairment, traumatic brain injury, anxiety disorder, and depression, was receiving hospice services. Despite documentation of her hospice admission and ongoing care, her care plan did not address her hospice services. Interviews with nursing staff and the MDS Coordinator confirmed that the omission was not identified or corrected, and responsibility for updating the care plan was unclear among staff. Another resident, a female with severe cognitive impairment and total dependence for eating, was receiving enteral nutrition via a feeding tube. Her physician orders specified continuous tube feeding and water flushes, but her care plan did not reflect her need for tube feeding. Nursing staff were aware of her feeding regimen through shift reports and direct care experience, but had not reviewed or updated the care plan to include this critical information. The MDS Coordinator and other staff acknowledged that the care plan should have included tube feeding and that its absence could lead to miscommunication about her care needs. Facility policy required that comprehensive, person-centered care plans describe all services to be provided and assign responsibility for each element of care. However, the care plans for both residents lacked essential information about their hospice and enteral feeding needs, as confirmed by staff interviews and record reviews. This failure to update and implement care plans as required placed the residents at risk of not receiving appropriate care.
Failure to Follow Physician Orders for Enteral Nutrition
Penalty
Summary
The facility failed to ensure that residents receiving enteral nutrition via feeding tubes were provided care in accordance with physician orders, resulting in deficiencies for two residents. For one resident with severe cognitive impairment and a diagnosis of malnutrition and Alzheimer's disease, the prescribed enteral formula (Isosource 1.5) was not available, and staff substituted it with a different formula (Jevity 1.5) without obtaining or documenting a physician order for the change. Observations confirmed that the substituted formula was administered over multiple days, and interviews with nursing staff and the DON revealed that although the nurse practitioner verbally approved the substitution, the required documentation and order entry were not completed. There was also no monitoring tool in place to ensure the correct formula was administered. For another resident with severe cognitive impairment and total dependence for eating, the facility failed to follow physician orders regarding the timing of enteral feedings. The resident's order specified that the feeding pump should be turned off at 8:00 AM and restarted at 12:00 PM to allow for a four-hour break. However, observations showed that the feeding continued past the prescribed stop time and was restarted before the full break was completed, resulting in less than the ordered downtime. The nurse responsible for the resident's care acknowledged not adhering to the order and had not contacted the physician or documented the deviation. Record reviews of the facility's policies confirmed that staff were required to administer enteral nutrition consistent with practitioner orders, including formula type, rate, and timing. Both the DON and ADON confirmed that it was the responsibility of nursing staff to follow these orders and document any changes or deviations, which did not occur in these cases.
Failure to Ensure Safe and Documented Dialysis Care
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring such services, as evidenced by incomplete documentation and lack of physician orders. For one resident with end-stage renal disease, there was no nursing documentation of post-dialysis vital signs monitoring, and dialysis communication forms for multiple dates were either incomplete or missing. Interviews with nursing staff confirmed that while vital signs were reportedly checked, there was no record of this in the resident's file or on the required forms. The resident's care plan and physician orders specified the need for monitoring and documentation, but these were not followed. For the second resident, also with end-stage renal disease, although communication forms regarding pre- and post-dialysis vital signs were present, there were no physician orders in place for the dialysis treatments or for obtaining and documenting vital signs before and after dialysis. Nursing staff interviews revealed that the admitting nurse, ADON, and DON were responsible for ensuring such orders were entered, but this was not done. The absence of orders was acknowledged by staff, who noted that this could lead to miscommunication and potential missed treatments. The facility's hemodialysis policy required nurses to monitor and document the status of the resident's access site after dialysis and to specify treatment orders, including frequency and duration. Despite this policy, the required documentation and orders were not consistently completed or maintained for the residents reviewed, resulting in a failure to meet professional standards of practice and the residents' care plans.
Failure to Accurately Document and Account for Narcotic Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three residents across three medication carts. Specifically, the narcotic counts on the medication carts for these residents did not match the actual number of pills in the blister packs. For example, the narcotic administration records for hydrocodone-acetaminophen and lorazepam for one resident, oxycodone for another, and hydrocodone-acetaminophen for a third resident all reflected one more pill than was present in the blister packs. The discrepancies were identified during observation and record review, which revealed that the nurse responsible for administering the medications had not signed off on the Narcotic Administration Record log after giving the medications. The nurse admitted to administering the medications but forgetting to document the administration on the required logs. She acknowledged that she was aware of the requirement to sign both the narcotic count sheet and the Medication Administration Record after administration but failed to do so. Interviews with the Director of Nursing confirmed that staff are expected to document narcotic administration on both the MAR and the narcotic log, and that failure to do so could result in missing pills or overdoses. Additionally, when training records on narcotic administration were requested, none were provided. The facility's own policy required all controlled substances to be recorded on the designated usage form with clear and legible documentation, which was not followed in these instances.
Failure to Follow G-Tube Medication Administration Protocols
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow physician orders for administering medications via gastrostomy tube to a resident. The LVN did not flush the gastrostomy tube with the prescribed 5-10 mL of water between each medication, as required by the resident's orders and facility policy. Instead, the LVN flushed the tube only before and after administering all medications, omitting the necessary flushes between each medication. Additionally, the LVN left residual medication in five cups, indicating that the full doses were not administered to the resident. The resident involved was an elderly female with diagnoses including hypertension and anemia, and was receiving nutrition and medications through a feeding tube. The LVN was aware of the correct procedure but stated she forgot to flush between medications and realized there was residual medication left after administration. Record review showed the LVN had not attended the most recent g-tube medication administration training. Facility policy and physician orders both required individual administration of medications with appropriate flushing between each dose, which was not followed in this instance.
Failure to Serve Correct Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to ensure that menus were followed and correct portion sizes were served for pureed foods during a lunch meal. Observations in the kitchen revealed that staff used incorrect scoop sizes for pureed broccoli and cauliflower, pureed pizza pasta bake, and pureed garlic bread. The Dietary Manager (DM) and a staff member reviewed the recipes and selected scoop sizes, but both became confused about the correct portions, particularly for the pureed garlic bread. As a result, the portions served were significantly smaller than required by the menu and recipe card. A sample tray reviewed by surveyors and the DM confirmed that the portions were not accurate. Interviews with the DM indicated that both she and the staff member did not realize the wrong scoop sizes were used during meal service. The DM acknowledged responsibility for ensuring correct portion sizes and stated that staff had been trained to review recipes and use the correct scoops, but nervousness led to the mistake. Record reviews showed that eight residents were on a pureed diet, and the facility's policy required specific portion sizes to be served using standard utensils. The deficiency was identified based on direct observation, interviews, and review of facility policies and menus.
Failure to Provide Properly Pureed Food for Residents on Modified Diets
Penalty
Summary
During the lunch meal service, the facility failed to provide pureed food with a smooth, pudding-like texture as required for residents on a pureed diet. Observation in the kitchen revealed that the Dietary Manager (DM) prepared a pizza pasta bake by pureeing it, but the resulting product still contained bits of pasta and was not smooth. A sample tray tasted by surveyors and the DM confirmed that the pureed pizza pasta bake was chunky and did not meet the required consistency. The DM acknowledged that the food was not properly pureed and stated that she should have mixed it more to achieve the correct texture. The DM indicated that both she and the cook are responsible for ensuring pureed foods meet the required consistency. Record review showed that eight residents were ordered a pureed diet, and the facility's policy assigns responsibility for preparing and serving the correct diet and fluid consistency to the food service department. The deficiency was identified through observation, interview, and record review, specifically during the lunch meal service.
Incomplete Documentation of Wound Care for Hospice Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a stage 4 pressure ulcer who was on hospice care and had severe cognitive impairment. Specifically, the wound care documentation for this resident was incomplete for several dates in April and May, as wound care was not recorded as completed on multiple occasions. The resident's care plan required adherence to facility protocols for wound prevention and treatment, and physician orders specified daily wound care procedures. However, the wound care report lacked entries for several days, and staff interviews confirmed that documentation was either omitted or not possible to complete due to limitations in the electronic health record system. The Wound Care Nurse acknowledged that the absence of documentation would indicate that wound care was not performed, and another nurse stated that blank entries likely meant the Weekend Supervisor performed the care but failed to document it. Attempts to contact the Weekend Supervisor were unsuccessful. The DON confirmed that the expectation was for charge nurses to provide and document wound care on weekends, and that blank wound care reports could indicate care was not given. Facility policy required all treatments to be documented in the treatment administration record or electronic health record, which was not consistently done in this case.
Failure to Maintain Infection Control During Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to proper hand hygiene and glove-changing protocols during resident care. Specifically, a Wound Care Nurse did not change gloves or perform hand hygiene after removing old dressings and before proceeding with wound cleansing and dressing changes for two residents with pressure ulcers and open wounds. The nurse continued to handle wounds and apply treatments without the required hand hygiene steps, despite having received training on infection control and wound care procedures. Additionally, two CNAs providing incontinence care to a resident did not consistently perform hand hygiene when changing gloves during the care process. One CNA changed soiled gloves without washing hands before donning new gloves, and both CNAs failed to ensure proper hand hygiene at critical points during and after care. The same CNA also handled supplies and equipment outside the resident's room without first washing hands, potentially contributing to cross contamination. The trash can used during care was not lined with a plastic bag, further increasing the risk of infection spread. Interviews with the involved staff and the Director of Nursing confirmed that the expected protocol was to perform hand hygiene and change gloves at specific points during wound care and incontinence care. Training records indicated that the staff had previously received instruction on infection control and hand hygiene, yet the observed practices did not align with facility policy or standard infection control procedures. The deficiencies were observed in residents with significant cognitive impairment and complex medical needs, including pressure ulcers and neurological conditions.
Failure to Provide Required Dementia Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required training in dementia management, as evidenced by the lack of documented annual dementia training for one certified nurse aide (CNA) reviewed. Personnel records showed that the CNA, hired in April 2023, did not have any evidence of annual dementia training, which was expected for her role. Interviews with the Human Resource Specialist revealed that new hires did not receive dementia training during orientation, and job description responsibilities were not reviewed with newly hired staff. The Human Resource Specialist indicated that the Director of Nursing (DON) was responsible for all training, but could not provide documentation of dementia training for staff. Further interviews with the Assistant Director of Nursing (ADON) and the DON confirmed that while group in-services were conducted monthly, there was no documentation that dementia training had been provided. The DON stated she was responsible for annual trainings but acknowledged that not all required topics were covered. The Administrator, who had recently joined the facility, was unable to provide evidence of annual trainings and expected employee files to be up to date. The facility's policy on training was requested but not provided before the survey exit.
Resident Relocated Without Personal Belongings or Entertainment
Penalty
Summary
A deficiency occurred when a resident was temporarily relocated to another room without any of her personal belongings or sources of entertainment. The resident, who had a history of depression, moderate cognitive impairment, limited mobility, and was dependent on staff for activities of daily living, was moved due to her roommate's declining condition and increased family presence. Upon relocation, the resident was left in a bare room with no television, non-functioning clock, and no reading materials or activities, despite her care plan indicating a need for activity engagement and her use of antidepressant medication. Observations and interviews revealed that the resident expressed sadness and discomfort about the move, stating she had nothing to do and was left with only blank walls to look at. Staff interviews confirmed that none of her personal items were moved with her, and there was no immediate effort to provide alternative entertainment or activities. Nursing staff acknowledged awareness of the resident's boredom and the lack of a television, but did not consider or provide other forms of engagement. The Activity Director was noted to leave activities for residents, but it was the responsibility of nursing staff to ensure the resident was not left bored or sad. Facility policy required that residents be oriented to transfers and reassured that all personal effects would be brought to the new room. However, this was not followed, as staff did not move the resident's belongings or provide adequate support to maintain a home-like and comfortable environment. Multiple staff members, including the ADON and DON, recognized after the fact that the resident should have had some of her personal items and entertainment to prevent feelings of sadness or depression during the temporary relocation.
Inadequate PPE for Droplet Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of appropriate Personal Protective Equipment (PPE) for staff entering rooms on droplet precautions. Observations revealed that rooms on Halls 600, 700, and 800, which were designated for droplet precautions, did not have face shields or goggles available in the PPE bins outside the rooms. This deficiency was noted in rooms #605, #607, #608, #703, #704, #801, and #805, all of which were on droplet precautions due to the presence of residents with COVID-19. Interviews with staff, including an LVN and the Director of Nursing (DON), confirmed the absence of necessary PPE, specifically face shields, which are required for droplet precautions. The LVN admitted to wearing only gloves and a mask, relying on her eyeglasses instead of a face shield, due to the unavailability of the latter. The DON acknowledged the protocol for droplet precautions, which includes wearing an N95 mask, face shield, gloves, and a gown if providing direct care, and stated that the responsibility for ensuring PPE availability lay with her and the Assistant Director of Nursing (ADON). Despite the facility's policy and CDC guidelines requiring full PPE, the lack of face shields in the PPE bins placed residents, staff, and visitors at risk of communicable diseases.
Inaccurate Medication Documentation on MDS Assessments
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one of the five residents reviewed for accuracy of assessments. Specifically, the facility did not correctly document the medications of a resident on their quarterly and annual Minimum Data Set (MDS) assessments. This discrepancy was identified during a review of the resident's face sheet and medication orders, which showed that the resident had been prescribed and administered several medications, including antipsychotics, antianxiety, and anticonvulsants, that were not accurately recorded in the MDS assessments. The resident in question was a male with multiple complex medical conditions, including metabolic encephalopathy, end-stage renal disease, quadriplegia, and schizophrenia, among others. The resident's annual MDS assessment indicated that he had not taken any high-risk drug classes in the seven days prior to the assessment, while the quarterly MDS assessment noted the use of antipsychotic, antianxiety, and anticonvulsant medications. However, a review of the resident's medication administration records (MARs) confirmed that these medications were indeed administered according to physician orders during the relevant periods. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the inaccuracies were not initially known to the staff responsible for completing the MDS assessments. The MDS Coordinator acknowledged the oversight and explained the process used to complete the assessments, which involved reviewing medical documentation and physician orders. The DON and the Administrator were informed of the inaccuracies and recognized the importance of accurate assessments to ensure appropriate care planning and service delivery for residents. Despite the acknowledgment of the issue, the report does not detail any corrective actions taken to address the deficiency at the time of the survey.
Resident Abuse Due to Improper Transfer by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who transferred the resident roughly and slapped her hand. The resident, who had a history of dementia and required substantial assistance for transfers, was handled inappropriately by CNA B during a transfer from her bed to a geri-chair. The CNA did not use a gait belt and attempted to lift the resident manually, resulting in a rough transfer where the resident's head and legs were placed on the armrests of the chair. This incident was captured on video by the resident's Power of Attorney (POA). The resident's medical history included non-Alzheimer's dementia, seizure disorder, and senile degeneration of the brain, which affected her cognitive abilities and required her to be dependent on staff for transfers. During the incident, the resident attempted to hold onto the bed, and CNA B forcefully removed her hand and slapped it. The facility's Director of Nursing (DON) and Administrator were notified of the incident by the resident's POA, who provided video evidence of the abuse. The facility's investigation confirmed the abuse, and the CNA was terminated. The facility's failure to ensure the resident's right to be free from abuse placed her at risk of physical and psychosocial harm. The incident was identified as past noncompliance, with immediate jeopardy beginning on the date of the incident and ending a few days later. The facility's policies on abuse and neglect were not followed, as the CNA's actions were considered willful infliction of injury, resulting in mental anguish for the resident.
Inadequate Supervision and Rough Transfer of Resident
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices to prevent accidents for a resident, leading to rough care during a transfer. The incident involved a CNA who did not use a gait belt while transferring a resident from a bed to a geri-chair. The resident, who had significant cognitive impairments and required substantial assistance for transfers, was handled roughly during the process. The CNA attempted to transfer the resident by lifting her without the proper equipment, resulting in a rough and unsafe transfer. The resident involved was a female with a history of non-Alzheimer's dementia, seizure disorder, and senile degeneration of the brain, which affected her cognitive abilities and required her to be dependent on staff for transfers. During the incident, the CNA struggled to transfer the resident safely, as the geri-chair moved backward, and the resident was placed in the chair improperly. The CNA's actions were captured on video, which showed the resident being handled roughly and without the use of a gait belt, as required by the facility's policy. The incident was reported by the resident's POA, who provided a video of the transfer to the facility's administrator. The video showed the CNA attempting to transfer the resident without the necessary assistance or equipment, leading to rough handling. The facility's policy required the use of a gait belt for transfers, and the CNA's failure to comply with this policy resulted in the deficiency. The resident did not sustain any visible injuries from the incident, but the handling was deemed inappropriate and abusive.
Deficiency in Timely Incontinence Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in timely incontinence care. Resident #1, a female with cognitive impairments due to non-Alzheimer's dementia and other neurological conditions, was observed in a geri-chair with a soaked brief. The Certified Nursing Assistant (CNA) responsible for her care admitted that the resident had not been changed since before 10:00 AM, despite the resident's high fluid intake. This delay in care was observed during a surveyor's visit, highlighting a lapse in the facility's adherence to its care plan for the resident, which aimed to prevent skin breakdown due to incontinence. Resident #2, who had no cognitive impairment but required moderate assistance for toileting due to physical limitations from a stroke, also experienced a delay in receiving incontinence care. The resident expressed frustration at having to wait since breakfast to be changed, resulting in a soaked brief and towel. The CNA assigned to Resident #2 confirmed that the resident had been changed earlier in the morning but was not informed of the need for additional care during breakfast service. This oversight resulted in the resident remaining in a wet state for an extended period, contrary to the facility's policy of providing care every two hours. Interviews with the Assistant Director of Nursing (ADON) and the facility Administrator revealed that the facility's policy required CNAs to provide timely incontinence care to prevent skin breakdowns and infections. However, the ADON was unaware of the delays in care, and the Administrator emphasized the importance of regular checks and rounds to ensure residents' needs are met. The facility's failure to adhere to its ADLs policy and care plans for these residents resulted in deficiencies that were observed and documented by surveyors.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, the facility did not consult with the physician when a resident refused to take her Lactulose medication on three occasions over two days. The medication was crucial for managing the resident's hyperammonemia, a condition characterized by elevated ammonia levels due to her cirrhosis of the liver and hepatic encephalopathy. The resident's refusal was not communicated to the physician or documented by the staff, which was against the facility's policy. The resident, who had a history of cirrhosis of the liver, hepatic encephalopathy, and diabetes, was receiving hospice care. Her medical records indicated that she had mild cognitive impairment and was on a regimen of Lactulose to manage her ammonia levels. Despite the importance of the medication, the resident missed three doses, and the facility staff failed to notify the physician or the family about these refusals. This lack of communication and documentation was a significant oversight, as the resident's condition could have been adversely affected by the missed doses. Interviews with facility staff revealed a breakdown in communication and adherence to policy. The medication aide did not inform the licensed vocational nurse (LVN) about the resident's refusal of Lactulose, and the LVN did not document the refusals or notify the physician. The facility's policy required that any medication refusal, especially those critical to the resident's health, be reported to the physician and documented. The failure to follow these procedures resulted in a delay in addressing the resident's altered mental status, which was eventually noticed by the family, leading to the resident being sent to the hospital for evaluation.
Resident Left Unattended in Shower Chair Resulting in Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to an accident. The incident involved a male resident who had a history of stroke and hemiplegia, making him dependent on staff for transfers. On the day of the incident, the resident was left unattended in a shower chair by CNA B, who left the room to find a Hoyer sling. During this time, the resident fell from the shower chair and sustained a right shoulder fracture. The resident's care plan indicated a high risk for falls, and staff were instructed to use a shower bed for showering. However, on the day of the incident, the resident was placed in a shower chair, and the necessary supervision was not provided. CNA B, who was responsible for monitoring the resident, left the room, resulting in the resident's fall and subsequent injury. Interviews with staff revealed that CNA B was not supposed to leave the resident unattended. The facility's policy on resident showers did not address the need for supervision while a resident is seated in a shower chair. This lack of supervision and failure to follow the care plan directly contributed to the resident's fall and injury.
Improper Food Storage and Labeling in Freezer
Penalty
Summary
The facility failed to ensure that food items stored in the freezer were properly labeled with the contents and dates after being removed from their original packages. Observations revealed multiple clear plastic bags containing frozen chicken parts, breaded patties, pork chops, tater tots, an unknown frozen meat, and meatballs that were undated and unlabeled. Additionally, a grey tub at the bottom of the freezer contained bags of chicken breast for easy access. A dark substance, identified as spilled tea, was observed frozen at the bottom of the freezer, indicating a lack of immediate cleaning. Interviews with Cook Q and the Dietary Manager confirmed that the labeling and dating process was not followed, and the spillage was not cleaned promptly as required by the facility's policy. The Dietary Manager stated that it was the responsibility of the cooks to label and date leftover food items and to conduct daily walk-throughs to remove any items stored for more than two weeks. The Dietary Manager also confirmed that any spillage in the freezer or refrigerator should be cleaned immediately. The facility's Food Storage policy, dated 2023, mandates that all foods should be covered, labeled, and dated, and that freezer units should be kept clean and in good working condition at all times. The failure to adhere to these policies could lead to serving residents food that is not appropriate for cooking or serving, potentially causing foodborne illness.
Failure to Report Positive Urine Culture Results
Penalty
Summary
The facility failed to ensure the system for identifying and reporting infections and communicable diseases was followed for a resident. Specifically, the staff did not notify the physician of a resident's positive urine culture for an infectious agent, resulting in a delay in starting antibiotics and implementing contact isolation. The resident, a [AGE] year-old female with diagnoses including difficulty swallowing, dementia, muscle weakness, and diabetes, had a urine sample collected on 03/04/24, which tested positive for klebsiella oxytoca on 03/08/24. However, the physician was not notified until 03/20/24, leading to a delay in treatment and isolation measures. Interviews with staff revealed that the delay was due to a lack of follow-through in reporting the lab results. The Nurse Practitioner discovered the positive results while reviewing lab reports on 03/20/24, and the Director of Nursing confirmed that the results should have been reported immediately upon receipt. The delay in reporting and subsequent delay in treatment and isolation could have prolonged the resident's infection and increased the risk of spreading the infection to other residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the facility was free of pests, specifically gnats, in three of six halls and one conference room. Observations over a three-day period revealed the presence of gnats in the conference room and multiple resident rooms in the 100 Hall. Residents reported seeing gnats in their rooms, and some mentioned that staff had sprayed chemicals to address the issue, but the gnats persisted. Interviews with residents confirmed that while their rooms were cleaned daily, the gnat problem remained unresolved, with some residents noting that the issue had been ongoing for an unspecified period. Staff interviews indicated that the presence of gnats had been observed by various personnel, including CNAs, LVNs, and housekeeping staff. The Maintenance Supervisor acknowledged the issue, attributing it to recent rain and standing water outside the facility. He mentioned that pest control services had been increased in frequency, and he had been spraying bug spray weekly. Despite these efforts, the gnats continued to be a problem, particularly in the 100 Hall and areas near the kitchen. The facility's pest control records from January to March 2024 showed multiple visits from pest control services for various pests, including gnats. The facility's Pest Control Program policy, dated April 2023, stated that the facility aimed to maintain an effective pest control program to eradicate and contain common household pests and rodents. However, the continued presence of gnats indicated that the program was not effectively implemented, leading to potential risks for residents' quality of life and infection control.
Failure to Follow Physician Orders and Obtain Necessary Orders for Resident Care
Penalty
Summary
The facility failed to follow physician orders for weekly weights for a resident, resulting in a significant weight fluctuation. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including dementia, depression, heart disease, and diabetes, had an active order for weekly weights. However, the resident was weighed weekly only until early August, sporadically in September, and then monthly thereafter. This inconsistency led to a 30-pound weight loss followed by a 30-pound weight gain over several months. The Director of Nursing (DON) acknowledged the failure and the potential risks associated with not adhering to the physician's orders. In another instance, the facility failed to obtain physician orders for the use of a hinged knee brace for a male resident with a history of falls, end-stage renal disease, and a recent leg fracture. The resident was provided with a knee brace after a fall but did not have corresponding physician orders in his electronic health record (EHR). Interviews with the resident, nursing staff, and the Therapy Director revealed that the brace was always worn and monitored for skin issues, but no formal orders were documented. The Assistant Director of Nursing (ADON) admitted to not noticing the missing orders and acknowledged the oversight. The facility's policy requires written and/or verbal orders for residents' immediate care needs to ensure essential care is provided. The DON emphasized the importance of following physician orders and monitoring for skin breakdowns. Despite the orthopedic order for the knee brace being available on paper, it was not updated in the resident's chart, highlighting a lapse in the facility's process for managing physician orders and ensuring proper documentation and care.
Inadequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two residents. The first incident involved a van driver who did not properly restrain a resident's wheelchair in the facility transportation van, resulting in the wheelchair tipping over on its side. The resident, who had multiple medical conditions including hypertension, diabetes, and arthritis, sustained a bruise and abrasion to the right side of her face and mild pain in the right rib area. The van driver claimed to have secured the wheelchair properly, but the incident occurred when the resident reached for her purse on the floor during transport. The second incident involved a resident who was stuck outside in the courtyard and unable to call the facility because the phone lines were down. The resident, who had coronary artery disease, hypertension, end-stage renal disease, and diabetes, was found by her family member after being outside for an hour and twenty minutes. The resident's wheelchair had gotten stuck in the landscape area around a water fountain. Despite being independent in her wheelchair and cognitively intact, the resident was unable to free herself and had to rely on her family member for assistance. Both incidents highlight the facility's failure to provide adequate supervision and ensure the safety of its residents. The first incident resulted from improper securing of a wheelchair during transport, while the second incident was due to a lack of supervision and communication issues caused by downed phone lines. These deficiencies could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.
Failure to Follow Physician Orders for Enteral Feeding
Penalty
Summary
The facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications. Specifically, the nursing staff did not follow the physician's orders for water flushes on the feeding pump for a resident with severe cognitive impairment and multiple medical conditions, including hypertension, stroke, and hemiplegia. The resident's care plan required adherence to specific water flush orders, but observations revealed discrepancies in the settings, which were not corrected over multiple days. Interviews with the nursing staff and administration confirmed that the water flush settings were not verified against the physician's orders, leading to incorrect administration. The Licensed Vocational Nurse (LVN) admitted to not checking the settings thoroughly, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the importance of following orders to ensure proper nourishment and hydration. The facility's policy on the care and treatment of feeding tubes emphasized the need to follow physician orders, which was not adhered to in this case.
Failure to Implement Policies and Report Incident
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent neglect, as evidenced by an incident involving Resident #302. The resident, a [AGE] year-old female with diagnoses including hypertension, diabetes, arthritis, and a left artificial shoulder joint, was being transported in a facility van when her wheelchair tilted, causing her to fall and sustain a bruise and abrasion to the right side of her face. Despite the incident, the facility did not report it to the State Survey Agency as required by their policy, which mandates reporting within specified timeframes depending on the severity of the incident. Interviews with the resident, the van driver, RN E, and the Administrator revealed that the resident's wheelchair tilted while the van was turning, and the resident was reaching for her purse. The van driver stopped and adjusted the wheelchair, and the resident was assessed upon return to the facility. The Administrator did not believe the incident warranted reporting because there was no severe injury, despite the facility's policy requiring such incidents to be reported. This failure to report could place residents at risk of lacking timely reporting of incidents.
Failure to Report Incident Involving Resident in Wheelchair
Penalty
Summary
The facility failed to report an incident involving a resident who tilted in her wheelchair while being transported in the facility van. The resident, a [AGE] year-old female with diagnoses including hypertension, diabetes, arthritis, and a left artificial shoulder joint, was being transported back to the facility from an orthopedic appointment. During the transport, the resident reached for her purse on the floor, causing her wheelchair to tilt. The van driver stopped and adjusted the wheelchair, and upon return to the facility, the resident was assessed by a nurse who noted a bruise and abrasion on her face and mild pain in her right rib area. X-rays were ordered, and the resident was medicated for pain. The incident was documented, but the facility did not report it to the State Survey Agency within the required 24-hour timeframe as it did not involve abuse or result in serious bodily injury. Interviews with the resident, van driver, RN, and Administrator revealed that the incident was not considered severe enough to report. The Administrator provided additional training to the van driver to ensure proper securing of residents in the van. The facility's policy on abuse, neglect, and exploitation requires reporting all alleged violations to the appropriate authorities within specified timeframes, but this incident was not reported as required. The failure to report could result in a delay in identifying abuse or neglect and a lack of timely follow-up on recommended interventions to prevent harm or impairment.
Failure to Complete PASARR Screening Accurately
Penalty
Summary
The facility admitted a resident with a mental disorder before the State mental health authority had determined she was appropriately placed. The MDS Coordinator failed to complete the PASARR screening process accurately for the resident, who had diagnoses including severe unspecified dementia with psychotic disturbance, cognitive communication deficit, and schizophrenia. The resident's PASARR I screening completed by the transferring facility indicated evidence of a mental illness, but the facility's screening incorrectly indicated no evidence of mental illness due to an unchecked box. This error prevented the PASARR Level II evaluation from being triggered, which is necessary for determining the appropriate setting and specialized services for the resident. The resident's quarterly MDS assessment revealed significant cognitive and functional impairments, including a BIMS score of 00, indicating the score was not able to be completed. The resident required various levels of assistance with daily activities and had active diagnoses including schizophrenia. The care plan included interventions for impaired thought processes, communication problems, and the use of antipsychotic medication. Despite these documented needs, the resident was not receiving PASARR services due to the screening error. Interviews with facility staff, including the ADON and MDS Coordinator, confirmed the resident's diagnosis of schizophrenia and the error in the PASARR screening process. The ADON acknowledged that the resident was not receiving PASARR services, which could place her at risk of not meeting care plan goals and having a lower quality of life. The MDS Coordinator admitted responsibility for the error and recognized that it placed the resident at risk of not receiving necessary specialized services.
Failure to Update Care Plan for Resident's Knee Brace
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who had a hinged knee brace following a fall that resulted in a fracture. The resident, a male with a history of hyperkalemia, end-stage renal disease, type 2 diabetes, and a fracture of the left tibia, was observed to always wear the knee brace. Despite this, the care plan did not address the use of the knee brace, which was confirmed by interviews with the resident, an LVN, the ADON, and the DON. The resident's care plan included interventions for falls but did not include specific instructions for the knee brace, which was necessary for the resident's fracture care and recovery. The deficiency was identified through observations, interviews, and record reviews. The resident had a BIMS score indicating intact cognition and had experienced a fall after returning from dialysis, leading to a fracture. The LVN and ADON acknowledged the omission in the care plan, and the DON confirmed that the care plan should have included the knee brace to ensure proper care and monitoring. The facility's policy required comprehensive care plans to meet residents' medical, nursing, and psychosocial needs, but this was not followed in this case, placing the resident at risk of not receiving appropriate care for his fracture.
Failure to Provide Necessary Grooming and Personal Hygiene Services
Penalty
Summary
The facility failed to provide necessary grooming and personal hygiene services to two residents who were unable to perform these activities themselves. Resident #35, who had severe cognitive impairment and required maximal assistance with activities of daily living (ADLs), was observed with facial hair that had not been removed. Despite the resident expressing a desire to have the facial hair shaved, staff had not addressed this need. Similarly, Resident #83, who had moderate cognitive impairment and also required maximal assistance with ADLs, was observed with facial hair and expressed dissatisfaction with it. The resident stated that she had asked staff to remove the facial hair, but it had not been done. Interviews with staff revealed a lack of clarity and responsibility regarding the removal of residents' facial hair. The assigned Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) indicated that they believed it was either the beautician's responsibility or were unsure if they were allowed to remove facial hair. The Director of Nursing (DON) stated that it was the responsibility of the CNAs, nurses, Assistant Director of Nursing (ADON), and herself to ensure ADLs were completed, including the removal of facial hair if the resident desired. The facility's policy on Activities of Daily Living (ADLs) indicated that care and services should be provided for grooming and personal hygiene. However, the failure to remove facial hair for Residents #35 and #83, despite their expressed wishes, demonstrated a lapse in adhering to this policy. This deficiency could affect the residents' dignity and personal hygiene, as noted by the DON.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide or obtain timely laboratory services for a resident, resulting in a significant delay in diagnosing and treating a urinary tract infection. The resident, a female with dementia, diabetes, and other health conditions, had physician orders for routine lab work on two occasions, but there were no records of the lab work being performed. Additionally, urine was collected for a urinalysis and culture, but the results indicating a bacterial infection were not reported to the physician until 12 days later, leading to a delay in starting antibiotics and placing the resident in isolation. Interviews with staff revealed that the lab results were not communicated to the physician in a timely manner, and there was a lack of follow-through by the nursing staff. The Director of Nursing confirmed that the results should have been reported immediately and acknowledged a failure in staff responsibilities. The delay in reporting and acting on the lab results posed a risk of worsening the resident's condition and spreading the infection to other residents.
Failure to Prepare Nutritious and Flavorful Pureed Meals
Penalty
Summary
The facility failed to provide food prepared by methods that conserved nutritive value, flavor, and appearance for residents on a pureed diet. On 03/24/24, the Dietary Manager prepared pureed lunches by blending shredded turkey pieces, hot water, and thickener, resulting in a pudding consistency. The Dietary Manager admitted to not following the recipe, which required using broth instead of water to avoid clumping and enhance flavor. This deviation from the recipe was due to her concern about over-seasoning the food. The pureed meal lacked seasoning and flavor, which was confirmed during a taste test on 03/26/24. The Dietary Manager acknowledged the importance of following recipes to ensure nutritious and palatable meals for residents. Further observations and interviews revealed that Cook P, who prepared the pureed lunch meal on 03/26/24, also did not follow the recipe. Cook P used chicken broth but was cautious with seasoning due to a recent reprimand for over-seasoning. Despite tasting the pureed food and finding it flavorless, Cook P believed the gravy would balance the taste. Both the Dietary Manager and Cook P recognized that failing to prepare food according to the recipe could lead to residents not eating properly, risking weight loss and malnutrition. The facility's policy and recipe guidelines emphasized the importance of using appropriate liquids and seasonings to maintain the nutritive value and flavor of pureed foods.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted as required for three consecutive days. Observations on 03/24/24, 03/25/24, and 03/26/24 revealed that the daily nursing staff posting displayed the date 03/22/24, indicating that the information had not been updated. This failure was confirmed through interviews with the Assistant Director of Nursing (ADON) and the Administrator, both of whom acknowledged that the daily postings had not been completed due to oversight. The ADON admitted that it was his responsibility to update the postings daily but had forgotten to do so amidst other tasks. The facility's policy, dated 01/01/23, mandates that nurse staffing information be made readily available to residents and visitors in a readable format. The policy specifies that the daily postings should include the facility name, current date, resident census, and the total number and actual hours worked by various categories of nursing staff. The failure to update this information could affect residents, their families, and visitors by depriving them of accurate staffing data and facility census information.
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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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
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.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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