Mesa Vista Inn Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 5756 N Knoll Dr, San Antonio, Texas 78240
- CMS Provider Number
- 455444
- Inspections on file
- 42
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Mesa Vista Inn Health Center during CMS and state inspections, most recent first.
During wound care for a resident with a stage IV pressure ulcer and skin tears on enhanced barrier precautions, an LVN and the DON failed to perform hand hygiene at required times. The DON touched non-sterile surfaces and then provided direct care without changing gloves or washing hands, while the LVN donned clean gloves after removing soiled ones without washing hands. Both staff acknowledged not following infection control protocols as per facility policy and training.
A resident with severe cognitive impairment and a history of falls was found with unexplained bruising to the right temple and left hand. Staff identified the injuries during shift change and notified the physician and nursing leadership, but failed to report the incident to the administrator and state authorities within the required two-hour timeframe, as mandated by facility policy and regulation. The delay in reporting was confirmed through staff interviews and record review.
Staff failed to consistently wear and properly remove PPE during wound care for three residents on enhanced barrier precautions, including a resident with diabetes and vascular disease and two residents with cognitive impairments. Observations revealed that staff did not don gloves or gowns as required and did not follow correct procedures for removing contaminated PPE, despite facility policy and CDC guidelines. Staff interviews confirmed lapses in infection control practices during resident care.
Two residents did not have their privacy and dignity maintained during wound care, as staff failed to close doors, blinds, or privacy curtains during procedures. One resident, who was cognitively intact, received care in a shared room without privacy measures, while another with severe cognitive impairment had wound care in a private room with the blinds left open. Staff interviews confirmed that privacy protocols were not consistently followed.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice care, but the care plan failed to include all ordered hospice diagnoses, resulting in a mismatch between the care plan and medical orders. The DON confirmed that the care plan should have matched the hospice order diagnoses, but it did not in this case.
A deficiency occurred when the Medical Records Director, under instruction from an administrator, used a physician's EMR credentials to electronically sign physician orders instead of the physician signing them personally. This practice went undetected for an extended period and was only discovered during an audit, with staff and the physician unaware that orders were being signed in this manner. The facility's policies and agreements required that only the physician sign their own orders and that credentials not be shared.
A facility failed to create and update a comprehensive care plan for a resident with Alzheimer's Disease who exhibited physical and verbal aggression, as well as other behavioral symptoms. Although staff recognized and managed these behaviors through redirection and monitoring, these interventions were not documented in the resident's care plan, contrary to facility policy and assessment findings.
A CNA failed to change soiled gloves and perform hand hygiene during incontinent care for a resident with chronic incontinence and multiple comorbidities. The CNA touched clean linens and a clean brief with contaminated gloves after providing perineal care, and the DON, who assisted, did not identify the lapse. Facility policy required glove changes and hand hygiene after such care, but these steps were not followed.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a laceration that required six sutures. Although the incident was documented and family, hospice, and physician were notified, the facility administrator and DON did not report the serious injury of unknown source to HHSC as required by the facility's abuse and neglect policy.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a forehead laceration that required six sutures. Although staff notified the family, hospice, and physician, the administrator did not report the incident to the State Survey Agency as required for injuries of unknown source or serious bodily injury. Staff interviews confirmed the lack of timely reporting, contrary to facility policy.
A resident with dementia, repeated falls, and a stage 4 pressure ulcer did not have her fall mat in place as specified in her care plan. The mat was found propped against a chair after being moved for a visitor and not returned, despite the care plan requiring its use to address fall risk and behaviors. Staff and family interviews confirmed the lapse, and facility policy mandates comprehensive care planning with measurable objectives.
A resident with a stage 4 sacral pressure ulcer and weighing 114 pounds was found to have an air mattress set to over 310 pounds, contrary to care plan and physician orders. The resident reported discomfort, and staff interviews confirmed the mattress should be set to the resident's weight, but there was no policy in place to ensure this adjustment.
A resident with diabetes and moderate cognitive impairment was found with nail clippers, posing a risk of self-injury. The facility failed to ensure the environment was free from hazards, as the resident's family often brought items, and there was no policy on accidents and hazards. The DON acknowledged the risk and the need for closer monitoring.
A resident with severe cognitive impairment and an indwelling urinary catheter received improper incontinent care, risking infection. CNAs used incorrect wiping techniques and reused wipes, contrary to facility policy. The DON confirmed the expected procedure was not followed, and one CNA had not received competency training.
A resident with severe cognitive impairment and functional limitations was observed using a left arm sling without a written physician's order. Despite hospice recommendations and staff observations, the facility failed to update the resident's medical records to reflect the continued use of the sling, as confirmed by interviews with facility staff.
The facility failed to maintain an effective infection control program, as evidenced by deficiencies in the care of two residents. A resident with a colostomy was not identified for Enhanced Barrier Precautions, and there was no signage indicating the need for such precautions. Additionally, two CNAs did not follow proper infection control practices during catheter and incontinent/peri care for another resident, failing to change gloves and perform hand hygiene appropriately. These lapses were confirmed by staff interviews and observations, highlighting significant gaps in the facility's infection control program.
A resident with dementia and other health conditions experienced a malfunctioning call light system, which did not alert staff when activated. The issue was confirmed by staff and later fixed by maintenance, but the delay in addressing the malfunction led to a deficiency in the facility's call system functionality.
A resident with severe dementia and a history of wandering eloped from the Memory Care wing by undoing a window lock and leaving the facility undetected. Despite having a care plan addressing his risk for wandering, the resident was not found until the next morning, indicating a lapse in supervision. The incident highlighted the need for improved safety measures and monitoring to prevent similar occurrences.
The facility failed to inform a resident and their responsible parties about the risks and benefits of the antipsychotic medication Lexapro, and did not obtain a signed consent for its use. The responsible parties were not notified of a dosage increase, leading to concerns about the resident's increased sleepiness and potential adverse reactions.
Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for a resident who was on enhanced barrier precautions due to a stage IV pressure ulcer and additional skin tears. During a wound care procedure, both the LVN and the DON initially washed their hands and donned gowns and gloves. However, the DON touched non-sterile surfaces, including a window blind, bed controls, and bed linens, and then proceeded to provide direct care to the resident without changing gloves or washing her hands. The LVN, after removing soiled gloves, walked to the treatment cart, obtained clean gloves, and donned them without performing hand hygiene in between. Both staff members acknowledged during interviews that they did not follow proper hand hygiene protocols as outlined in the facility's policy and their training. The resident involved was non-responsive during the procedure and had a significant medical history, including Parkinsonism and a stage IV pressure ulcer requiring daily wound care. The failure to perform hand hygiene at appropriate times during wound care was observed and confirmed by both staff members involved.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported immediately, but not later than two hours after the allegation was made, for one resident whose records were reviewed for suspicious injuries. The resident in question had a history of cerebral infarction and unspecified dementia, with severe cognitive impairment and disorganized thinking. She resided in a secure care unit due to her dementia and risk for elopement, and required supervision for mobility and activities of daily living. On the date in question, the resident was noted to have bruising on her right temple and left hand, with the temple bruise later worsening and requiring hospital evaluation. Staff interviews and record reviews revealed that the initial discovery of the bruising was made during a shift change, with the night nurse reporting the findings to the day nurse. The day nurse assessed the resident, notified the physician, and reported the findings to the ADON/DON. However, the incident was not reported to the administrator until the following day, rather than immediately as required by facility policy and state regulations. The administrator confirmed that she was not informed of the incident until the next day, and that the required report to the state was made only after she became aware of the situation. The facility's policy required immediate verbal reporting of suspected abuse, neglect, or injuries of unknown source to the Abuse Preventionist or designee, and for the administrator to report qualifying incidents to the state within the required timeframe. Despite these policies, the delay in reporting the resident's injury of unknown origin resulted in noncompliance with regulatory requirements. The deficiency was identified through observation, interviews with staff and the resident's physician, and review of medical records and facility policies.
Failure to Adhere to PPE Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to proper use of personal protective equipment (PPE) during wound care for residents on enhanced barrier precautions. For one resident with Type 1 Diabetes and Peripheral Vascular Disease, staff did not don gloves or gowns while exposing and observing a wound, despite the care plan specifying enhanced barrier precautions. The staff involved admitted to forgetting or misunderstanding the need for PPE, even though the resident had an open wound and was on enhanced barrier precautions. In additional observations, staff did not follow correct procedures for removing PPE after providing wound care to two other residents with cognitive impairments and vascular dementia. Specifically, staff removed gloves and gowns in a manner that could lead to contamination, such as touching the front of the gown with bare hands and not following recommended glove removal techniques. Interviews with staff and administration confirmed a lack of adherence to established protocols for donning and doffing PPE, with staff acknowledging the importance of these practices but failing to implement them correctly during care. The facility's own infection control policy and CDC guidelines were not followed, as staff did not consistently wear or remove PPE as required when providing care to residents with wounds or indwelling devices. The Director of Nursing and Assistant Director of Nursing both recognized the correct procedures and the necessity of PPE use, but these were not observed in practice during the survey. The deficiency was identified through direct observation, interviews, and record review, demonstrating a breakdown in infection control practices for multiple residents.
Failure to Maintain Resident Privacy and Dignity During Wound Care
Penalty
Summary
The facility failed to maintain resident privacy and dignity during wound care for two residents. In one instance, a resident with Type 1 Diabetes and Peripheral Vascular Disease, who was cognitively intact, received wound care in a shared room without the door, blinds, or privacy curtain being closed, while the roommate was present. The resident reported that privacy was inconsistently provided and expressed feeling neglected. The Assistant Director of Nursing (ADON) acknowledged that the privacy curtain should have been used and admitted not considering the resident's preference due to familiarity with the roommate. In another case, a resident with Vascular Dementia, Type 2 Diabetes, and Aphasia, who had severely impaired cognitive skills, underwent wound care in a private room where the blinds were not closed, although the door was shut. The LPN involved stated that full privacy measures, including closing doors, curtains, and blinds, were expected but not followed. Both the ADON and Director of Nursing (DON) confirmed that privacy should always be provided during care, regardless of the resident's ability to communicate discomfort, and recognized that the failure to do so could compromise resident dignity.
Failure to Align Hospice Care Plan with Ordered Diagnoses
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting a focus area and interventions for the resident's ordered hospice care diagnosis. Record review showed that a female resident with severe cognitive impairment and multiple diagnoses, including senile degeneration of the brain and cerebral atherosclerosis, was admitted to hospice care. However, the care plan only included senile degeneration of the brain as the hospice diagnosis, while the hospice order also listed cerebral atherosclerosis. This discrepancy was identified during a review of the resident's records and confirmed by the Director of Nursing (DON), who acknowledged that the care planned diagnosis should match the medical diagnoses and orders. The DON stated that the facility's process is to include the diagnosis from the order in the care plan, and upon review, recognized that the hospice order diagnosis did not match the care planned diagnosis for the resident. The facility's policy requires the comprehensive care plan to describe the services needed to attain or maintain the resident's highest practicable well-being, but in this case, the care plan did not reflect all relevant hospice diagnoses as ordered. This failure was identified through observation, interview, and record review, and was acknowledged by facility leadership as not meeting expectations for care planning.
Unauthorized Electronic Signing of Physician Orders Using Physician Credentials
Penalty
Summary
The facility failed to ensure that physician orders were properly signed and dated by the responsible physician, specifically Physician R, as required during each visit. Instead, the Medical Records Director was instructed by Administrator O to electronically sign Physician R's orders in the electronic medical record (EMR) system using Physician R's username and password. This practice was carried out for an extended period, with the Medical Records Director logging into the EMR approximately twice a month to sign off on pending orders for Physician R. The Medical Records Director reported that she was initially asked to perform this task after the previous DON left, and that she continued to do so under the direction of Administrator O, despite feeling uncomfortable and recognizing through later training that this was not appropriate. The deficiency was discovered during an audit conducted by the Regional Medical Records Director, which revealed over 100 unsigned physician orders pending in the EMR. Upon investigation, it was found that the Medical Records Director had been using credentials provided by Administrator O to sign these orders, and that this practice had been ongoing for several years. Interviews with staff, including the ADON and MDS Coordinator, confirmed that they were unaware of this practice and that Physician R was not signing his own orders in the EMR. Physician R himself stated that he was not aware his credentials were being used in this manner and that he had been signing paper documents provided to him during his visits, believing these included all necessary orders. The facility's own policies and the Medical Director Agreement required that only the physician sign their own orders, and that usernames and passwords not be shared. The Medical Records Director did not report the inappropriate practice to anyone else, citing fear of job loss, even though an anonymous compliance hotline was available. The improper signing of orders was not detected until the audit, and no evidence was found that the Medical Records Director or Administrator O originated or created new orders, only that they signed off on existing ones entered by nursing staff.
Failure to Develop and Implement Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's identified needs, specifically omitting interventions for physical and verbally aggressive behaviors. The resident in question, an elderly female with Alzheimer's Disease and severe cognitive impairment, had documented incidents of both physical and verbal aggression toward others, as well as other behavioral symptoms such as wandering and inappropriate behaviors. Despite these behaviors being identified in assessments and incident reports, the care plan did not include specific interventions or measurable objectives to address the aggressive behaviors. Record reviews showed that the resident had a history of behavioral symptoms, including an incident where she attempted to strike another resident after a verbal altercation. Staff interviews confirmed that the resident was redirectable and that monitoring was implemented after the incident, but these interventions were not reflected in the resident's care plan. Multiple staff members, including LVNs, CNAs, ADONs, the MDS Coordinator, and the Administrator, acknowledged that the care plan should have been updated to include the resident's aggressive behaviors and appropriate interventions. The facility's own policy required the development and implementation of a person-centered comprehensive care plan to address each resident's medical, physical, mental, and psychosocial needs. However, the care plan for this resident did not include interventions for her aggressive behaviors, despite clear evidence from assessments, incident reports, and staff interviews that such behaviors were present and required management.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a resident with multiple diagnoses, including dementia, schizophrenia, bipolar disorder, and chronic incontinence. The CNA was observed wiping the resident's perineal area and then, without changing soiled gloves, touched the bed linen. After removing soiled gloves and using hand sanitizer, the CNA donned clean gloves but again failed to change gloves after wiping fecal material from the resident's legs, subsequently touching the resident and clean brief with contaminated gloves. The Director of Nursing (DON) assisted during the care but did not notice the improper glove use or cross-contamination at the time. Interviews with the CNA revealed she had received recent training on proper perineal care and acknowledged the need to change gloves when soiled, but did not recall the specific lapses observed. The DON confirmed the facility's policy required glove changes and hand hygiene after perineal care and before touching clean linens or briefs. Facility policies reviewed indicated hand hygiene should be performed after contact with body fluids, after removing gloves, and after handling soiled linens, but these procedures were not followed during the observed care event.
Failure to Report Serious Injury of Unknown Source as Required by Policy
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse and neglect, as evidenced by the handling of a serious injury of unknown source involving a resident. The administrator did not follow the Abuse/Neglect/Exploitation (ANE) policy, which requires reporting all injuries of unknown source resulting in serious bodily injury to the state agency (HHSC) within specified timeframes. Specifically, a resident with multiple diagnoses including dementia, major depressive disorder, Parkinson's disease, and metabolic encephalopathy experienced an unwitnessed fall, resulting in a laceration to the forehead that required six sutures. The incident was documented, and the family, hospice, and physician were notified, but the required report to HHSC was not made. Interviews with the DON, RN, and administrator confirmed that the fall was unwitnessed and resulted in significant injury, but the event was not reported to the appropriate authorities as required by facility policy and state regulations. The resident was severely cognitively impaired, frequently incontinent, at risk for falls, and required substantial assistance with activities of daily living. Despite the clear policy on reporting such incidents, the administrator and DON did not consider the event as abuse or neglect and therefore did not report it, leading to a deficiency in the facility's abuse and neglect prevention procedures.
Failure to Timely Report Unwitnessed Fall with Serious Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, as required by regulation. Specifically, a resident with multiple diagnoses including dementia, major depressive disorder, Parkinson's disease, and metabolic encephalopathy experienced an unwitnessed fall resulting in a laceration to the forehead. The resident was sent to the emergency room, received six sutures, and returned to the facility the same day. Despite the serious nature of the injury and the fact that the fall was unwitnessed, the incident was not reported to the State Survey Agency (HHSC) by the administrator as required. Record reviews confirmed that the resident was severely cognitively impaired, required substantial assistance with activities of daily living, and was at risk for falls. The care plan documented multiple risk factors, including impaired cognitive and neurological function, impaired vision, and a history of falls. The incident report and progress notes indicated that the resident was found on the floor with a laceration, and staff responded by notifying the family, hospice, and physician, and arranging for emergency care. However, there was no documentation or evidence that the incident was reported to the appropriate state authorities within the required timeframe. Interviews with facility staff, including the DON and administrator, confirmed that the unwitnessed fall with injury was not reported to HHSC. Staff stated that they did not consider the incident to be abuse or neglect since they believed they understood how the fall occurred, despite the lack of witnesses. The facility's own policy required reporting of all injuries of unknown source or those resulting in serious bodily injury within two hours, but this procedure was not followed in this case.
Failure to Implement Comprehensive Care Plan for Fall Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including dementia, repeated falls, a stage 4 pressure ulcer, and a history of seizures. The resident's care plan specified the use of fall mats as an intervention due to her history of falls and behaviors such as intentionally placing herself on the mats or throwing herself to the floor. However, during an observation, the fall mat was found propped vertically against a chair rather than being placed on the floor next to the resident's bed as required by her care plan. Interviews with staff and the resident's family revealed that the mat had been moved to accommodate a visitor and was not returned to its proper position. The Director of Nursing and MDS nurse confirmed that the fall mats were part of the care plan to address the resident's behaviors and risk of falls. The facility's policy requires the development and implementation of a comprehensive care plan with measurable objectives and timeframes, but this was not followed in this instance, resulting in the resident not receiving the specified intervention.
Incorrect Air Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident with a stage 4 sacral pressure ulcer was found to have an air mattress set incorrectly for her weight. The resident, who weighed 114 pounds and had diagnoses including dementia, repeated falls, a stage 4 sacral pressure ulcer, and osteoporosis with fracture, was observed to have her air mattress dial set to over 310 pounds. The care plan and physician orders specified the use of an air mattress, and the resident's medication administration record indicated the mattress was provided as ordered. However, the mattress setting did not correspond to the resident's actual weight. During interviews, the resident reported discomfort on the air mattress. The DON and MDS LVN confirmed that the air mattress should be set according to the resident's weight and that nurses were responsible for making these adjustments. The DON was unaware that the mattress was set incorrectly and stated there was no policy in place regarding the adjustment of air mattress settings. This failure to ensure the correct mattress setting constituted a deficiency in providing necessary treatment and services to promote healing and prevent further pressure ulcers.
Resident Safety Hazard Due to Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that the environment for a resident, who was on anticoagulant therapy and had a history of diabetes, was free from potential hazards. During an observation, the resident was found in possession of a pair of nail clippers, which posed a risk of self-injury and potential complications due to his diabetic condition. The resident, who had moderate cognitive impairment, was attempting to use the clippers himself, despite the risk of injury and infection. The Assistant Director of Nursing (ADON) was informed and subsequently secured the clippers. The Director of Nursing (DON) acknowledged the potential risk of infection if a diabetic resident were to injure themselves with nail clippers. It was noted that the resident's family often brought him items, which could have included the clippers. The facility did not have a policy on accidents and hazards, and the DON mentioned the need to monitor items brought by family members more closely. The facility's lack of a specific policy and the oversight in monitoring items brought by family members contributed to the deficiency.
Improper Incontinent Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder and bowel, leading to a risk of urinary tract infections. The resident, who was severely cognitively impaired and had an indwelling urinary catheter, was observed with stool and remnants of a thick white substance on her thighs and buttocks. During care, CNAs used improper techniques by wiping in a back-and-forth and circular motion instead of the required front-to-back motion, and they reused wipes instead of discarding them after each pass. This improper cleaning method was acknowledged by the CNAs during interviews, and it was noted that one of the CNAs had not received competency training at the facility. The Director of Nursing (DON) confirmed that the expected procedure was to wipe from front to back and discard wipes after each use to prevent cross-contamination and infection. The facility's policy on perineal care also emphasized the importance of using a new wipe for each pass and wiping from the urethral area toward the rectal area. The DON, who was newly employed, was unsure if the CNAs had completed any competency training for incontinent care, which contributed to the deficiency in care provided to the resident.
Incomplete Medical Records for Resident's Arm Sling Use
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the use of a left arm sling. The resident, who was severely cognitively impaired and had functional limitations in range of motion, was observed wearing a left arm sling without a corresponding written physician's order. The resident's medical records, including the Order Summary Report and Medication Administration Record (MAR), did not reflect an updated order for the continued use of the sling, despite hospice recommendations and observations by nursing staff. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed the absence of a physician's order for the sling's continued use. The LVN acknowledged that the Order Summary was not updated to reflect the hospice's recommendation, and the DON emphasized the necessity of a physician's order for monitoring the sling's use and potential skin issues. The facility's policy on physician's orders was not adhered to, resulting in incomplete documentation of the resident's care plan.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by deficiencies observed in the care of two residents. Resident #33, who had a colostomy, was not identified for Enhanced Barrier Precautions (EBP), and there was no signage indicating the need for such precautions in or around her room. This oversight was confirmed by staff interviews, where it was acknowledged that EBP signage should have been posted to prevent infections. The facility's internal document on EBP did not provide a clear system for informing staff about which residents required these precautions. In the case of Resident #31, the facility failed to ensure proper infection control practices during catheter and incontinent/peri care. Observations revealed that CNAs A and B did not change gloves or perform hand hygiene appropriately while providing care. CNA A used soiled gloves to handle clean items and did not change gloves after cleaning stool, which could lead to cross-contamination. CNA B also failed to sanitize her hands between glove changes, further contributing to the risk of infection. Interviews with the CNAs and the DON confirmed these lapses in infection control practices. The facility's policy on hand hygiene and PPE was not adhered to during the care of Resident #31. The policy outlined the importance of hand hygiene before and after patient contact and after removing gloves, but these steps were not followed by the CNAs. The DON acknowledged that the failure to perform hand hygiene and the movement from dirty to clean areas without proper precautions could result in the resident developing an infection. These deficiencies highlight significant gaps in the facility's infection control program, potentially putting residents at risk for infections.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically affecting one resident. Resident #41, who has a history of dementia, atherosclerotic heart disease, and chronic obstructive pulmonary disease, was observed using his call light, which did not illuminate the nurse call light outside his room. This malfunction was confirmed during an interview with the resident, who reported that it took a long time, approximately two hours, for staff to respond to his call light. The call light was lit at the pull station but not outside the door, indicating a malfunction. Further investigation revealed that the call light system was not functioning properly, as confirmed by a CNA and the ADON, who both verified that the call light was not sounding at the nurse's station. The Maintenance Director later reported that the call light had been fixed and explained that the system could be grounded if the call light was pulled without being reset. The facility's maintenance policy outlines the repair and replacement of damaged equipment, but the issue with the call light system had not been addressed promptly, leading to the deficiency.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident in the Memory Care wing. The resident, who had a history of wandering and was at risk for elopement, managed to undo the lock on his window, kick out the screen, and leave the facility undetected. This incident occurred despite the resident's care plan, which included interventions to prevent wandering and elopement. The resident was not located until the following morning, indicating a lapse in supervision and monitoring. The resident involved was a male with severe dementia, major depressive disorder, paranoid schizophrenia, and epilepsy. His care plan noted his risk for wandering due to disorientation and impaired safety awareness. On the day of the incident, the resident was last seen in his room after receiving medication. Staff later discovered his absence and the open window, suggesting he used a closet rod to unscrew the window fastener and escape. The facility's response to the missing resident included implementing elopement protocols, notifying family and authorities, and conducting a search. The resident was eventually found unharmed but disoriented. The incident highlighted the need for improved safety measures and supervision to prevent similar occurrences, as the resident's actions posed a risk of harm, serious injury, or death.
Failure to Inform Resident and Responsible Parties of Medication Changes
Penalty
Summary
The facility failed to ensure that Resident #1 was fully informed and understood the risks and benefits of his treatment, specifically regarding the administration of the antipsychotic medication Escitalopram Oxalate (Lexapro). The facility did not obtain a signed consent for the medication, and the resident's responsible party was not informed of the benefits, risks, and options available after a recommendation to increase the dosage. This failure was identified through interviews and record reviews, which revealed that the resident's responsible parties were not notified of the medication changes, leading to concerns about the resident's increased sleepiness and potential adverse reactions to the medication. Resident #1, an elderly male with severe cognitive impairment, dementia, insomnia, and major depressive disorder, was admitted to the facility with a care plan that included the use of antidepressant medication. Despite the care plan's requirement to educate the resident and family about the medication's risks and benefits, the facility did not obtain a signed consent for the use of Lexapro. Additionally, when the dosage of Lexapro was increased, the facility failed to inform the resident's responsible parties, leading to confusion and dissatisfaction among the family members. Interviews with the resident's responsible parties and facility staff revealed a lack of communication and documentation regarding the medication changes. The responsible parties expressed concerns about the resident's increased sleepiness and the lack of notification about the dosage increase. Facility staff, including the ADON and DON, admitted that the facility's policy did not require notification for dosage changes of existing medications, which contributed to the oversight. The facility's policy on psychotropic drugs and resident rights emphasized the importance of informed consent and communication, but these procedures were not followed in this case.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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