Misty Willow Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 12921 Misty Willow Dr, Houston, Texas 77070
- CMS Provider Number
- 676251
- Inspections on file
- 26
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 16 (5 serious)
Citation history
Health deficiencies cited at Misty Willow Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident with stroke-related hemiplegia, morbid obesity, and high fall risk required extensive assistance for transfers. During an assisted wheelchair-to-bed transfer by two CNAs, the resident slipped, was lowered to the floor, reported hearing a crack in her leg, and described crying out in pain as staff struggled to get her up, with her leg becoming caught under equipment. No nurse assessed her at the time, no fall was documented in the record, and the DON, MD, and family were not notified when the event occurred. Over the next days, the resident experienced significant pain and later swelling and severe leg pain before being sent to the hospital, where a left femur fracture was diagnosed. Surveyors found the facility failed to assess the resident after the fall and failed for several days to seek medical guidance or report a fall that resulted in pain, swelling, and a broken femur, constituting noncompliance with professional standards of practice and the resident’s care plan.
A resident with a history of stroke, hemiplegia, and significant mobility limitations experienced an assisted fall during a wheelchair-to-bed transfer performed by two CNAs, during which her leg slipped forward and she was lowered to the floor. The resident reported hearing a crack, crying on the floor, and later having severe pain and difficulty sleeping, while her roommate observed her curled up in bed, crying and complaining of a painful fall. Despite facility policy that all falls be reported to the DON, the fall was not promptly reported or fully assessed; staff accounts conflicted about whether an LVN had been notified and whether a head-to-toe assessment was attempted. Over the next days, the resident’s documented pain scores increased, and only after severe pain and visible swelling were noted by nursing leadership was she sent to the hospital, where a left femur fracture was diagnosed, and her family was informed of the fall. This sequence reflects a failure to follow fall protocols, ensure timely nursing assessment, and uphold the resident’s right to dignified care and communication.
A male resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly touched female residents inappropriately, including incidents in hallways, the dining room, and resident rooms. Despite staff awareness and documentation of these behaviors, the facility did not implement effective supervision or interventions to prevent further abuse, resulting in multiple incidents involving vulnerable residents with cognitive impairments.
A male resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly inappropriately touched two female residents with severe cognitive impairment. Staff were not consistently informed or trained on the resident's behaviors or required interventions, and incidents were not always reported immediately to the Administrator. Care plans were not promptly updated, and supervision measures were inconsistently applied, resulting in repeated incidents of sexual abuse.
A male resident with a history of sexually inappropriate behaviors was involved in multiple incidents of sexual abuse against two female residents with severe cognitive impairment. Despite repeated incidents, the facility did not consistently update care plans, inform staff of necessary interventions, or provide adequate supervision, resulting in ongoing risk of abuse and lack of thorough investigation.
A resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly touched other residents inappropriately over several months. The care plan was not adequately updated after each incident, and staff, including LVNs and CNAs, were not consistently informed or trained on interventions to prevent further occurrences. This lack of timely care plan revision and insufficient staff awareness resulted in ongoing risk to other residents.
A resident with dementia and depression was not informed by facility staff of a visitation restriction placed on her family member due to safety concerns involving staff. The facility did not document or communicate the restriction to the resident, instead relying on another family member to relay the information, and did not follow its own policy requiring notification of visitation rights and restrictions.
A resident with severe cognitive impairment and total dependence for care was found on the floor by her roommate, displaying signs of injury including head bleeding and hip pain. Staff failed to immediately assess her condition, did not administer ordered PRN pain medication, and moved her from the floor to the bed before calling 911, contrary to care plan and physician orders. The resident sustained a hip fracture and head injury, and was left unsupervised with her roommate after the incident.
A resident with severe cognitive impairment and hemiplegia was found on the floor after a fall and complained of hip pain. Staff lifted the resident from the floor to the bed without following proper assessment and transfer protocols, resulting in multiple injuries including a head laceration and femur fracture. Staff interviews revealed inconsistent understanding and application of fall and transfer procedures, and the transfer was not performed according to facility policy.
Two residents did not receive medications as ordered due to failures in medication administration and communication. One resident was given aspirin without a physician's order following a head injury, and another did not receive prescribed IV antibiotics for a UTI due to miscommunication between the facility and dialysis center, as well as incomplete follow-up and documentation by staff.
The facility failed to maintain proper infection control practices, as a CNA did not follow hand hygiene protocols during incontinence care for a resident, and a wound care nurse neglected hand hygiene before and after assessing a resident's heels. Both staff members acknowledged the importance of hand hygiene but did not adhere to the facility's policy.
A resident with dementia and other medical conditions was not afforded privacy during Foley catheter care, as CNAs failed to close the blinds, compromising the resident's dignity. The facility's policy and care plan emphasized the importance of privacy, which was not adhered to during this incident.
A resident with multiple health issues, including dementia and diabetes, developed a pressure ulcer on the right heel due to the facility's failure to offload the heels as per the care plan. Despite having heel protectors available, staff did not use them, and the resident's heels were not offloaded during care, leading to an unstageable pressure wound. Interviews confirmed that it was the responsibility of both nursing staff and CNAs to prevent such injuries, as per facility policy.
A resident with a history of urinary tract infections and other health issues did not receive proper incontinence care, as a CNA failed to follow the facility's perineal care policy. This included not opening the labia to clean and not wiping around the buttocks, which was confirmed by the DON as a risk for infections.
A resident requiring continuous oxygen therapy had an unlabeled oxygen humidifier, contrary to facility policy. The resident, with chronic obstructive pulmonary disease and other conditions, was observed with the unlabeled equipment. An LVN admitted responsibility for ensuring proper labeling, which should be checked every shift. The facility's policy requires humidifiers to be dated and replaced every ten days.
The facility failed to properly label medications, including eye drops and nasal sprays, on medication carts and in the medication room. Observations revealed that several medications were opened but not labeled with resident names or dates, contrary to facility policy. The DON confirmed that all medications must have pharmacy labels with open dates to ensure effectiveness, and improperly labeled medications must be discarded.
Failure to Assess and Report Assisted Fall Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively intact resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices following an assisted fall. The resident was an older female with multiple significant diagnoses, including hypertension, type 2 diabetes, anemia, stroke with left-sided hemiplegia/hemiparesis, cognitive communication deficit, muscle weakness, morbid obesity, and high fall risk. Her MDS showed she required substantial to total assistance for bed mobility and transfers, including dependence on staff for sit-to-stand and bed-to-chair transfers. Her care plan identified her as at risk for falls related to weakness and hemiplegia and documented the need for assistance with ADLs and transfers. According to interviews and record review, the resident reported that on an evening after dinner she fell during a transfer from wheelchair to bed when two CNAs attempted to assist her. She stated her leg slipped forward, she heard a crack, and the CNAs lowered her to the floor. While on the floor, she reported hollering and crying in pain as the CNAs tried to get her up, during which her leg became caught under the wheelchair and then under the bed. She stated no nurse was called to assess her, and no nurse came to evaluate her for pain or injury at that time. A roommate later reported seeing the resident in bed crying and curled up, saying she had a nasty fall and was in pain, and that the resident continued whining and whimpering for hours. Facility documentation showed no fall entry in the progress notes between the dates surrounding the alleged event, and the incident report later created reflected only that the resident was alert in bed alleging a fall a few days prior, with no specific date and no witnesses. The DON stated she was not notified of the fall when it occurred, despite facility protocol requiring the DON to be called for all falls, and that she only learned of the event days later when the resident complained of pain and swelling in the left leg. The DON’s investigation found that two CNAs had assisted the transfer when the resident slipped to the floor and that they claimed to have reported the fall to a nurse, while the LVN on duty denied being informed of any fall. During the period after the fall and before hospital transfer, documentation showed administration of PRN acetaminophen for pain, but there was no contemporaneous nursing assessment or documentation of a fall, and the family was not informed of the fall until the resident was sent to the hospital, where she was diagnosed with a left femur fracture. The facility’s failure included not promptly assessing the resident after the assisted fall, not documenting the fall in the medical record at the time it occurred, not notifying the DON, physician, or family when the fall happened, and not seeking timely medical guidance despite the resident’s subsequent complaints of pain and later-observed swelling and severe leg pain. The surveyors determined that the facility failed to seek medical guidance or report a fall that resulted in injury, including pain, swelling, and a broken femur, for approximately three days, and that the nurse failed to assess the resident after the fall. These failures were cited as noncompliance with the requirement to provide treatment and care in accordance with professional standards of practice and the resident’s comprehensive assessment and care plan. The report also notes that this deficient practice was identified as Immediate Jeopardy to resident health and safety at a specific time and date, based on the delay in appropriate medical evaluation and treatment following the fall and resulting fracture. The Immediate Jeopardy was later removed, but the facility remained out of compliance at a lower scope and severity while it continued to monitor implementation and effectiveness of its corrective actions. The failures were described as placing residents at risk for delay of appropriate medical treatment leading to pain, discomfort, and death.
Failure to Follow Fall Protocols and Provide Timely Assessment After Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to treat a cognitively intact resident with respect and dignity and to follow fall protocols, including timely nursing assessment and reporting, after an assisted fall. The resident was an older female with a history of stroke resulting in hemiplegia/hemiparesis on the left side, muscle weakness, lack of coordination, morbid obesity, and other neurologic and functional impairments. Her discharge MDS showed a BIMS score of 13/15, indicating she was cognitively intact, and she required extensive assistance for bed mobility and transfers, with helpers doing all the effort or requiring two or more helpers. Her care plan identified her as at risk for falls related to weakness and hemiplegia/hemiparesis. According to the complaint and interviews, the resident experienced an assisted fall during a wheelchair-to-bed transfer performed by two CNAs. One CNA reported that during the transfer the resident began to slip, her leg slipped forward, and she was slowly lowered to the floor. The resident stated she heard a crack, was lowered to the floor, cried while on the floor, and that the CNAs struggled to get her back into bed. She reported significant pain that night, difficulty sleeping, and emotional distress as she replayed the fall in her mind. Her roommate later observed her curled up in bed, crying and whimpering, and reported that the resident said she had a “nasty fall” and was in pain. The roommate stated the resident continued to whine and whimper in bed for hours. The facility did not ensure that the fall was promptly assessed and reported according to protocol. The DON stated that all falls were to be reported to her, but she was not notified until days later, after the resident complained of leg pain. There were conflicting accounts among staff: the CNAs stated they reported the fall to an LVN, while the LVN initially stated she had not been made aware of the fall, then later stated she was contacted by the ADON about a reported fall and was instructed to perform a head-to-toe assessment, which she said the resident refused. The resident’s pain assessments on the MAR showed varying pain scores over the days following the fall, culminating in a severe pain score, and only then was she assessed by nursing leadership, found to have pain and swelling in the left leg, and sent to the hospital where a left femur fracture was diagnosed. The family was not informed of the fall until the day of transfer to the hospital. These actions and inactions demonstrate that the facility did not follow its fall protocols, did not ensure timely nursing assessment after the fall, and did not uphold the resident’s right to dignified care and communication about her condition.
Failure to Prevent Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, resulting in multiple incidents involving a male resident who inappropriately touched female residents on several occasions. The male resident, who had severe cognitive impairment and a history of sexually inappropriate behaviors, was observed by staff touching the breasts and thighs of female residents, some of whom also had severe cognitive impairment and were unable to advocate for themselves. These incidents occurred in various locations within the facility, including hallways, the dining room, and resident rooms, and were witnessed by CNAs and reported to nursing staff. Despite the initial incident of sexual abuse, the facility did not implement effective measures to prevent further occurrences. The male resident continued to have access to vulnerable female residents, and additional incidents of inappropriate touching were documented over several months. Staff interviews revealed that the male resident would sometimes offer snacks to other residents as a means of interaction, and that supervision and monitoring were inconsistent. Care plans for the involved residents noted their cognitive impairments and wandering behaviors, but interventions to prevent abuse were not adequately enforced or updated in a timely manner following each incident. Documentation and interviews indicated that staff were aware of the male resident's behaviors and the risks posed to other residents, yet failed to consistently separate him from potential victims or provide sufficient supervision. The facility's policies required protection from abuse, but these were not effectively implemented, resulting in repeated incidents. The failures placed residents at risk of abuse, mental anguish, and fearfulness, as confirmed by the survey findings.
Failure to Prevent and Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse, specifically sexual abuse, among residents. Over a four-month period, a male resident with severe cognitive impairment and a history of sexually inappropriate behaviors inappropriately touched at least two female residents, both of whom also had severe cognitive impairment and were unable to advocate for themselves. Despite documented incidents of inappropriate touching, including fondling of breasts and inner thighs, the facility did not consistently update care plans, provide adequate supervision, or ensure staff were informed of the resident's behaviors and necessary interventions. Staff members, including LVNs and CNAs, were not consistently aware of the male resident's history of sexual behaviors or the interventions required to prevent further incidents. Several staff interviews revealed a lack of specific training or in-service education regarding the resident's behaviors and the facility's abuse prevention protocols. In some cases, staff did not immediately report incidents of abuse to the Administrator as required by policy, and there was confusion about the appropriate steps to take following such incidents. The care plans for the involved residents were not always updated promptly to reflect new risks or interventions after incidents occurred. The facility's failure to separate residents after incidents, provide 1:1 supervision when indicated, and ensure all staff were aware of and trained on abuse prevention measures contributed to repeated occurrences of sexual abuse. The male resident continued to have access to vulnerable female residents, and interventions such as increased supervision or room changes were inconsistently applied. These failures placed residents at risk of further abuse, mental anguish, and fearfulness, as documented by surveyor observations, interviews, and record reviews.
Removal Plan
- Facility Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator.
- Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made.
- The ED/ DON/ Social Worker and RN, Clinical Resource will be trained on Abuse/ Neglect Investigation and Reporting by Risk Management Resource, including how to conduct a thorough investigation to implement measures to prevent further incidents and protect other residents.
- Training and knowledge checks (Post-Test) were initiated with all staff on shift regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by RN, Clinical Resource. Training & Knowledge Check including Post-Test will be completed with all staff. Any remaining staff member(s) pending Training & Knowledge check will complete the Training & Knowledge Check including Post-Test prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks.
- Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan.
- This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.
- DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s)) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. This audit was completed and no additional discrepancies were identified.
- Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents.
- Safe-Surveys were conducted by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident(s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility to report.
Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of sexual abuse and did not take adequate steps to prevent further potential abuse for two residents with severe cognitive impairment. Over a four-month period, a male resident with a history of sexually inappropriate behaviors was involved in multiple incidents of sexual abuse against two female residents and an unidentified female resident. Despite documented incidents where the male resident was observed touching female residents inappropriately, the facility did not consistently implement or update interventions to prevent recurrence, nor did they ensure that all staff were informed of the resident's behaviors and the necessary supervision measures. Record reviews and staff interviews revealed that the male resident had a documented history of sexually inappropriate behaviors, including touching female residents' breasts and inner thighs. Staff members reported that they were not always informed of the resident's history or the interventions required to prevent further incidents. In several cases, staff intervened only after witnessing inappropriate behavior, and there was a lack of evidence that care plans were updated or that supervision was consistently provided following each incident. Additionally, some incidents were not reported or investigated according to the facility's abuse prevention policy, and staff training on specific interventions for the resident was lacking. The affected female residents had severe cognitive impairment and were unable to advocate for themselves or recall the incidents. The facility's failure to thoroughly investigate all allegations, update care plans, and ensure staff were adequately trained and informed resulted in repeated incidents of sexual abuse. The lack of consistent supervision and failure to implement protective measures placed residents at risk of further abuse, mental anguish, and fearfulness.
Removal Plan
- Facility Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator.
- Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made.
- Training and knowledge checks (Post-Test) were initiated with all staff on shift regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s).
- Training & Knowledge Check including Post-Test will be completed with all staff. Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks.
- Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan, as additional intervention tool to ensure timely interventions/investigation(s) are implemented.
- DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s)) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. No additional discrepancies were identified.
- Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents.
- This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.
- DON/ designee/ Cluster Partners will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated appropriately.
- DON/ Designee will review the 24-[NAME]
Failure to Update and Implement Comprehensive Care Plan for Resident with Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address the nursing, mental, and psychosocial needs of a resident who exhibited sexually inappropriate behaviors. Despite multiple incidents of the resident inappropriately touching other residents over a four-month period, the care plan was not revised in a timely or adequate manner to reflect new interventions or increased supervision. Nursing staff, including LVNs and CNAs, were not consistently aware of or trained on specific interventions to prevent further incidents, and several staff members reported not being informed of the resident's behaviors or the necessary preventive measures. The resident in question had a history of severe cognitive impairment, mild depression, and diagnoses including dementia and adjustment disorder with anxiety. Multiple documented incidents occurred in which the resident touched female residents inappropriately, often targeting those with poor cognition who could not advocate for themselves. Staff responses to these incidents varied, with some staff intervening immediately and others unaware of the resident's behavioral history or required interventions. The care plan was only sporadically updated, and interventions such as 1:1 supervision were inconsistently implemented or communicated among staff. Interviews with staff revealed gaps in communication, training, and care plan updates following each incident. Some staff were unaware of the resident's behavioral risks until after witnessing an incident, and others did not review the care plan or receive specific in-services related to the resident's behaviors. The lack of a coordinated, updated care plan and insufficient staff awareness placed other residents at risk of not having their behavioral needs met, potentially leading to further abuse and emotional distress.
Failure to Inform Resident of Visitation Rights and Restrictions
Penalty
Summary
The facility failed to inform a resident of her visitation rights and the related facility policy and procedures, including any safety restrictions or limitations, the reasons for such restrictions, and to whom the restrictions applied. This deficiency was identified for one resident who was not notified by the facility when her family member was no longer allowed to visit due to safety concerns. The resident, who had diagnoses of dementia, adjustment disorder, and depression, reported feeling lonely and isolated, and stated she missed her family member, who had not been allowed to visit for several months. She also stated she never received any policy or notice about the visitation restriction. Interviews with facility staff, including the former DON, social worker, administrator, and ADON, revealed that the family member was restricted from visiting after incidents involving inappropriate behavior toward a staff member, which led to police involvement. The administrator and other staff members confirmed that the decision to restrict visitation was made for staff safety, but there was no documentation in the resident's medical record regarding the restriction, nor evidence that the resident was formally informed by facility staff. Instead, it was believed that another family member had informed the resident about the restriction. The facility's own policy required informing residents and/or their representatives of their visitation rights and any clinical or safety restrictions. However, the administrator acknowledged that the resident rights policy was not reviewed or followed when addressing the visitation issue, and the incident was handled primarily from the perspective of staff safety. There was no documentation or formal communication to the resident regarding the restriction, resulting in the resident being unaware of her rights and the reasons for the limitation.
Failure to Provide Person-Centered Care and Proper Response After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, and total dependence for activities of daily living was found on the floor by her roommate. Staff failed to immediately assess and respond to the resident's condition according to her care plan and physician orders. The resident was observed to be face down, bleeding from the head, and later complained of hip pain. Despite these symptoms, staff picked the resident up from the floor and placed her in bed before calling 911, potentially causing further harm. The resident's care plan included interventions for fall risk, pain management, and monitoring for complications due to her medical history, which included a stroke, hypertension, and use of anticoagulants. However, staff did not follow these interventions. The resident's verbal complaints of pain were not adequately addressed, and her prescribed PRN pain medication was not administered as ordered. Additionally, the staff left the resident and her roommate alone in the room after the incident, contrary to expectations for supervision and safety. EMS documentation and hospital records confirmed that the resident sustained a right femoral fracture, head laceration, and brain bleed. The EMS report noted that the resident was found on the bed with no sheets, indicating she had been moved from the floor by staff prior to their arrival. Interviews with staff revealed inconsistencies in the assessment and response to the fall, with some staff unsure of the appropriate actions to take and others acknowledging that the resident's position and complaints of pain were not properly addressed before moving her. The failure to follow established protocols and care plans resulted in significant injury and ultimately the resident's death.
Failure to Ensure Safe Transfer After Resident Fall Resulting in Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure a resident was free from accident hazards and received adequate supervision and assistance during a transfer after a fall. The resident, an elderly female with a history of stroke, severe cognitive impairment, hemiplegia, and total dependence for activities of daily living, was found face down on the floor. Despite her verbal complaint of hip pain, staff lifted her from the floor and placed her in bed without proper precautions, potentially causing further harm. The resident sustained multiple injuries, including a laceration above the eye, a closed head injury, and a broken femur. Interviews and record reviews revealed that staff did not follow appropriate assessment and transfer protocols. Staff acknowledged hearing the resident complain of hip pain but proceeded to move her, with one staff member later admitting that moving the resident could have caused further injury. The facility's policy required a two-person lift with specific support for the head, torso, and hips, but staff described lifting the resident by her head, legs, and ankles, which was not in accordance with policy. Further interviews with nursing and administrative staff indicated inconsistent understanding and application of fall and transfer protocols. Some staff believed it was acceptable to move the resident after a basic assessment, while others stated that a resident with pain or possible injury should not be moved until EMS arrived. Documentation of assessments and vital signs was incomplete, and there was confusion about the correct procedure for transferring a resident after a fall, especially when injury was suspected.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for two residents. For one resident with a history of stroke, hypertension, and severe cognitive impairment, a nurse administered a non-scheduled aspirin as a PRN pain medication without a physician's order, despite the resident having a known head injury. The resident's medication administration record did not reflect an order for PRN aspirin, and facility policy required medications to be administered only as ordered by the physician and documented accordingly. For another resident with diagnoses including anemia, renal failure, dementia, and a history of chronic urinary tract infections (UTIs), the facility failed to ensure the resident received prescribed IV antibiotic therapy as ordered by the physician. The resident was discharged from the hospital with orders for Tobramycin to be administered post-dialysis, but due to miscommunication between the facility, dialysis center, and hospital, the medication was not administered. Facility staff became aware that the medication had not been given only after discovering the initial dose was still in the refrigerator days later. Attempts to administer the medication at the facility were unsuccessful due to the resident's refusal of IV insertion, and there was no evidence that the nephrologist was consulted for alternative arrangements in a timely manner. Interviews and record reviews revealed that staff did not consistently communicate medication refusals or administration issues to the resident's family or the prescribing physicians. Documentation was incomplete regarding the administration or refusal of medications, and there was a lack of follow-up to ensure the resident received necessary antibiotic therapy. These failures resulted in residents not receiving medications as ordered and not having medication administration properly documented, as required by facility policy.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices by staff members. Specifically, CNA W did not follow proper hand hygiene protocols during incontinence care for a resident. CNA W was observed using the same gloves to handle clean wipes, apply barrier cream, and change the resident's brief without washing hands before or after the procedure. This resident, who was moderately cognitively impaired and required extensive assistance with activities of daily living, was at risk due to these lapses in infection control. Additionally, the wound care nurse did not practice hand hygiene before and after assessing another resident's heels. The nurse entered the resident's room, applied gloves without washing or sanitizing hands, and left the room without performing hand hygiene after removing the gloves. Both staff members acknowledged the importance of hand hygiene in preventing infections, yet failed to adhere to the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent the spread of infections.
Failure to Ensure Privacy During Catheter Care
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident during Foley catheter care. The resident, a male with a history of dementia, urinary retention, acute kidney failure, hydronephrosis, benign prostatic hyperplasia, and diabetes mellitus, was observed in bed with an indwelling Foley catheter. During a scheduled catheter care session, two CNAs provided care without closing the blinds to the resident's window, thereby compromising the resident's privacy. The resident's care plan included interventions to promote dignity by ensuring privacy during personal care. However, during the catheter care, the CNAs did not adhere to this aspect of the care plan. An interview with one of the CNAs revealed an acknowledgment of the oversight, rating her performance as 7.5 out of 10 due to the failure to close the blinds. The Director of Nursing confirmed that privacy should be provided during care to promote dignity, aligning with the facility's policy on dignity, which emphasizes maintaining and protecting resident privacy during personal care.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to the development of a pressure ulcer on the resident's right heel. The resident, a male with multiple diagnoses including dementia, diabetes mellitus, and impaired mobility, was admitted without any pressure ulcers. However, the care plan identified a potential for pressure ulcer development due to impaired mobility, with interventions such as weekly skin assessments and floating heels as tolerated. Despite these interventions, the resident developed an unstageable pressure wound on the right heel, measuring 6cm x 7.5cm, which was observed during a care session. During an observation, the resident was found in bed without his heels being offloaded, and no heel protectors were in use, despite the presence of heel protectors in the resident's drawer. Interviews with the CNA and RN revealed that it was the responsibility of both the nursing staff and CNAs to ensure the resident's heels were offloaded to prevent pressure injuries. The facility's policy on skin and wound management emphasized the importance of preventing new pressure injuries and providing necessary treatment for existing ones, which was not adhered to in this case.
Inadequate Incontinence Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, a female with a history of urinary tract infection, cerebrovascular disease, muscle wasting, type 2 diabetes, and morbid obesity, was always incontinent of bowel and bladder and required extensive assistance with all activities of daily living. During an observation, a CNA did not perform proper perineal care by failing to open the labia to clean and not wiping around the buttocks after an incontinent episode. The CNA, despite being deemed competent in performing perineal care, acknowledged the importance of proper cleaning to prevent infections. The facility's policy on perineal care, which includes specific steps for cleaning the perineal and rectal areas, was not followed. The Director of Nursing confirmed that not adhering to these procedures placed residents at risk of urinary tract infections.
Failure to Label Oxygen Humidifier
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as evidenced by the lack of proper labeling on the resident's oxygen humidifier. The resident, a [AGE] year-old with multiple medical conditions including chronic obstructive pulmonary disease and dementia, was observed with an unlabeled oxygen humidifier. The resident's care plan and physician's orders specified the need for continuous oxygen therapy and regular changes of the oxygen tubing and humidifier bottle. However, the humidifier was not labeled with the date it was last changed, which is a requirement according to the facility's policy. During an interview, a Licensed Vocational Nurse (LVN) acknowledged that the resident often changes the humidifier independently, with supplies provided by family members. Despite this, the LVN admitted that it was her responsibility to ensure the humidifier was labeled correctly, which should have been checked every shift. The facility's policy, last revised in 2007, mandates that oxygen therapy equipment be maintained in a clean and sanitary manner, with pre-filled humidifiers dated and replaced every ten days or as needed. This oversight in labeling could potentially affect the quality of oxygen support provided to residents.
Improper Labeling of Medications in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles, which included the appropriate accessory and cautionary instructions and expiration dates. During an observation, it was found that the medication carts for Halls 300 and 400 contained several medications, such as Dorzol/Timolol solution, Latanoprost solution, Fluticasone Propionate nasal spray, and various eye drops, that were opened but not labeled with the resident's name or dated. This oversight was confirmed during an interview with a medication aide (MA A), who acknowledged that opened medications should be dated and labeled with the resident's name to determine when they should be discarded. Additionally, the medication room refrigerator contained vials of Tuberculin Purified Protein Derivative (PPD) that were open but not dated. The Director of Nursing (DON) confirmed that all medications must have pharmacy labels, including the open date, to ensure their effectiveness. The lack of proper labeling and patient identifiers on the medications observed was inconsistent with the facility's labeling practices, as outlined in their policy. The DON stated that medications lacking patient names could no longer be used and must be discarded, as the use of multidose PPD containers without an open date could lead to medication errors.
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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.
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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