Mountain View Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 1600 Muchison Rd, El Paso, Texas 79902
- CMS Provider Number
- 455471
- Inspections on file
- 44
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 15 (2 serious)
Citation history
Health deficiencies cited at Mountain View Health & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to develop and implement comprehensive, person-centered care plans addressing smoking for multiple residents who used tobacco. Several residents with documented nicotine dependence, significant mobility limitations, cardiopulmonary disease, cognitive impairment, seizure disorder, neuropathy, and visual impairment were smoking without individualized smoking risk assessments or care plan interventions for supervision, assistance to the designated smoking area, or lighter and cigarette control. One resident with lower-extremity amputations and impaired mobility smoked in the designated area without documented smoking supervision or hazard mitigation, while another with CHF, COPD, and schizophrenia reported smoking with staff-provided cigarettes and lighting but no known safety assessment. A cognitively intact resident’s care plan was only updated on the survey date to include smoking status and supervision needs, and another resident with seizures and moderate cognitive impairment was observed smoking after starting two weeks earlier, despite no smoking status or assessment documented in her record. Additional residents were found with cigarettes and, in one case, a lighter in their rooms, and staff, including a CNA and the Activities Director, reported concerns that smoking assessments were not consistently completed and that facility policies for smoking safety and control of smoking materials were not being followed.
The facility failed to consistently assess and manage residents’ smoking behaviors and to promptly report a fall, resulting in noncompliance with professional standards and care plans. Several residents with nicotine dependence, chronic smoking histories, cognitive impairment, mobility limitations, and serious cardiorespiratory conditions smoked without documented safe smoking assessments, clear supervision requirements, or individualized fire-safety interventions in their care plans. Some residents possessed cigarettes and lighters in their rooms despite facility policy requiring smoking materials to be secured and supervised, and staff responsible for overseeing smoking did not know which residents had completed smoking assessments. In a separate incident, a resident with a recent hip fracture, severe cognitive impairment, legal blindness, and a history of repeated falls fell during a transfer, and the CNA who witnessed the fall assisted the resident back to bed but did not immediately notify a nurse or the DON, contrary to facility fall and event-reporting policies.
Multiple residents who smoked or began smoking were not consistently assessed or care planned for safe smoking, and smoking materials were not always controlled according to facility policy. One resident with significant mobility and cognitive communication deficits and another with COPD and respiratory failure smoked in the designated area without documented safe smoking assessments or individualized supervision and safety interventions. A resident with bilateral BKAs, muscle weakness, and on anticoagulants was care planned not to keep smoking materials in the room, yet was found with a pack of cigarettes in his jacket. A cognitively impaired resident with seizure disorder, neuropathy, and impaired vision began smoking after admission, obtained cigarettes from other residents, and had no smoking status documented, no smoking assessment, and no smoking-related care plan interventions. Another resident with dementia and on anticoagulants was found with cigarettes and a lighter in his nightstand despite documentation that smoking materials were to be kept at the nurses’ station and a safe smoking assessment only being completed by the surveyor. Staff interviews confirmed they did not always know who had completed smoking assessments and that facility smoking policies and assessment requirements were not consistently followed.
A resident with multiple chronic conditions and moderately impaired cognition, but documented independent decision-making ability, requested a soda late at night. A CNA refused the request, stating it was too late and offering water instead, despite no care plan restrictions on soda or other beverages. The resident reported feeling angry and that his preferences were not respected, and a family member’s room video confirmed the CNA’s refusal. Another CNA present believed the refusal was wrong, and both the DON and Administrator acknowledged that residents have the right to choose food and beverages unless medically contraindicated, consistent with the facility’s resident rights policy on self-determination.
A resident with severe cognitive and physical impairments, requiring total care and two-person assistance for repositioning, was injured when a CNA attempted to reposition the resident alone, contrary to the documented care plan. The resident fell from the bed, sustaining a brain bleed, facial laceration, and fractures. Staff interviews and records confirmed the care plan was not followed, leading directly to the resident's injuries.
A resident who was totally dependent on staff for all care and required two-person assistance for repositioning was injured when a CNA attempted to reposition him alone, contrary to the care plan. The resident fell from the bed, sustaining a brain bleed, laceration, and facial fractures. Staff interviews confirmed the CNA was aware of the care plan requirements but did not request help or follow protocols, leading to the incident.
A resident with a chronic pressure ulcer was found without a required dressing on the wound, despite care plan orders and staff training to report missing dressings. Both a CNA and an LVN observed the absence of the dressing but did not notify nursing staff, and the DON confirmed this was not acceptable practice. Facility policy required routine skin assessment and prompt reporting of abnormalities.
Staff failed to follow Enhanced Barrier Precautions during wound care for a resident with a chronic pressure ulcer, as both an LVN and a CNA did not perform hand hygiene or use required PPE such as gowns and gloves before providing care, despite EBP signage and prior training. The resident, who was severely cognitively impaired and had multiple wounds, did not have a wound dressing in place, and this was not reported as required. The facility's infection control protocols were not followed during the observed care.
A resident with complex medical conditions and a preliminary positive AFB result was not placed in appropriate isolation upon return from the hospital. Facility staff did not consistently use PPE or follow airborne precautions, and the resident participated in group activities. Despite recommendations from the health department, the facility did not implement post-exposure interventions or monitor potentially exposed individuals, resulting in a failure to follow infection control policies.
A resident with a history of substance abuse and traumatic brain injury was admitted and subsequently readmitted without receiving the required admission packet or notice of resident rights. Staff interviews confirmed that neither the resident nor the family member received this information due to behavioral incidents and lack of communication among staff responsible for admissions. Facility policy requires provision and acknowledgment of these documents, but this process was not followed, and the necessary documentation was missing from the resident's record.
A resident with a history of traumatic brain injury and behavioral health issues was admitted and re-admitted without the required admission packet or signed agreement. Due to behavioral incidents and lack of clear communication, neither the resident nor the family received information on resident rights or facility policies, as confirmed by staff interviews and record review.
A resident with a history of substance abuse and cognitive impairment was discharged without receiving the required 30-day written notice, and the responsible party was only verbally informed. The Office of the State LTC Ombudsman was not notified of the discharge at the time it occurred, contrary to regulatory requirements. Facility staff confirmed that the standard notification procedures were not followed in this instance.
A resident with an indwelling catheter was found with their catheter bag lying on the floor rather than being hooked to the bed, as required by facility policy and care plans. Staff interviews confirmed that catheter bags should not touch the floor due to infection control concerns, and all staff acknowledged responsibility for ensuring proper placement. The resident's habit of unhooking the bag when repositioning contributed to the issue, but the deficiency was observed during a survey.
A resident with a history of substance abuse and traumatic brain injury exhibited acute behavioral symptoms, including aggression and suicidal ideation. Despite escalating behaviors, staff did not utilize the on-call psychiatric service for evaluation or intervention, relying instead on redirection and 1:1 supervision. The facility's behavioral management policy and care plan were not followed, and multiple staff confirmed that psychiatric support was not sought.
A resident with advanced dementia and hemiplegia, requiring a mechanical lift and two-person assistance for transfers, was injured when a hospice aide attempted to transfer him without the required equipment or help, leading to a fall and cervical fracture. The hospice and facility staff did not coordinate care plans or consistently communicate transfer requirements, and the hospice aide proceeded with the transfer alone after being unable to locate the lift sling. The facility did not have a fall prevention policy in place, and hospice staff were not routinely included in care plan meetings.
A hospice aide failed to use a mechanical lift and two-person assist when transferring a resident with severe cognitive and mobility impairments, resulting in a fall that caused a head laceration and cervical fracture. The resident's care plan and physician orders required total assistance with transfers, but the aide did not follow these protocols, and there was a lack of coordination between hospice and facility care plans. The incident highlighted gaps in communication and adherence to transfer procedures.
A resident with advanced dementia and hemiplegia, requiring total assistance and a mechanical lift for transfers, was transferred by a hospice CNA without the required equipment or assistance, resulting in a fall and serious injury. The hospice care plan did not reflect the need for a mechanical lift, and hospice staff were not consistently included in care planning or provided with updated facility care plans, leading to a lack of coordination and communication between facility and hospice staff.
A resident with advanced dementia and hemiplegia, requiring total assistance and a mechanical lift for transfers, was transferred by a hospice aide without the required equipment or two-person assistance, resulting in a fall and serious injury. The facility did not investigate the incident or coordinate care plans with hospice staff, failing to follow its own abuse/neglect prevention policies.
A resident with advanced dementia and significant mobility limitations was transferred by a hospice aide without the required mechanical lift and two-person assistance, resulting in a fall that caused a head laceration and cervical fracture. The facility did not initiate a timely or thorough investigation into the incident, and there was poor coordination between facility and hospice staff regarding the resident's care plan and transfer needs.
A resident with a history of cardiac and syncopal episodes alleged that a night nurse matching the description of an LVN struck him on the chest. Despite facility policy requiring immediate suspension of any staff member identified as an alleged perpetrator of abuse, the LVN was not promptly suspended after being identified. Staff interviews and record reviews revealed inconsistencies and lack of documentation regarding the suspension, and the LVN continued to work during the investigation, contrary to policy.
A resident with impaired cognition and visual impairment reported missing money from his wallet. Although staff were informed and an internal investigation began, the DON and ADON did not immediately notify the administrator or report the incident to the state agency as required by policy and law, resulting in a deficiency for failure to timely report suspected misappropriation of property.
The facility failed to ensure call lights were within reach for two residents, both with cognitive impairments, leading to a deficiency in accommodating their needs. One resident was found without a call light connected, while another had the call light on the floor, out of reach. This placed them at risk of unmet needs due to their inability to contact staff.
The facility failed to provide a private area for residents to make phone calls, compromising their privacy rights. A resident with diabetes and schizoaffective disorder was observed making a call in a public hallway, while another resident with Parkinson's and bipolar disorder used the phone at the nurses' station. Both expressed a need for more privacy. Staff interviews confirmed the absence of a designated private area, and attempts to provide one were unsuccessful, violating the facility's policy on resident rights.
A deficiency was identified involving a breach of privacy and confidentiality for residents' personal and medical records. The report highlights that residents have the right to access telephones, including TTY and TDD services, and a private space for calls. Two residents were mentioned in relation to privacy concerns, indicating a failure to ensure their communications and personal information remained confidential.
A dietary aide at an LTC facility used a pitcher placed on an unsanitized cart to serve tea, risking cross-contamination. Despite training on food safety, the aide's actions violated sanitation policies, potentially leading to foodborne illnesses. The unsanitized cart had visible dirt, and the facility's administration acknowledged the risk of bacterial infections from such practices.
Two incidents of infection control lapses were identified in a facility. A CNA failed to change gloves during incontinent care for a resident with dementia, while an LVN and ADON neglected to use required PPE during PEG tube medication administration for a resident on EBP. Both incidents were attributed to nervousness and oversight, despite existing training and signage.
A facility failed to change a resident's PICC line dressing as ordered, posing a risk of infection. The resident, with a history of sepsis and other conditions, had a PICC line requiring dressing changes every seven days. Despite being due for a change, the dressing remained unchanged, causing discomfort to the resident. Staff interviews confirmed the oversight and acknowledged the potential risk of infection.
A resident with moderately impaired cognition was found with unauthorized over-the-counter medications at their bedside, without an assessment for self-administration. The facility failed to provide adequate pharmaceutical services, as there were no orders for these medications, and the issue was not reported to management in a timely manner. Staff interviews revealed lapses in monitoring and adherence to the facility's policy on medication safety.
The facility failed to secure a treatment cart, leaving it unlocked and unsupervised with needles, dressings, and medicated ointments accessible. LVN A admitted to forgetting to lock the cart while attending to a resident with a doctor. The DON and Administrator confirmed the expectation for carts to be locked when unattended, as per facility policy.
A resident with a PICC line had their dressing change inaccurately documented by an RN, who signed off on the task without completing it. The resident's care plan required regular dressing changes, but an observation revealed the dressing was not updated as documented. Interviews with facility staff confirmed the error and highlighted the importance of accurate documentation to prevent inadequate care.
A resident with mobility issues had conflicting transfer instructions in their care plan, leading to inconsistent care and a fall incident. The care plan specified both a two-person Hoyer lift and a one-person transfer, causing confusion among staff. Interviews revealed that staff were unaware of the correct procedure, posing a risk of injury.
A resident in a long-term care facility, requiring a two-person transfer with a mechanical lift, was improperly transferred by a single CNA using a gait belt, leading to a fall and subsequent pain. The incident was not reported to nursing staff, and the resident's care plan contained conflicting instructions. Interviews revealed a lack of communication and adherence to the care plan, contributing to the deficiency.
A facility failed to ensure residents were free from physical restraints, as a resident with severe cognitive impairment was found with full bed rails without proper consent, physician's order, or care plan. The bed, provided by Hospice, was used for about a month without necessary documentation or authorization.
The facility failed to maintain an infection prevention and control program for a resident isolated for Covid-19. Despite training and clear signage, staff did not keep the resident's door closed, increasing the risk of cross-contamination and infection. The resident had severe cognitive impairment and multiple health conditions, and the facility's policy required doors to be closed for Covid-19 isolated rooms.
The facility failed to ensure proper catheter care for two residents, leading to risks of infection and catheter trauma. One resident was observed without a catheter leg strap, and another had a drainage bag lying on the floor and no catheter strap, contrary to their care plans and physician orders.
Failure to Develop and Implement Comprehensive Smoking Safety Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans addressing smoking for multiple residents who used tobacco. The facility’s own policy required development of a comprehensive care plan within seven days of the comprehensive assessment, with ongoing review and revision based on changing needs. Record review showed that several residents had documented nicotine dependence or reported smoking, yet their care plans did not include specific smoking-related problem statements, risk assessments, or interventions such as supervision, designated smoking locations, lighter control, or fire prevention strategies. Instead, care plans focused on other medical conditions and, in some cases, only included general education about the adverse effects of tobacco without individualized smoking safety measures. For one male resident with osteomyelitis, multiple amputations, peripheral vascular disease, CAD, DM2, impaired mobility, and chronic tobacco use, the admission MDS documented nicotine dependence and significant physical limitations, including a left below-knee amputation and toe amputations that impaired safe ambulation to and from the smoking area. His care plan addressed hypertension, diabetes, anticoagulant therapy, impaired cognition, ADL self-care deficit, and enhanced barrier precautions, and included tobacco education, but did not include smoking supervision interventions, assistance to the designated smoking area, lighter control, or individualized hazard mitigation. This resident reported that he smoked in the designated area, began smoking about a week after admission, did not know if the facility had evaluated him for smoking safety, and did not recall being educated on the facility’s smoking policies or the need to notify staff when he wished to start smoking. During observation, a CNA lit his cigarette, noted his hand tremors, and asked if he needed help, indicating concern about his ability to smoke safely. Another male resident had extensive cardiopulmonary and psychiatric diagnoses, including CHF, CKD, pleural effusion, nicotine dependence, atherosclerotic heart disease, respiratory failure with hypoxia, pneumonia, HTN, anemia, and schizophrenia. His quarterly MDS and care plan addressed CHF, COPD, oxygen therapy, monitoring for respiratory distress, lab monitoring, fall precautions, skin integrity, antidepressant monitoring, and pain, but did not include a smoking safety assessment or smoking-related interventions. He stated he smoked in the designated area, that staff provided and lit his cigarettes, and that he did not know if he had been assessed to smoke safely. A female resident with intact cognition (BIMS 15) had her care plan updated only on the survey date to reflect that she was a smoker and required constant supervision while smoking, with interventions for designated smoking area use, removal of smoking materials from her room, and monthly safe smoking assessments. She reported that staff kept her cigarettes and lighter and were responsible for lighting her cigarettes. A female resident with seizure disorder, DM2 with hyperglycemia, bipolar disorder, metabolic encephalopathy, anxiety, diabetic neuropathy, impaired vision, chronic pain, and other conditions had a history and physical that documented denial of tobacco use and no documentation identifying her as a smoker. Her MDS showed moderately impaired cognition (BIMS 12), supervision needs for eating, transfers, and toileting, and impaired vision requiring corrective lenses, but did not document smoking status or a smoking assessment. Her care plan addressed HTN, diabetes, diuretic therapy, impaired vision, depression, and ADL self-care deficit, and included education on adverse effects of tobacco, but lacked a specific smoking problem statement, risk assessment, or interventions for supervision or safe smoking location. She was later observed sitting in the smoking area with other residents who were smoking and stated she had started smoking about two weeks earlier, obtained cigarettes from other residents, and did not know if she had been evaluated for safe smoking or the facility’s smoking rules beyond needing to go outside. Additional observations showed other residents possessing cigarettes and, in one case, a lighter in their rooms. One resident admitted to being a smoker, showed a pack of cigarettes in his jacket pocket, and stated he was supposed to turn them in to the facility for safekeeping, was aware of the policy that residents should not keep such items, and denied having a lighter or matches. Another resident stated he did not know he needed to inform the facility that he smoked and did not believe he had been evaluated for safe smoking; he knew he could not smoke inside and had to use the designated area. This resident had a pack of cigarettes and a lighter in his nightstand and acknowledged he knew he needed to give smoking equipment to staff, explaining that the items had been given to him by a family member the previous day. Staff interviews confirmed that cigarettes and lighters were supposed to be kept in a locked box, that staff supervised residents during smoking times, and that some staff were concerned that residents with tremors and poor hand control might not have appropriate smoking assessments. The Activities Director acknowledged the facility was not following its policies and procedures for resident safety and that residents having lighters in their rooms could result in fire hazards, while the facility’s comprehensive care planning policy required person-centered care plans addressing identified needs from the assessment, including review and revision after each MDS assessment.
Failure to Implement Safe Smoking Practices and Timely Fall Reporting
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, person-centered care plans, and resident choices, specifically related to smoking assessment/supervision and fall reporting. Multiple residents with documented or reported nicotine dependence or smoking behavior did not have complete or consistent smoking assessments, care plans, or supervision interventions in place as required by facility policy. For one resident with chronic tobacco use, osteomyelitis with toe amputation, peripheral vascular disease, impaired mobility, and cognitive deficits, the care plan included education on adverse effects of tobacco but did not clearly identify specific smoking supervision interventions, assistance to and from the designated smoking area, lighter control, fire prevention strategies, or individualized hazard mitigation despite his mobility and cognitive limitations. Another resident with a diagnosis of nicotine dependence, COPD, respiratory failure with hypoxia, and other serious cardiorespiratory conditions had a care plan that only encouraged refraining from smoking and did not include a specific smoking supervision plan, designated smoking area guidance, staff supervision requirements, smoking safety precautions, lighter control procedures, or fire risk mitigation interventions; there was no safe smoking assessment in the electronic record. A third resident with a history of chronic smoking, respiratory issues, substance use disorder, and anxiety had an admission MDS that did not clearly document smoking behaviors or supervision requirements, even though a separate safe smoking assessment indicated supervision was required. Her care plan, updated later, identified her as a smoker and required that she always be supervised by a visitor or staff member, that she smoke only in the designated area, that no oxygen be present while she smoked, that no smoking materials be stored in her room, and that monthly safe smoking assessments be completed. Another resident with seizure disorder, diabetic neuropathy, impaired vision, and chronic pain denied tobacco use in the history and physical, and there was no documentation identifying her as a smoker, no smoking status on the MDS, and no smoking assessment completed. Her care plan included education on adverse effects of tobacco but did not identify her as a smoker or include interventions for supervision, safe smoking location, or monitoring for smoking-related hazards. This resident was later observed sitting in the smoking area near other residents who were smoking and reported she had started smoking about two weeks earlier using cigarettes given by other residents; she stated she did not know if she had been evaluated to safely smoke and did not know the facility’s smoking rules beyond needing to go to the designated smoking area. Another resident with dementia, atrial fibrillation, anticoagulant therapy, and other chronic conditions had a care plan that encouraged avoidance of smoking for GERD management and stated smoking materials were kept at the nurses’ station, but it did not clearly describe supervision frequency, monitoring for burns, or risk mitigation related to his cognitive impairment and anticoagulant use. A safe smoking assessment completed by the surveyor at the time of entrance documented that he was safe to smoke unsupervised and that all smoking materials were kept at the nurses’ station, but during an interview he stated he did not know he needed to inform the facility that he smoked, did not know he had been evaluated to safely smoke, and had a pack of cigarettes and a lighter in his nightstand that had been given by a family member. Another resident admitted to being a smoker and had a pack of cigarettes in his jacket pocket, stating he had just received them from a family member and was supposed to turn them in to the facility for safekeeping; he reported he did not have a lighter and was aware of the policy that residents should not keep such items and must turn them in. Additional interviews with residents revealed that several smokers did not know whether they had been assessed for safe smoking, while staff interviews showed that CNAs supervising smoking did not know which residents had completed smoking assessments and expressed concern about residents with tremors and poor hand control smoking without clear confirmation of individualized safety evaluations. The deficiency also includes a failure to report and respond to a resident fall according to facility policy. One resident with a nondisplaced intertrochanteric fracture of the left femur, atrial fibrillation, legal blindness, repeated falls, mild dementia, and severe cognitive impairment (BIMS score of 01) required staff assistance for bed mobility, transfers, and ambulation and had a care plan identifying him as at risk for falls, with interventions including staff assistance with transfers. A CNA reported that this resident lost balance during a transfer from wheelchair to bed and fell onto his buttocks and left side onto a floormat. The CNA acknowledged she knew she was required to report the fall immediately to the charge nurse or DON but forgot to do so and assisted the resident back to bed without notifying licensed staff at that time. Another CNA confirmed he assisted the first CNA in helping the resident after the fall and stated that the first CNA told him she would notify the charge nurse. Interviews with other CNAs, an LVN, the DON, and the Administrator confirmed that facility expectations and policies required all falls to be reported immediately to a licensed nurse for assessment, that CNAs were not permitted to independently determine a resident’s condition after a fall or reposition the resident without nursing evaluation, and that this fall was not reported as required.
Failure to Conduct and Implement Safe Smoking Assessments and Controls
Penalty
Summary
The deficiency involves the facility’s failure to maintain a smoking environment free of accident hazards and to provide adequate supervision and assessment for multiple residents who smoked or wished to smoke. For one male resident with a history of daily tobacco use, multiple vascular diseases, diabetes, impaired mobility including a left below-knee amputation and toe amputations, and cognitive communication deficits, the facility documented nicotine dependence but did not complete a safe smoking assessment. His care plan addressed various medical conditions and included general education on adverse effects of tobacco, but it did not specify smoking supervision interventions, assistance to and from the designated smoking area, lighter control measures, fire prevention strategies, or individualized hazard mitigation despite his mobility and cognitive limitations. This resident reported he began smoking about a week after admission, requested staff to take him outside, and received cigarettes from staff in the designated smoking area, but he did not know if he had been evaluated for smoking or educated on the facility’s smoking policies. Another male resident with diagnoses including nicotine dependence, COPD, respiratory failure with hypoxia, pneumonia, CKD stage 5, anemia, and bipolar disorder had inconsistent documentation regarding smoking status: nicotine dependence was listed as a diagnosis, but the social history stated he denied tobacco use. His quarterly MDS showed intact cognition with mild recall difficulty. His care plan addressed coronary artery disease and included an intervention to encourage him to refrain from smoking, but it did not include a specific smoking supervision plan, designated smoking area guidance, safety precautions, lighter control procedures, or fire risk mitigation interventions, and there was no safe smoking assessment in the electronic record. This resident stated he was a smoker, smoked in the designated area, staff provided his cigarettes and lit them for him, and he did not know if he had been assessed to smoke safely. A third male resident with bilateral below-knee amputations, infections of the amputation stumps, muscle weakness, unsteadiness on feet, age-related cognitive decline, major depressive disorder, anxiety disorder, and on anticoagulant and diuretic therapy had a care plan identifying that he smoked. The plan stated he should smoke only in designated areas, have no oxygen present while smoking, be informed of the smoking policy, be prohibited from storing smoking materials or igniters in his room, and receive a monthly safe smoking assessment. He was considered safe to smoke unsupervised, and a safe smoking assessment documented that he knew the designated smoking area, could get there independently, and could safely light, extinguish, and dispose of smoking materials. However, during observation he was found in bed with a pack of cigarettes in his jacket pocket, which he said had just been given by family and that he was supposed to turn in to the facility for safekeeping, indicating that cigarettes were present in his room contrary to the care plan and policy. A female resident with seizure disorder, metabolic encephalopathy, bipolar disorder, anxiety disorder, diabetic neuropathy, impaired vision requiring corrective lenses, chronic pain, obesity, and other chronic conditions had documentation in the history and physical that she denied tobacco use, and there was no documentation identifying her as a smoker. Her MDS showed moderately impaired cognition and need for supervision with eating, transfers, and toileting, but did not identify her as a smoker and contained no smoking status or assessment. Her care plan addressed hypertension, diabetes, diuretic therapy, impaired visual function, depression, and ADL self-care deficit, and included education on adverse effects of tobacco, but there was no problem statement identifying her as a smoker, no smoking risk assessment, and no interventions for supervision or safe smoking location. Facility record review confirmed there were no safe smoking assessments for her. During observation in the smoking area, she sat near other residents who were smoking while a CNA supervised the group; she stated she had started smoking about two weeks earlier, obtained cigarettes from other residents, did not know if she had been evaluated to smoke safely, and only knew she had to go outside to smoke. Another male resident with dementia, hypertension, diabetes, atrial fibrillation, arthritis, GERD, and cognitive communication deficit had a social history documenting that he denied smoking at admission. His MDS showed moderate cognitive impairment and shortness of breath. His care plan addressed hypertension, diabetes, anticoagulant therapy, GERD, arthritis, and cognitive impairment, and included education encouraging avoidance of smoking for GERD management, and indicated that smoking materials were kept at the nurses’ station. However, prior to the survey the care plan did not clearly describe supervision frequency, monitoring for burns, or risk mitigation related to his dementia and anticoagulant therapy, and it was updated only on the date of the investigation. The safe smoking assessment on file, indicating he was safe to smoke unsupervised and that all smoking materials were kept at the nurses’ station, was completed by the investigator at the time of entrance, not by facility staff beforehand. During observation, this resident was found in bed with a pack of cigarettes in his nightstand and a lighter inside the pack; he stated he did not know he needed to inform the facility that he smoked, did not believe he had been evaluated to smoke safely, and said the cigarettes and lighter had been given by family the previous day. Staff interviews further demonstrated gaps in the facility’s smoking safety practices. A CNA who supervised smoking breaks stated that cigarettes and lighters were kept in a locked box, staff handed out cigarettes, and residents were supervised while smoking, but she did not know which residents had completed smoking assessments and expressed concern that some residents with tremors and poor hand control might not have appropriate assessments. The DON stated that residents who identified as smokers on admission were supposed to receive a smoking assessment and that residents should not smoke without an assessment, but acknowledged that staff often relied on routine and smoking schedules rather than verifying current assessments. The ADON, Administrator, and Activities Director each stated that residents should be assessed before smoking and that residents having lighters or smoking equipment in their rooms could create fire hazards or result in burns or injuries. Review of the facility’s Uniform Smoke Free Policy showed requirements for assessments, prohibition of smoking in resident rooms, storage of smoking paraphernalia in secured areas, and direct supervision for residents assessed as unsafe, which were not consistently implemented for the residents reviewed.
Failure to Honor Resident Beverage Choice and Self-Determination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices about aspects of his daily life, specifically his beverage preference. The resident was an adult male with multiple diagnoses including vascular dementia, type 2 diabetes mellitus, hypertension, chronic systolic congestive heart failure, COPD, seizure disorder, left-sided hemiparesis, hemiplegia, and peripheral vascular disease. His quarterly MDS showed a BIMS score of 10, with cognitive skills for daily decision-making documented as independent. Review of his care plan revealed no restrictions related to soda, caffeine, or other beverages. According to a psychological services progress note and subsequent interviews, the resident reported that on a late-night occasion he requested a soda from a female CNA, who refused and told him it was too late for a soda and offered water instead. The resident stated he felt angry, asserted that he could make his own decisions, and reported that the CNA ignored him and walked away. He reported that this interaction made him feel like the facility did not care about his preferences. A family member, who had video cameras installed in the resident’s room, stated they reviewed the footage after the resident reported the incident and confirmed hearing the CNA offer water instead of soda. In interviews, the CNA involved stated she knew the resident already had a soda and, based on her own judgment, thought it would be best to offer water, acknowledging that she should have provided the soda and consulted the charge nurse. Another CNA present at the time stated it was wrong not to ask a supervisor and that denying the soda could cause the resident to feel his choices were not being considered. The DON and Administrator both stated that residents have the right to make choices regarding food and beverage preferences unless medically contraindicated, that there were no indications in this resident’s care plan restricting soda at night, and that staff are responsible for respecting resident wishes. The facility’s Resident Rights policy states that residents have the right to self-determination, to make choices about aspects of their life in the facility, and to exercise their rights without interference, coercion, discrimination, or reprisal.
Failure to Follow Two-Person Repositioning Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to implement a comprehensive, person-centered care plan for a resident who was totally dependent on staff for all activities of daily living and required two-person assistance for repositioning. The resident, who was nonverbal, had a tracheostomy, and suffered from multiple complex medical conditions including anoxic brain injury, cirrhosis, and severe cognitive impairment, was care planned for two-person assistance during repositioning due to his total dependence and limited mobility. Despite this, a CNA attempted to reposition the resident alone, without the required assistance. During the solo repositioning attempt, the resident rolled off the bed and struck his head on a suctioning machine, resulting in a brain bleed, a 2 cm laceration above the right eyebrow, an orbital fracture, and a sinus fracture. The incident was documented in the resident's progress notes and confirmed by interviews with staff, including the CNA involved, who admitted to not following the care plan and acknowledged being aware of the two-person requirement. The CNA did not request help, even though other staff were nearby and available. Interviews with nursing staff and facility leadership confirmed that the care plan and Kardex clearly indicated the need for two-person assistance for repositioning, and that all staff had been trained to access and follow these care plans. The failure to follow the established care plan directly led to the resident's fall and subsequent injuries, as confirmed by multiple staff interviews and record reviews.
Failure to Provide Required Two-Person Assistance During Repositioning Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during peri care and repositioning of a resident who was totally dependent on staff for all activities of daily living. The resident, who was nonverbal, in a vegetative state, and required two-person assistance for all repositioning and peri care as documented in his care plan and Kardex, was repositioned by a single CNA without the required help. During this process, the resident rolled off the bed and struck his head on a suctioning machine, resulting in a brain bleed, a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The resident had a complex medical history, including long-standing alcohol use disorder, alcoholic encephalopathy, cirrhosis, pancreatitis, gastrointestinal bleeding, hypertension, and an anoxic brain injury requiring a tracheostomy and gastrostomy. He was admitted for skilled nursing care, medical management, and total assistance with activities of daily living. The care plan clearly indicated the need for two-person assistance for all repositioning and peri care due to his severely impaired cognition and physical limitations. Despite being aware of the care plan requirements and having received prior training, the CNA proceeded to reposition the resident alone, did not request assistance, and did not follow established protocols. Multiple staff interviews confirmed that the CNA knew the resident required two-person assistance and that the care plan and Kardex were accessible and should have been followed. The incident was attributed directly to the CNA's failure to adhere to the resident's care plan, resulting in significant injury to the resident.
Failure to Maintain Pressure Ulcer Dressing as Ordered
Penalty
Summary
A resident with a chronic right gluteal pressure ulcer did not receive necessary treatment and services consistent with professional standards of practice. The resident, who was severely cognitively impaired and required pressure ulcer care, was observed without a dressing on his pressure ulcer as ordered in his care plan. During an observation, staff found a thick white substance on the resident's buttocks and directly on the pressure injury, but no dressing was in place. The care plan required the administration of treatments as ordered and monitoring the effectiveness by replacing loose or missing dressings. Interviews revealed that both a CNA and an LVN noticed the absence of the wound dressing but did not report it, despite being trained to immediately notify nursing staff of missing dressings for residents with pressure ulcers. The DON confirmed that wounds without dressings increase infection risk and delay healing, and stated that it was the responsibility of the wound care nurse to ensure dressings were in place as ordered. The facility's policy required staff to assess skin routinely and report abnormalities to nursing staff to prevent skin breakdown and promote healing.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) during wound care for a resident with a chronic right gluteal pressure ulcer. On the observed date, an LVN and a CNA entered the resident's room, which had an EBP sign posted, but neither performed hand hygiene nor donned the required personal protective equipment (PPE) such as gowns and gloves before making physical contact with the resident. Both staff members proceeded to turn the resident and provide care without following these infection control protocols. The resident involved was an elderly male with a history of a chronic right gluteal pressure ulcer, iron deficiency, and anemia, and was severely cognitively impaired. His care plan required the use of pressure-reducing devices, regular wound care, and the application of nonsurgical dressings and medications. During the observed care, a second stage II ulcer was identified, and it was noted that the wound dressing was missing, which had not been reported to the licensed staff as required by facility protocol. Interviews with the involved staff revealed that both had been trained on EBP and the necessity of using PPE when caring for residents with wounds, but they could not provide a reason for not following these procedures during the incident. The DON confirmed that EBP signage was in place and that staff were expected to use gowns and gloves for direct contact with residents under these precautions. The facility's infection control policy required hand hygiene and the use of PPE to prevent the spread of infection, but these protocols were not followed during the observed care.
Failure to Implement Infection Control Precautions for Suspected TB Case
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a resident who was admitted with multiple complex medical conditions, including cavitation pneumonia, end-stage renal disease, and diabetes mellitus. The resident had a history of hospitalizations for severe lung infections and was under suspicion for tuberculosis (TB) after a preliminary positive acid-fast bacilli (AFB) result was reported. Despite this, upon the resident's return from the hospital, the facility did not implement appropriate isolation precautions or interventions to prevent potential transmission of communicable diseases. Staff interviews and record reviews revealed that there was confusion and lack of clarity among facility staff regarding the need for isolation and the use of personal protective equipment (PPE) for the resident. The resident was allowed to participate in group activities and dine with other residents, and staff were not consistently wearing N95 masks or following airborne precautions. Multiple staff members, including nurse practitioners, licensed vocational nurses, and the DON, indicated uncertainty about the facility's protocol for handling suspected or confirmed TB cases, especially in the absence of a negative pressure room. The facility's own policies required immediate respiratory isolation and use of PPE for suspected TB cases, but these were not followed. Furthermore, after the facility received notification of a positive AFB result, no post-exposure interventions were implemented for residents or staff who may have been exposed. There was no monitoring for signs or symptoms of infection among those potentially exposed, and no chest x-rays or other assessments were conducted. Communication with the local health department confirmed that the facility was advised to use isolation and N95 masks as a precaution, but these recommendations were not fully enacted. The facility's failure to follow its own infection control policies and to implement necessary precautions placed residents and staff at risk for the development and transmission of communicable diseases.
Failure to Provide Resident Rights and Admission Packet Upon Admission
Penalty
Summary
The facility failed to provide a notice of rights and services to a resident prior to or upon admission, as well as during the resident's stay, and did not ensure receipt and written acknowledgment of such information. The resident in question was admitted with a history of psychoactive substance abuse, traumatic brain injury, and a recent traumatic subarachnoid hemorrhage. Upon admission and subsequent readmission, neither the resident nor the family member received the required admission packet or information regarding resident rights, as confirmed by interviews with the family member, administrator, and other facility staff. The deficiency was further substantiated by staff interviews, which revealed that the admission packet, containing essential information such as resident rights, consent forms, and facility policies, was not provided due to the chaotic circumstances surrounding the resident's behavioral issues. The administrator acknowledged that the admission packet was not given because of the behavioral incidents that occurred shortly after admission. The receptionist, who was responsible for distributing admission packets on weekends, stated she did not receive instructions to provide the packet to the resident or family member during the relevant period. Facility policies reviewed indicated that it is standard procedure to provide residents and their representatives with written information about their rights and services, and to obtain a signed acknowledgment for the clinical record. However, in this case, the process was not followed, and the required documentation was not present in the resident's record. The family member also reported not receiving any incident report or information about the resident's rights, and was not informed about the process for appealing a discharge.
Failure to Provide Admission Packet and Resident Rights Information
Penalty
Summary
The facility failed to establish and implement proper admission policies for a resident who was admitted and subsequently re-admitted following a hospital stay. Upon review, it was found that neither the resident nor the resident's family members completed or signed an admission agreement at the time of admission. The facility did not provide the required admission packet, which includes essential information such as resident rights, facility services, and policies. This omission was confirmed through interviews with the family member, the administrator, the admission coordinator, the receptionist, and the DON, all of whom acknowledged that the admission packet was not given due to the chaotic circumstances surrounding the resident's behavioral issues. The resident in question had a complex medical history, including psychoactive substance abuse, traumatic brain injury, and a recent traumatic subarachnoid hemorrhage with loss of consciousness. Upon admission, the resident exhibited acute mental status changes, including inattention, disorganized thinking, and mood disturbances such as depression, suicidal ideation, and aggressive behaviors. These behaviors led to the resident being sent to the hospital and subsequently returned to the facility, where the situation remained unstable. Interviews revealed that the facility's process for distributing admission packets was not followed. The admission coordinator was responsible for providing packets during weekdays, while the receptionist handled this task on weekends if instructed. However, during the resident's admission, the receptionist did not receive instructions to provide the packet, and the family member confirmed that no admission materials or resident rights information were received. The facility's own policies require that residents and families receive and sign for these documents, but this did not occur in this case.
Failure to Provide Required Written Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide the required 30-day written notice of discharge to a resident and the resident's responsible party prior to the resident's discharge. The resident, who had a history of psychoactive substance abuse, traumatic brain injury, and impaired cognitive function, was discharged home without the mandated written notification. Documentation shows that the family member was informed verbally and given discharge instructions, but refused to sign the discharge paperwork, stating disagreement with the decision and lack of prior notice. The family member reported not receiving any written 30-day notice or incident report and was told by the administrator that the resident had to leave by the end of the day. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman of the resident's discharge as required. The ombudsman confirmed that he was not informed of the discharge and emphasized the importance of timely notification, especially in emergency or unplanned discharges, to ensure advocacy and safe transition for the resident. The facility's practice was to send a list of discharges to the ombudsman once a month, rather than immediately upon discharge, which did not meet regulatory requirements for timely notification. Interviews with facility staff, including an LVN and the administrator, confirmed that the standard procedure of providing a 30-day written notice was not followed in this case. The administrator acknowledged that the notice was not given and that the ombudsman would be notified later as per facility policy. The lack of timely written notice and ombudsman notification was a deviation from both regulatory requirements and the facility's own policy, as documented in the report.
Catheter Bag Not Properly Secured, Leading to Infection Control Deficiency
Penalty
Summary
A deficiency was identified when a resident with an indwelling catheter was observed with their catheter bag lying on the floor instead of being properly hooked to the bed. The resident, a male with a history of diabetes mellitus and cerebrovascular accident, had moderately impaired cognition and was on enhanced barrier precautions. Facility records and care plans specified that the catheter bag should be positioned below the level of the bladder, in a privacy bag, and anchored to the bed or wheelchair to prevent pulling and contamination. Despite these instructions, direct observation revealed the catheter bag on the floor, and a licensed vocational nurse (LVN) was seen entering the room, noticing the issue, and then hooking the bag to the bed. Multiple staff interviews confirmed that catheter bags should never be on the floor due to concerns about cross-contamination and infection control. Staff, including LVNs, RNs, the Assistant Director of Nursing (ADON), Nurse Practitioner (NP), and Director of Nursing (DON), all acknowledged that it was everyone's responsibility to ensure catheter bags were properly hung. It was also noted that the resident had a habit of unhooking the catheter bag when repositioning, which contributed to the issue, but staff reiterated that maintaining proper placement of the catheter bag was necessary to prevent infection.
Failure to Provide Necessary Behavioral Health Services for Resident with Acute Behavioral Symptoms
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of psychoactive substance abuse, traumatic brain injury, and traumatic subarachnoid hemorrhage. The resident exhibited significant behavioral symptoms, including verbalized suicidal ideation, physical aggression, agitation, and wandering. Despite these acute behavioral changes, the facility did not utilize the on-call psychiatric service for evaluation or intervention on the day the behaviors escalated. Interviews and record reviews revealed that the resident was admitted for therapy following an accident and initially showed no behavioral issues. However, on the day in question, the resident became aggressive, was physically combative with staff, expressed suicidal thoughts, and disrupted other residents. Staff attempted to manage the behaviors through redirection and 1:1 supervision, but did not contact the on-call mental health provider, despite having access to this resource. The facility's own behavioral management policy outlined the use of such interventions, but these were not implemented. Multiple staff members, including the Administrator, DON, and nursing staff, confirmed that the on-call mental health service was not contacted. The mental health nurse practitioner and the resident's nurse practitioner both stated that the facility should have reached out for psychiatric support, which could have provided assessment, de-escalation, and medication management. The lack of timely referral to psychiatric services was identified as a failure to follow the resident's care plan and the facility's behavioral management policy.
Failure to Coordinate Care and Ensure Safe Transfers Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's right to be free from neglect by not coordinating care and services with the hospice provider, resulting in a lack of alignment between the facility's and hospice's written plans of care. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, was dependent on staff for all activities of daily living and required a mechanical lift with two-person assistance for all transfers, as documented in the facility's care plan and physician orders. However, the hospice plan of care did not specify the need for a mechanical lift and two-person assistance for transfers. On the day of the incident, a hospice aide attempted to transfer the resident from a shower chair to the bed without using the required mechanical lift or obtaining assistance from facility staff, despite being aware of the resident's transfer requirements. The aide reported being unable to locate the sling for the lift and proceeded with the transfer alone. During this process, the resident fell, sustaining a laceration to the forehead and a cervical fracture. The incident was not immediately reported to the facility's charge nurse, and the hospice aide did not call for assistance before or after the fall. Interviews and record reviews revealed that the hospice and facility staff did not routinely share or coordinate care plans, and hospice staff were not consistently included in care plan meetings. The hospice aide admitted to sometimes transferring the resident without assistance due to lack of available staff or equipment. Facility staff were not always aware when hospice staff were providing care, and there was no established process to ensure hospice staff reviewed the facility's care plan or Kardex before providing care. The facility also lacked a fall prevention policy and procedure at the time of the incident.
Failure to Provide Adequate Supervision and Assistance During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a hospice aide failed to use a mechanical lift and two-person assistance to transfer a resident with significant mobility and cognitive impairments, resulting in a fall. The resident, a male with diagnoses including advanced dementia, cerebral infarction, hemiplegia, contractures, and a history of falls, required total assistance for transfers as documented in his care plan and physician orders. Despite these requirements, the hospice aide attempted to transfer the resident without the mechanical lift and without a second person, leading to the resident falling and sustaining a 2 cm laceration to the forehead and a cervical spine fracture. The incident took place during a transfer from a shower chair to the bed after bathing. The hospice aide did not request assistance from facility staff, even though staff were available and had previously instructed her to seek help for all transfers. The aide later stated she was aware of the need for a mechanical lift and two-person assist but did not use the lift because she could not find the sling and sometimes performed transfers alone when help was unavailable. There was also confusion and lack of coordination between the hospice and facility care plans, with the hospice care plan not specifying the need for a mechanical lift and two-person assist, while the facility care plan and physician orders did. Interviews revealed that the hospice aide and facility staff had inconsistent understandings of the transfer requirements, and the hospice aide admitted to not always following the prescribed procedures. The facility did not have a fall prevention policy in place at the time of the incident, and there was no established process for sharing or coordinating care plans between the facility and hospice staff. The lack of communication and adherence to established transfer protocols directly contributed to the resident's fall and subsequent injuries.
Failure to Coordinate Care for Hospice Resident Results in Fall and Injury
Penalty
Summary
The facility failed to ensure proper coordination of care between its staff and hospice staff for a resident receiving hospice services, resulting in a significant incident. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, required total assistance for transfers, specifically with a mechanical lift and two-person assistance as documented in the care plan and physician orders. However, the hospice care plan did not reflect this requirement, and hospice staff were not consistently included in care plan meetings or provided with updated facility care plans. On the day of the incident, a hospice CNA attempted to transfer the resident from a shower chair to the bed without using the mechanical lift and without assistance, despite being aware of the resident's need for such support. The CNA reported being unable to find the sling for the lift and, after informing a facility LVN, was told it was acceptable to proceed with a manual transfer. During this process, the resident fell, sustaining a laceration to the forehead and a cervical spine fracture, which required hospitalization and ICU care. The incident was not immediately investigated by facility administration, and there was a lack of communication regarding the event until hospice staff later reported the failure to use the mechanical lift. Interviews revealed that hospice staff were not routinely invited to facility care plan meetings, and there was no established process for sharing or reconciling care plans between the facility and hospice. The hospice CNA admitted to sometimes transferring the resident without assistance due to lack of available staff or equipment. Facility and hospice staff both acknowledged gaps in communication and coordination, with hospice staff relying on their own care plans, which did not include the mechanical lift requirement, and facility staff not ensuring hospice staff were aware of or following the facility's care plan interventions.
Removal Plan
- The alleged perpetrator will not be returning to the facility.
- Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan.
- The Nursing staff/ current hospice agencies CNAs were in-serviced by facility DON/ADON and Regional Compliance Nurse on how to find the level of assistance required for transfer and mechanical devices required in the kiosk.
- Mechanical lifts were tagged with bright colored sign stating, two people required to operate the lift. This was done by the Maintenance Director. This will give a second opportunity for staff to be reminded prior to using the equipment.
- Facility Charge Nurses were in-serviced by the facility DON on how to read the facility Kardex.
- Current hospice agencies CNAs/facility nursing staff providing services to residents at the facility were in-serviced by the facility DON on how to review the residents Kardex located in the kiosk with the Charge Nurse prior to providing direct care to the residents to ensure that the staff is aware of the number of people required for transfers and use of any mechanical lifts. This will be randomly monitored by DON/ADON/Admin. To prevent the recurrence of falls and injuries.
- The facility Social Worker will be sending reminder emails to contracted hospice agencies to attend the required mandatory care plan meetings at the facility as scheduled. To ensure the coordination of services. This will be randomly monitored by Admin/DON/ADON.
- 100% of residents' records were reviewed to ensure that the information reflected in the Kardex/Care plans for any residents requiring assistance with transfer to include any assistive devices. This was done by DON/ADON and the Regional Compliance Team.
- Facility staff and current hospice agencies were in-serviced by the DON/ADON and compliance nurse on Abuse and neglect. No facility staff member or contract hospice agency staff will be allowed to provide care until receiving the in-service mentioned above.
- Hospice CNAs must sign in upon arrival and review the Kardex with the charge nurse to ensure the plan of care and level of assistance are understood before providing care. Education is posted at the nurse's station.
- All hospice staff must report to charge nurse and review Kardex. All hospice staff must report to the charge nurse upon arrival and review the Kardex before providing care. They must sign off that they have reviewed and understood the Kardex.
- In-service training on identifying and reporting abuse, neglect, and exploitation for hospice staff.
- Training addressed recognizing signs of abuse, neglect, and exploitation and the importance of timely reporting.
Failure to Implement and Follow Neglect Prevention Policies During Resident Transfer
Penalty
Summary
The facility failed to implement and follow written policies and procedures to prohibit and prevent neglect, as well as to investigate allegations of neglect, for a resident with significant cognitive and physical impairments. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, required total assistance with transfers using a mechanical lift and two staff members, as documented in his care plan and physician orders. Despite these requirements, a hospice aide transferred the resident without the mechanical lift and without two-person assistance, resulting in a fall that caused a laceration to the forehead and a cervical fracture. The incident occurred when the hospice aide, unable to locate the mechanical lift sling, proceeded to transfer the resident with the help of an LVN, but without the required equipment. After the shower, the aide attempted to transfer the resident back to bed alone, again without the mechanical lift or assistance, during which the resident fell from the bed. The aide admitted to not following the required transfer protocol and not seeking help, despite being aware of the resident's needs. The facility staff, including the LVN and the administrator, were not aware of the improper transfer until after the incident, and the administrator did not initiate an investigation into the cause of the fall as required by the facility's abuse/neglect policy. Additionally, there was a lack of coordination and communication between the facility and hospice staff regarding the resident's care plan and transfer requirements. The hospice care plan did not document the need for a mechanical lift and two-person assistance, and hospice staff were not included in the facility's care plan meetings. The facility's policies required all reports or suspicions of neglect to be investigated, but this was not done in this case. The failure to implement and follow these policies and procedures placed the resident at risk of not receiving necessary care and services.
Failure to Investigate and Prevent Neglect During Resident Transfer
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated, specifically in the case of a male resident with significant cognitive and physical impairments. The resident, who had diagnoses including advanced dementia, cerebral infarction, hemiplegia, and a history of falls, required total assistance with transfers using a mechanical lift and two staff members, as documented in his care plan and physician orders. Despite these requirements, a hospice aide transferred the resident without the mechanical lift and without adequate assistance, resulting in a fall that caused a laceration to the forehead and a cervical fracture. The incident occurred when the hospice aide, unable to locate the sling for the mechanical lift, proceeded with the transfer with only one staff member and without the required equipment. The aide admitted to not always using the mechanical lift and sometimes transferring the resident alone due to lack of available help. Facility staff, including the LVN, were aware of the resident's care needs but did not ensure the proper transfer method was used. The event was not immediately or thoroughly investigated by the facility administration, and the administrator was unaware of the improper transfer until informed by hospice staff days later. There was no evidence that the facility initiated an investigation into the cause of the fall or monitored adherence to care plan interventions for transfers. Additionally, there was a lack of coordination and communication between the facility and hospice staff regarding the resident's care plan. Hospice staff did not have the updated care plan reflecting the need for a mechanical lift and two-person assistance, and they did not participate in the facility's interdisciplinary care plan meetings. The facility's policy required all reports or suspicions of abuse or neglect to be investigated, but this protocol was not followed in this case, as the administrator did not begin an investigation or ensure protective measures were in place during the process.
Failure to Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of one resident who alleged that a night nurse had hit him on the chest and acted aggressively. The resident, a male with a history of pulmonary hypertension, right-sided heart failure, and episodes of syncope, reported that a male night nurse matching the description of a staff member had struck him. Multiple staff interviews confirmed that the description provided by the resident matched a specific LVN, who was working during the relevant period. Despite the facility's abuse policy requiring immediate suspension of any employee identified as an alleged perpetrator pending investigation, the LVN in question was not promptly suspended after being identified. Interviews with the DON, HR, and the Ex-Administrator revealed inconsistencies and lack of documentation regarding the LVN's suspension. HR could not find any record of a suspension, and timesheets indicated the LVN continued to work during the period in question. The Ex-Administrator and other staff acknowledged that the LVN matched the resident's description and that policy required suspension, but this was not consistently or clearly carried out. The facility's own abuse and neglect policy states that employees alleged to have committed abuse must be immediately suspended pending investigation to protect residents. However, the investigation summary and provider action taken did not reflect this requirement, and the LVN continued to work, only being removed from the specific resident's care after the investigation. Staff interviews confirmed awareness of the policy but also highlighted a failure to follow it, as the LVN was not suspended as required when first identified as the alleged perpetrator.
Failure to Timely Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that alleged violations involving misappropriation of resident property were reported immediately to the administrator and to the state agency, as required by both facility policy and state law. Specifically, when a resident with impaired cognition, legal blindness, anxiety, and major depressive disorder reported missing money from his wallet, the initial report was made by a CNA to an LVN, and subsequently to the DON and ADON. However, the administrator was not notified immediately, and the incident was not reported to the state agency within the required timeframe. Interviews revealed that the CNA and LVN were aware of the resident's claim of missing money and had recounted the funds on two separate occasions, noting a decrease from $84 to $34. The DON and ADON acknowledged receiving the report from staff but did not promptly inform the administrator or ensure that the state agency was notified. The social worker was conducting an investigation, but the reporting process was not followed as outlined in the facility's abuse and neglect policy. The administrator confirmed that he was not made aware of the missing money until much later and that, had he been notified, he would have followed the facility's abuse protocols. The facility's policy clearly states that all allegations of abuse, neglect, exploitation, or misappropriation of property must be reported to the administrator and the state agency within specified timeframes. The failure to report the incident as required constituted a deficiency in the facility's handling of suspected misappropriation of resident property.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident #49, a cognitively impaired female with a traumatic brain injury and other mental health issues, was found without a call light connected to the wall near her bed. She was unable to understand or use the call light due to her cognitive impairments. This lack of access to a call light placed her at risk of being unable to contact staff for assistance. Similarly, Resident #68, a male with Huntington's chorea and cognitive impairments, was observed with his call light on the floor, out of reach. Despite having a history of dropping the call light, the facility did not ensure it was consistently within his reach. The CNA noted that the resident had previously used a different type of call light but was unable to operate it effectively. The absence of a reachable call light for Resident #68 increased the risk of unmet needs, as he was nonverbal and unable to call for help.
Lack of Private Phone Call Area for Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable access to a private area for making telephone calls, which compromised the privacy rights of two residents. Resident #63, a cognitively intact female with a history of Type 2 diabetes, hypertension, and schizoaffective disorder, was observed making a phone call in a public hallway where other residents and staff were nearby. She expressed dissatisfaction with the lack of a private space for phone calls, noting that a previously available private area had been repurposed, leaving her to make calls in public areas. Similarly, Resident #94, a cognitively intact male with Parkinson's disease, bipolar disorder, and sleep apnea, was observed making a phone call at the nurses' station, surrounded by staff and other residents. He indicated a preference for a more private setting due to difficulties hearing over the noise in the lobby area. Interviews with staff revealed that there was no designated private area for phone calls, and residents typically used phones in hallways or at the nurses' station, with the option to request a cell phone from the Social Worker for use in their rooms. The Director of Nursing acknowledged the lack of a designated private area and stated that staff were expected to redirect residents to private spaces for phone calls. However, the facility's attempts to provide a private phone area had been unsuccessful, as a previous space was converted into a chapel, and technical issues prevented the installation of a phone line. The facility's policy on resident rights emphasized the importance of providing a private area for phone calls, which was not being adhered to, resulting in the deficiency.
Privacy Breach in Resident Communications
Penalty
Summary
The deficiency involves a failure to maintain the privacy and confidentiality of residents' personal and medical records. Specifically, the report highlights that residents have the right to reasonable access to telephones, including TTY and TDD services, and a private space to make calls without being overheard. This includes the right to retain and use a cellular phone at their own expense. The report mentions two residents in relation to privacy concerns, indicating a breach in maintaining the confidentiality of their communications and personal information.
Improper Food Handling and Cross-Contamination Risk
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the actions of a dietary aide. The aide used a pitcher that had been placed on an unsanitized black cart to refill it with tea by scooping from a tea container, then poured the tea into cups for serving. This practice was observed multiple times, with the pitcher being placed back on the black cart, which was noted to have white sugar-like dirt particles and stains. The unsanitized cart posed a risk of cross-contamination, as confirmed by the Kitchen Director and the dietary aide, both of whom acknowledged the potential for foodborne illness due to improper sanitation practices. Interviews with the Kitchen Director and the Administrator revealed that training on cross-contamination and food safety was provided during hire and annually, with additional monitoring by the dietitian and dietary consultant. Despite these measures, the dietary aide's actions demonstrated a lapse in following the facility's sanitation and food handling policies, which require work surfaces to be kept clean during preparation and service. The Administrator highlighted the primary risks associated with such deficiencies, including foodborne illnesses and bacterial infections, which could arise from improper handling or contamination, such as bacteria transferred from the unsanitized cart.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving improper use of personal protective equipment (PPE) and hand hygiene. In the first incident, a Certified Nursing Assistant (CNA) performed incontinent care for a resident with Alzheimer's disease and dementia without changing gloves between handling soiled and clean items. The CNA used the same gloves to wipe the resident's vaginal and rectal area and then proceeded to handle clean items, such as a new brief and bed sheets, without sanitizing her hands. This oversight was acknowledged by the CNA, who admitted to forgetting the proper procedure due to nervousness. In the second incident, a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) failed to use the required PPE during medication administration via a PEG tube for a resident on Enhanced Barrier Precautions (EBP). Despite the presence of a sign indicating the need for gloves and gowns for high-contact activities, both staff members only sanitized their hands and wore gloves, neglecting to don gowns and face masks. Both the LVN and ADON admitted to forgetting the EBP requirements, attributing their lapse to nervousness and unfamiliarity with the resident's care routine. These deficiencies were identified through observations and interviews with the involved staff, the Director of Nursing (DON), and the facility Administrator. The DON and Administrator both acknowledged the lapses in infection control practices, noting that the staff had received training on proper procedures. However, the incidents highlighted a failure to consistently apply these practices, potentially placing residents at risk of infections.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice for the care of a midline in a resident requiring intravenous therapy. Specifically, the facility did not change the PICC line dressing for a resident as ordered by the physician. The resident, a male with a history of sepsis, hemiplegia, muscle weakness, and cognitive communication deficit, was admitted with a PICC line that required dressing changes every seven days. However, during an observation, it was noted that the dressing had not been changed since 12/08/24, despite being due for a change on 12/15/24. The resident expressed discomfort and had been waiting for the dressing to be changed, although no signs of infection were observed at the site. Interviews with facility staff, including an RN, ADON, and DON, revealed that the responsibility for changing the PICC line dressing fell to the charge nurses, who were expected to follow physician orders and facility policy. The staff acknowledged the risk of infection if the dressing was not changed as required, although no immediate signs of infection were present. The facility's policy outlined that PICC line dressings should be changed every seven days or as needed, and the failure to comply with this protocol was identified as a deficiency in the care provided to the resident.
Deficiency in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, leading to a deficiency in medication management. The resident, who had a moderately impaired cognitive status, was found with over-the-counter Selenium and Aspirin at his bedside without any assessment for self-administration. The resident was unable to articulate the purpose of these medications and could not recall when they were last taken. The facility's records showed no orders for these medications, and there was no care plan addressing self-medication administration for the resident. Interviews with staff revealed that the resident had a history of possessing unauthorized over-the-counter medications, and although redirection and education were provided, the issue was not reported to upper management until later. The facility's policy required an assessment to determine a resident's ability to self-administer medications safely, which was not conducted in this case. Staff were expected to monitor and remove unauthorized medications during rounds, but this was not effectively implemented, leading to the deficiency in ensuring medication safety for the resident.
Failure to Secure Treatment Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with the treatment cart on hall 200. During an observation, the treatment cart was found unlocked and unsupervised, containing several needles, dressings, and medicated ointments. LVN A admitted to leaving the cart unlocked when she stepped away to check on a resident with the doctor present, acknowledging that she normally locks the cart but forgot on this occasion. Interviews with the Director of Nursing (DON) and the Administrator confirmed that it is expected for medication or treatment carts to be locked when not in use or under direct supervision. Both acknowledged that leaving the cart unlocked could allow unauthorized access to its contents by staff, family members, or residents. The facility's policy from 2003 also indicated that carts must be locked when not in use or under direct supervision.
Inaccurate Documentation of PICC Line Dressing Change
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident, identified as Resident #27, who was admitted with diagnoses including sepsis, hemiplegia, muscle weakness, and cognitive communication deficit. The resident's care plan required a PICC line dressing change every seven days. However, RN C documented that the dressing change was completed on a specific date, despite not performing the task. This discrepancy was discovered during an observation where the dressing was found to be dated several days earlier, and the resident reported waiting for the dressing change. Interviews with RN C, the ADON, the DON, and the Administrator revealed that the facility had protocols and training in place to prevent such documentation errors. RN C admitted to signing off on the task without completing it, acknowledging the training received on accurate documentation. The ADON and DON highlighted the risks of assuming tasks were completed based on inaccurate documentation, which could lead to inadequate care. The facility's documentation policy emphasized the importance of maintaining complete and accurate records, but the failure to adhere to this policy resulted in a deficiency.
Conflicting Transfer Instructions in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, leading to conflicting transfer instructions. The resident, a male with a history of physical injury, repeated falls, and various mobility issues, was admitted and re-admitted to the facility earlier in the year. His care plan included conflicting instructions for transfers, specifying both a two-person transfer with a mechanical lift and a one-person transfer, which were implemented simultaneously. The deficiency was identified through observations, interviews, and record reviews. The resident's care plan dated June 5th indicated the need for a two-person Hoyer lift for transfers, yet staff were observed using different methods, including a gait belt. Interviews with staff revealed confusion and inconsistency in the transfer methods used, with some staff unaware of the correct procedure. The Regional MDS and other staff acknowledged the risk of injury due to the conflicting care plan instructions. The facility's comprehensive care planning policy requires the development of a person-centered care plan with measurable objectives and timeframes. However, the failure to update and communicate the correct transfer method for the resident led to a fall incident, as noted in the resident's event note. The facility's preventive strategies to reduce fall risk emphasize individualized care plans, but the inconsistency in the resident's care plan posed a risk of injury, as confirmed by multiple staff members during interviews.
Improper Transfer and Unreported Fall in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident, who required a two-person transfer with a mechanical lift, was transferred appropriately. Instead, the resident was transferred by a single CNA using a gait belt, which was not in accordance with the resident's care plan. This improper transfer led to the resident's right leg getting caught between the wheelchair and bed, resulting in a fall where the resident hit the floor and experienced pain. The resident, identified as having a history of repeated falls, muscle weakness, and poor safety awareness, was not provided with the necessary supervision and assistance during the transfer. The care plan for the resident was inconsistent, with conflicting instructions regarding the number of staff required for transfers. Despite the resident's complaints of pain following the fall, the incident was not reported to the nursing staff, and no immediate assessment was conducted. Interviews with facility staff revealed a lack of communication and adherence to the resident's care plan. The CNA involved admitted to not reporting the incident, and there was confusion among staff regarding the correct transfer method for the resident. The facility's policies on event reporting and safe transfer procedures were not effectively implemented, contributing to the deficiency in care provided to the resident.
Failure to Ensure Residents Are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Specifically, the facility did not obtain consent, a physician's order, or a care plan for a resident's full bed rails, which restricted the resident's movements. The resident, who had severe cognitive impairment and required total assistance with bed mobility and transfers, was observed lying on a bed with raised full side bed rails without any documentation indicating the necessity of these restraints for medical symptoms. The resident's medical history included atrial fibrillation, CVA with right-sided deficits, dementia, depression, and seizures. Despite these conditions, there was no documentation in the resident's care plan or order summary regarding the use of bed rails. The bed with full side rails was provided by Hospice, and facility staff, including an RN and the DON, were unaware of the need for an order for the bed rails. The bed had been in use for about a month without proper authorization or documentation. Interviews with facility staff revealed a lack of awareness and understanding regarding the use of bed rails as restraints. The DON and Administrator both stated that full side bed rails were not allowed at the facility as they could be considered restraints. The facility's policy on restraints emphasized that restraints should only be used with a physician's order, informed consent, and a care plan, none of which were in place for the resident. The facility had previously received a citation on restraints and had in-serviced staff on identifying and reporting restraint issues, yet the bed rails remained in use for an extended period without proper oversight.
Failure to Maintain Infection Control for Covid-19 Isolated Resident
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, specifically for a resident who was isolated for Covid-19. The resident, a [AGE] year-old female with diagnoses of COPD, asthma, and schizoaffective disorder, had a severely impaired cognitive status as indicated by a BIMS score of 4. Despite being isolated for Covid-19, observations on multiple occasions revealed that the resident's door was wide open, contrary to the facility's policy and training that required Covid-19 isolated rooms to have their doors closed to prevent cross-contamination and infection spread. Red tape and signs indicating the need for the door to be closed were present but not adhered to by the staff. Interviews with multiple CNAs, a Med Tech, and the DON confirmed that all staff had received training on Covid-19 precautions, which included keeping the doors of Covid-19 isolated rooms closed. Despite this training, the staff failed to ensure that the resident's door remained closed, thereby increasing the risk of cross-contamination and infection. The facility's policy on patient placement during the Covid-19 pandemic also explicitly stated that doors should be kept closed for patients with suspected or confirmed SARS-CoV-2 infection, which was not followed in this case.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure that two residents with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and to secure their catheters properly. Resident #16, a [AGE] year-old female with severe cognitive impairment and multiple medical conditions, was observed without a catheter leg strap, contrary to her care plan and physician orders. The absence of the catheter strap posed a risk of the catheter being pulled out, causing pain and discomfort. RN C confirmed the lack of the catheter strap and acknowledged the associated risks during an interview. Similarly, Resident #17, a [AGE] year-old male with severe cognitive impairment and an indwelling catheter, was observed with his catheter drainage bag lying on the floor and without a catheter strap. This was against the care plan instructions to keep the drainage bag off the floor and ensure the catheter strap was in place. RN C confirmed the observations and acknowledged the risks of infection and catheter trauma. The Director of Nursing (DON) also confirmed that the drainage bag should not be on the ground and highlighted the risks of contamination and infection due to improper catheter care practices.
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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