Mustang Park Therapy And Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carrollton, Texas.
- Location
- 4501 Plano Parkway, Carrollton, Texas 75010
- CMS Provider Number
- 676363
- Inspections on file
- 50
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Mustang Park Therapy And Living Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a behavioral care plan reported waiting approximately 15 minutes for staff to respond to her call light, ultimately calling 911 for assistance. Staff interviews confirmed frequent call light use and behavioral challenges, but facility policy required responses within five minutes. The deficiency was based on the failure to provide timely assistance as outlined in the facility's policy.
A resident with multiple medical conditions submitted a grievance about an undercooked meal, but facility staff failed to provide an appropriate response or written resolution as required by policy. The resident did not receive an apology or follow-up, and the outcome of the grievance was not communicated, resulting in a failure to honor the resident's right to prompt grievance resolution.
Two staff members transferred a resident with severe cognitive impairment and multiple medical conditions from the floor to a wheelchair without using a gait belt, instead lifting her under the armpits. This action was contrary to facility policy and staff training, which required the use of a gait belt for all transfers to prevent injury.
A resident with multiple chronic conditions was served an undercooked baked potato and lukewarm soup, with observations and staff interviews confirming inconsistent food quality and temperature. A test tray also showed food items not at appropriate serving temperatures, indicating the facility did not consistently provide palatable and properly prepared meals.
A resident with significant mobility and fall risk was unable to reliably summon staff due to a malfunctioning call light system. Despite repeated complaints and staff awareness of the issue, the problem persisted for weeks, resulting in delayed responses to the resident's needs and the resident resorting to calling 911 for help. Facility policy requiring a functional call system and timely response was not met.
A resident with Alzheimer's disease and moderate cognitive impairment was found in bed with the call light on the floor and out of reach. The resident was unable to access the call light and requested help from the surveyor. Staff interviews and facility policy confirmed that call lights should always be within reach to allow residents to request assistance.
A CNA failed to perform hand hygiene after touching a potentially contaminated curtain and before donning clean gloves to provide incontinence care for a resident with vascular dementia and incontinence. This lapse was inconsistent with facility policy and standard precautions, as confirmed by interviews with the DON and an LVN.
Six residents with varying levels of cognitive and physical impairment were found to have nurse call lights out of reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed the expectation that call lights be within reach, but observations showed this was not consistently done.
Four dependent residents did not receive their scheduled showers, and there was no documentation to confirm that bathing assistance was provided. Interviews revealed that residents received showers less frequently than scheduled, often only after complaints, due to CNA shortages and turnover. Both the DON and ADON were unable to produce records of shower provision, citing changes in ownership and documentation systems.
Four residents requiring respiratory care did not have their respiratory equipment, such as nasal cannulas and a trach hose, properly stored when not in use. Instead, the equipment was found unbagged and on the floor, contrary to care plans and physician orders. Facility staff confirmed that this practice did not meet expected standards for infection prevention and equipment management.
A resident with severe cognitive impairment and a suprapubic catheter was observed with an uncovered catheter bag visible from the room entrance, in violation of facility policy and dignity standards. Both an LVN and the DON acknowledged that the catheter bag should have been covered to protect the resident's dignity.
A resident with cognitive impairment and aphasia exited the facility undetected and walked several miles to an emergency department, after staff failed to promptly notice and report the absence. The resident was not previously identified as an elopement risk, and the door used did not alarm, resulting in a lack of adequate supervision and failure to prevent the accident.
A resident with multiple medical conditions experienced ongoing issues with ill-fitting dentures, resulting in pain and difficulty eating. Although the resident reported the problem to the ADON and requested to see an outside dentist, there was no timely follow-up, documentation, or communication with the Social Worker or DON. The lack of action and coordination among staff led to the resident's dental needs not being addressed as required by facility policy.
The facility failed to submit PBJ staffing data to CMS for Q2 2024 due to a change in ownership and lack of access to previous records. The new management could not retrieve necessary data from the bankrupt previous owners, leading to a deficiency in reporting. The facility also lacked a specific policy for PBJ data submission.
The facility failed to provide palatable and attractive meals, as observed by state surveyors and reported by residents. Meals were often tasteless, cold, and improperly prepared, with issues such as bland mashed potatoes and overly vinegary green beans. Despite following recipes, the Dietary Manager was unaware of resident complaints, indicating a gap between policy and practice.
A resident with a suprapubic catheter was found with unsecured tubing, contrary to facility policy requiring a stabilization device every shift. The resident, who had severely impaired cognition and a history of UTIs, was at risk of trauma and infection. The oversight occurred after a shower, as confirmed by the DON and LVN involved.
A resident with a suprapubic catheter did not receive care in accordance with Enhanced Barrier Precautions, as CNAs failed to wear gowns during high-contact care activities. Despite signage and PPE availability, the CNAs believed the precautions were no longer necessary. The resident had multiple medical conditions and required specific precautions due to his indwelling catheter, but staff miscommunication led to a lapse in infection control protocols.
A resident with severely impaired cognition was left exposed during incontinent care due to a missing privacy curtain, which was not replaced after a room cleaning. Staff failed to prevent unauthorized entry during care, violating resident privacy and dignity. The facility's policies on privacy were not followed, leading to a risk of embarrassment for the resident.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Cook F did not log food temperatures for a dinner service, and several opened food items were not labeled with a received or opened date. These actions could place residents at risk for foodborne illness.
The facility failed to clean a resident's bathroom for three consecutive days, despite the resident's severe obesity, cellulitis, type 2 diabetes, and major depressive disorder. This neglect increased the resident's depression and risk of infection, as confirmed by multiple observations and staff interviews.
A facility failed to maintain an infection control program when an LVN did not wear a gown while providing care to a resident on contact isolation precautions for a multidrug-resistant organism. Despite being in-serviced on proper PPE use, the LVN entered the room with only a mask and gloves, risking the spread of infection.
A resident with severe cognitive impairment and existing pressure ulcers experienced a significant deterioration in health due to a new pressure ulcer on the sacrum. The facility failed to notify the wound physician in a timely manner, resulting in the wound developing into a Stage 4 pressure ulcer. Staff did not follow proper notification procedures, and there was a lack of documentation and follow-up, leading to delayed wound care and management.
A resident with severe cognitive impairment and existing pressure injuries did not receive consistent weekly skin assessments, leading to the development of an unstageable pressure ulcer on the sacrum. Despite physician orders for treatment and a WMD consultation, the facility delayed consulting the WMD for 12 days, during which the wound worsened. Inadequate documentation and communication among staff contributed to the deficiency.
Failure to Ensure Timely Response to Call Light for Resident with Behavioral Care Plan
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodations for her needs, specifically regarding timely response to her call light. The resident, a cognitively intact female with diagnoses including cerebral edema, chronic respiratory failure with hypoxia, diabetes, and acute kidney failure, required partial to moderate assistance with toileting hygiene and was dependent for toilet transfers. On the date in question, the resident reported that she pressed her call light multiple times and waited approximately 15 minutes without a response, leading her to call 911 for assistance. Police responded to her call and spoke with both the resident and facility staff. Interviews with staff revealed that the resident was known for frequent use of the call light and for changing her mind about care needs shortly after declining assistance. Staff described repeated entries into her room to address her requests, and noted that she was care-planned for behaviors such as making false allegations and requesting continuous staff presence. On the day of the incident, staff recounted that the resident refused care from one CNA, requested another, and then refused that CNA as well, before eventually allowing the original CNA to return. During this time, the police arrived in response to her 911 call. Facility records and staff interviews indicated that the resident had a history of making allegations about delayed or refused care, and her care plan included interventions for these behaviors. The facility's policy required call lights to be answered within five minutes, but the resident reported a significantly longer wait time. Staff and administration acknowledged the resident's behavioral patterns and the ongoing investigation into her grievance, but the deficiency centered on the failure to ensure timely response to her call light as required by facility policy.
Failure to Promptly Resolve and Communicate Resident Grievance
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances was honored and that prompt efforts were made to resolve those grievances. Specifically, a cognitively intact male resident with a history of anxiety, depression, diabetes, morbid obesity, and multiple sclerosis submitted a grievance regarding an undercooked baked potato served at dinner. The resident reported that after submitting the grievance form to the Assistant Director of Nursing (ADM), the Dietary Manager (DM) approached him but did not apologize or take responsibility for the issue. Instead, the DM asked if the resident had requested the dietary staff to reheat the potato and suggested that he should notify staff immediately if such issues occur again. The resident felt that his concerns were not properly addressed and that there was no direct follow-up regarding the status of his grievance. Further review revealed that the facility's grievance policy required prompt resolution and a written response to the resident, including details of the investigation and outcome. However, neither the DM nor the ADM provided the resident with a written resolution or communicated the outcome of the grievance. The ADM confirmed that the grievance form was handed to the DM for follow-up, but no resolution was documented or conveyed to the resident as required by policy. This lack of appropriate response and communication constituted a failure to resolve the resident's grievance in accordance with facility policy.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents during a transfer. Specifically, two staff members, an RN and a CNA, transferred a resident from the floor to her wheelchair without using a gait belt and instead lifted her by placing their arms under her armpits. This method of transfer was observed in a video provided by a family member and was reviewed by facility leadership, who confirmed that it was not in accordance with facility policy or standard practice. The resident involved was an elderly female with multiple diagnoses, including coronary artery disease, hypertension, renal insufficiency, hyperlipidemia, and dementia, resulting in severe cognitive impairment. Her care plan indicated she required partial to moderate assistance for transfers and was able to bear weight and pivot with support. Staff interviews and record reviews confirmed that the resident was assessed as a one-person transfer with a gait belt for all transfers, and that staff had been trained and were expected to use gait belts rather than lifting under the arms. Multiple staff members, including the DON, CNA, LVN, and PT, acknowledged that transferring a resident by lifting under the armpits was not appropriate and could cause injury. The facility's policy and in-service training materials also specified the use of gait belts and prohibited lifting residents by or under their arms. Despite this, the observed transfer did not follow these protocols, resulting in a deficiency related to accident prevention and safe transfer practices.
Failure to Provide Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Specifically, one resident with multiple medical diagnoses, including diabetes, morbid obesity, and multiple sclerosis, reported receiving an undercooked baked potato and lukewarm vegetable soup. Observations and interviews confirmed that the resident was served a half-baked potato, which he saved to show to staff, and that the quality and temperature of food varied from day to day. The resident had not discussed these issues directly with the dietary manager at the time of the incident. Staff interviews revealed that meal trays were delivered to the dining room and rooms after being checked by a nurse, with drinks passed out first. A test tray prepared for surveyors showed food items at varying temperatures, with some items not at appropriate serving temperatures. The facility's policy required food to be prepared in a way that conserved nutritive value, flavor, and appearance, but the observed practices and resident reports indicated this standard was not consistently met.
Failure to Maintain Functional Resident Call System
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident in her room, resulting in the resident being unable to reliably summon staff assistance. The resident, who had a history of cervical disc disorder, spinal fusion, osteoporosis, and anxiety, required substantial assistance with toileting and was at moderate risk for falls. Despite repeated reports from the resident that her call light was malfunctioning—sometimes not working at all or only intermittently functioning—maintenance checks did not resolve the issue, and the problem persisted for approximately two weeks. Multiple staff interviews confirmed that the call light in the resident's room was unreliable, with some staff noting a possible wiring shortage and delays in response. The resident reported waiting for up to two hours for assistance and ultimately called 911 to have emergency services contact the facility on her behalf. Staff acknowledged the ongoing issue, with maintenance staff indicating that a technician should have been called to inspect the system, but no documentation of repairs or technician visits was provided. The resident was offered a room change, which she declined, and was eventually provided with a manual call bell as a temporary solution. Facility policy required that the call system remain functional at all times and that calls for assistance be answered within five minutes. However, the resident's repeated complaints and the lack of timely resolution to the malfunctioning call light system demonstrated a failure to meet these standards. The deficiency was substantiated through observations, interviews, and record reviews, which consistently indicated that the resident did not have reliable access to staff assistance through the required communication system.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs and preferences for a resident by not maintaining the call light system in an accessible position. On the date of observation, the resident, who had Alzheimer's disease, moderate cognitive impairment, and muscle wasting, was found lying in bed with the call light on the floor, out of reach. The resident confirmed she could not access the call light and requested assistance from the surveyor. The Director of Nursing (DON) entered the room, observed the call light on the floor, and repositioned it within the resident's reach. The DON stated that the call light should always be accessible to the resident. Interviews with facility staff, including a CNA, an LVN, and the Administrator, confirmed the expectation that call lights should be within reach of all residents to ensure they can communicate their needs and request help. The resident's care plan specifically included an intervention to keep the call light within reach due to her risk for falls and need for assistance with self-care and mobility. Facility policy also required that call lights be accessible to residents when in bed.
Failure to Ensure Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident reviewed for infection control. During incontinence care, a CNA performed hand hygiene and donned gloves before beginning care, but after removing soiled gloves and touching the resident's curtain with bare hands to retrieve new gloves, the CNA did not perform hand hygiene before putting on clean gloves to continue care. The curtain was identified as a potentially contaminated surface. The CNA acknowledged after the incident that she should have used hand sanitizer before putting on new gloves, recognizing the curtain could be dirty. The resident involved was an elderly female with diagnoses including hypertension, hyperlipidemia, and vascular dementia, and was always incontinent of bowel and bladder. The resident's care plan required regular checks and assistance with toileting and incontinence care. Interviews with the DON and an LVN confirmed that facility policy and standard precautions require hand hygiene before and after glove use, and that the observed lapse was inconsistent with both facility policy and recent staff training. Review of the facility's hand hygiene policy further confirmed the expectation for hand hygiene before donning gloves and after glove removal.
Failure to Ensure Accessible Nurse Call System for Multiple Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for six out of ten residents reviewed for call system access. Observations on the specified date revealed that the call lights in the rooms of these residents were not within their reach. In several cases, the call lights were found hanging from the bed near the floor, on the floor under or behind the bed, or on another bed in the room, making it impossible for the residents to access them when needed. The residents affected had significant medical histories, including severe cognitive impairment, muscle weakness, repeated falls, lack of coordination, and difficulty walking. Their care plans specifically included interventions to ensure the call light was within reach and to encourage use of the call system. Despite these documented needs and interventions, staff did not consistently ensure the call lights were accessible, as evidenced by direct observations and resident interviews. One resident with intact cognition was observed nearly falling while trying to retrieve her call light from the floor. Interviews with staff, including LVNs, CNAs, the ADON, and the DON, confirmed that call lights should be within reach of residents and that staff are expected to check call light placement during rounds. Staff acknowledged the importance of call light accessibility and recognized that the observed situations did not meet facility expectations or policy. The facility's policy states that residents are to be provided with a means to call staff for assistance through a communication system, but this was not consistently implemented.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary assistance to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, four residents who required varying levels of assistance with bathing did not receive their scheduled showers, and there was no documentation available to confirm that these showers had been provided. The lack of records was confirmed by both the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who were unable to produce any Bath/Shower Sheets for the month in question. Interviews with the affected residents revealed dissatisfaction with the care provided, particularly regarding the infrequency of showers and delayed response to call lights. Residents reported only receiving about one shower per week, despite being scheduled for more frequent bathing, and attributed this to staff shortages and high turnover among Certified Nursing Assistants (CNAs). Some residents stated that they only received showers after making complaints to the DON, and expressed discomfort with feeling unclean. The DON acknowledged receiving complaints about missed showers upon starting her position and confirmed that either showers were not being given or CNAs were not documenting them. The facility had recently experienced a change in ownership, which led to inconsistencies in the system used to track shower provision. The ADON also noted concerns about the lack of documentation and was unable to confirm whether residents were receiving their scheduled showers. The facility's policy required appropriate support and assistance with hygiene for residents unable to carry out ADLs independently, but this was not consistently provided or documented.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four out of seven residents reviewed for respiratory care. Specifically, three residents who required oxygen therapy via nasal cannula were observed to have their nasal cannulas left unbagged and on the floor when not in use, contrary to professional standards and facility policy. Another resident with a tracheostomy was observed to have her trach hose on the floor rather than properly stored. These actions were inconsistent with the residents' comprehensive care plans and physician orders, which specified the need for proper respiratory equipment management. Interviews with facility staff, including an LVN, the DON, and the ADON, confirmed that the expectation was for all respiratory equipment, such as nasal cannulas and trach hoses, to be bagged or properly stored when not in use to prevent contamination. The staff acknowledged that the observed practices did not meet these expectations. Record reviews indicated that the affected residents had significant medical histories, including heart disease, heart failure, tracheostomy, and a history of COVID-19, and required varying levels of assistance with activities of daily living.
Failure to Maintain Resident Dignity by Not Concealing Catheter Bag
Penalty
Summary
A deficiency was identified when a male resident with severe cognitive impairment, renal failure, and a suprapubic catheter was observed with his catheter bag hanging from his bed in clear public view, without a privacy bag covering it. The catheter bag was visible from the entrance to the resident's room, and there was no intervention in the resident's care plan addressing the use of a catheter bag. The resident required full assistance with activities of daily living and had a diagnosis of bladder incontinence, but the care plan did not specify measures to maintain dignity regarding catheter use. During the survey, a Licensed Vocational Nurse (LVN) confirmed that the catheter bag should have been covered with a privacy bag to protect the resident's dignity. The Director of Nursing (DON) also acknowledged the issue, stating that it was a dignity concern and that the catheter bag should always be covered. The facility's policy on dignity emphasized the importance of promoting residents' sense of well-being and self-worth, but this policy was not followed in the observed instance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dementia, aphasia, anxiety disorder, and major depressive disorder exited the facility without staff knowledge and walked 2.7 miles to a free-standing emergency department. The resident's wandering risk assessment, completed prior to the incident, indicated a low risk for elopement, and the comprehensive care plan noted the need for supervision and assistance with all decision-making due to impaired cognitive function. Staff interviews revealed that the resident was last seen in his room late in the evening, but was not accounted for during subsequent rounds, and his absence was not immediately reported to supervisory staff. The facility's staff did not notice the resident was missing until several hours after he had left the building. During this period, the resident was able to leave through an unknown door, which did not trigger an alarm, and was later found outside a hospital emergency room by a bystander. The resident was unable to communicate his intentions or the reason for his departure due to his aphasia and cognitive impairment. Staff interviews indicated that the resident had not previously displayed exit-seeking behavior, and the facility's criteria for high elopement risk did not identify him as such prior to the incident. The delay in recognizing the resident's absence and the lack of immediate notification to supervisory staff contributed to the failure to provide adequate supervision and prevent the accident. The facility's policies required staff to determine if a resident was on authorized leave, initiate a search if not, and notify appropriate parties if the resident could not be located. However, these procedures were not effectively implemented in this case, resulting in the resident's unsupervised exit and subsequent discovery at an external emergency department.
Failure to Provide Timely Dental Services and Address Denture Concerns
Penalty
Summary
The facility failed to provide or obtain appropriate dental services for a resident who experienced issues with his dentures. The resident, a male with diagnoses including COPD, dysphagia, and bipolar disorder, was admitted to the facility and initially received new dentures, which he reported fit well. However, within a short period, he reported that the bottom denture did not fit, causing him pain and difficulty eating certain foods. Despite informing the ADON about the issue, the resident did not receive timely follow-up or resolution for his denture concerns. The resident stated he communicated his denture problem to the ADON both shortly after receiving the dentures and again approximately two weeks prior to the survey. He expressed a preference to see a dentist outside of the facility's usual provider. The ADON acknowledged being told about the issue but did not check the resident's insurance, notify the Social Worker or DON, or document the concern in the resident's record. The Social Worker and DON were both unaware of the resident's ongoing denture problem until the time of the survey. Facility staff interviews revealed a lack of communication and follow-up regarding the resident's dental needs. The Social Worker indicated she would have arranged for dental services if she had been informed, and the DON stated she would have acted immediately had she known. The facility's policy required routine and emergency dental services to be provided according to the resident's assessment and care plan, but this was not followed in the resident's case.
Failure to Submit PBJ Staffing Data for Q2 2024
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the second quarter of fiscal year 2024, covering January 1 to March 31, 2024. This deficiency was identified through interviews and record reviews, which revealed that the facility did not submit the required Payroll Based Journal (PBJ) staffing data. The failure to submit this data could potentially place all residents at risk for unmet personal needs, decreased quality of care, and a decline in health status and well-being. The deficiency was attributed to a change in ownership of the facility in May 2024. The new management reported that the previous owners, who were bankrupt, did not pay their vendors, resulting in the current owners being unable to access the necessary records to submit the PBJ data. The Chief Operations Officer confirmed that he is responsible for submitting the PBJ data but was unable to do so for the specified quarter due to the lack of access to previous records. The facility also lacked a specific policy for PBJ data submission, relying instead on the CMS PBJ Policy Manual.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide palatable and attractive food for two consecutive lunch meals, as observed by state surveyors. On both occasions, the meals were tasted by four surveyors who found the food to be lacking in flavor. Specifically, the glazed carrots, dinner roll, and noodles were described as tasteless on the first day, while the mashed potatoes were bland and the green beans had a strong vinegar taste on the second day. The kitchen staff was observed plating the food using warmer plates and covers, but this did not seem to improve the taste or temperature of the meals. Multiple residents reported dissatisfaction with the food, citing issues such as meals being served cold, food being overly salty, and desserts being improperly packaged and prepared. One resident mentioned that meals were often late on weekends, and another noted that French fries were frequently cold by the time they reached the dining tables. Despite these complaints, the Dietary Manager was unaware of any resident grievances regarding the food quality. The facility's dietary policies and procedures were reviewed, revealing that food should be prepared to conserve nutritive value, flavor, and appearance, and served at an appetizing temperature. However, the surveyors' observations and resident interviews indicated that these standards were not consistently met. The Dietary Manager and Dietitian confirmed that recipes were followed, but the surveyors' tasting results contradicted the intended flavors, suggesting a disconnect between policy and practice.
Failure to Secure Catheter Puts Resident at Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, identified as Resident #24, who was incontinent of bladder and had a history of urinary tract infections. The resident, a male with severely impaired cognition and dependent on staff for daily activities, had an indwelling suprapubic catheter. The facility's records indicated that the catheter should be secured with a stabilization device every shift to prevent trauma and infection. However, during an observation, it was noted that the catheter tubing was not secured to the resident's body, which was confirmed by a CNA who stated that the tubing was sometimes secured with a strap but was not at that time. Further interviews revealed that the resident's charge nurse, LVN C, had forgotten to replace the catheter stabilization device after the resident's shower. The Director of Nursing (DON) acknowledged the risk of not securing the catheter, which could lead to dislodgement and bleeding. The facility's policy on catheter care emphasized the importance of securing the catheter to reduce friction and movement at the insertion site. Despite this policy, the failure to secure the catheter was documented, and the resident was at risk of urinary tract infections and injury from trauma.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A and CNA B who did not adhere to Enhanced Barrier Precautions while providing care to a resident. The resident, who had a suprapubic catheter, was observed receiving incontinent care without the CNAs donning gowns, despite the presence of signage and PPE supplies indicating the need for such precautions. Both CNAs were aware of the risks associated with improper infection control procedures but were under the impression that the resident's precautions had been lifted. The resident in question was a male with severely impaired cognition, dependent on staff for various activities of daily living, and had multiple medical conditions including a history of urinary tract infections. His care plan specifically required Enhanced Barrier Precautions due to his indwelling catheter, which necessitated the use of gowns and gloves during high-contact care activities. Despite this, the CNAs only used gloves and masks, neglecting the gown requirement, which was a critical component of the precautions. Interviews with facility staff, including the DON, ADON, and the resident's charge nurse, revealed a lack of clarity and communication regarding the resident's ongoing need for Enhanced Barrier Precautions. The staff acknowledged the risk of cross-contamination and infection spread due to the failure to follow proper PPE protocols. The facility's policy and CDC guidelines clearly outlined the necessity of these precautions for residents with indwelling medical devices, yet the oversight occurred, leading to the deficiency.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure that Resident #24 was treated with respect and dignity, as required by resident rights regulations. During an observation, it was noted that the resident, who has severely impaired cognition and is dependent on staff for various activities, was exposed from the waist down while receiving incontinent care. The resident's bed was positioned close to the door, and there was no privacy curtain to shield him from view when the door was opened by unknown individuals. This lack of privacy was not addressed by the CNAs providing care, who did not call out to prevent entry or indicate that care was being provided. The absence of a privacy curtain was attributed to a recent deep cleaning of the resident's room, during which the curtain was removed but not replaced. Interviews with staff, including the CNAs, DON, ADON, and housekeeping personnel, revealed a lack of awareness and communication regarding the missing curtain. The CNAs admitted they should have noticed the missing curtain and taken steps to ensure the resident's privacy. The DON and ADON acknowledged the violation of privacy and the need for staff to announce care activities to prevent unauthorized entry. The facility's policies on resident rights and privacy were not adhered to, as evidenced by the failure to provide adequate privacy during personal care. The Administrator and Housekeeping Supervisor confirmed that privacy curtains are typically replaced immediately after removal for cleaning, but this procedure was not followed in this instance. The lack of a specific policy on privacy curtains was noted, and the risk of embarrassment and loss of dignity for the resident was acknowledged by multiple staff members.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. On one occasion, Cook F did not log food temperatures for the dinner service, as observed on the Trayline Temperature Log. The Dietary Manager confirmed that Cook F, a new employee, was responsible for logging food temperatures before serving residents but failed to do so. The dinner menu included sausage links, chocolate chip sheet pan pancakes, hashbrown casserole, strawberries and bananas, margarine, syrup, salt and pepper, milk, and water. The facility's food policy required that food temperatures be monitored by food service staff, but this was not adhered to, potentially placing residents at risk for foodborne illness due to unsafe food temperatures or improperly cooked food. Additionally, the facility failed to label and date opened food items. Observations revealed that two loaves of bread, a bag of hot dogs, and six hamburger buns were not labeled with a received or opened date. The Dietary Manager admitted responsibility for labeling and dating food but did not label the bread products, citing uncertainty about whether bread needed to be labeled. The facility's policy required that opened food items be dated and sealed during storage. The Food and Drug Administration Food Code also mandates that refrigerated, ready-to-eat time/temperature control for safety food be clearly marked with the date or day by which the food should be consumed, sold, or discarded. The failure to label and date these food items could lead to foodborne illness from expired or stale food.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for one resident. Specifically, the facility did not clean the bathroom of a resident for three consecutive days. The resident, who has severe obesity, cellulitis, type 2 diabetes, and major depressive disorder, reported that housekeeping staff only cleaned the main room but neglected the bathroom. The resident expressed that this neglect increased her depression and made her feel self-conscious. Observations confirmed the presence of a white powder-like substance and gloves on the bathroom floor over multiple days. Interviews with staff revealed that the issue was communicated to housekeeping, but the bathroom remained uncleaned. The facility's policy requires daily cleaning and sanitization of resident bathrooms, which was not adhered to in this case. The Assistant Director of Nursing (ADON) and other staff acknowledged the oversight and its potential impact on the resident's mental health and infection risk. The facility's Housekeeping Services Policy mandates the use of disinfectants to sanitize all surfaces, including bathroom fixtures, which was not followed in this instance.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one resident observed for infection control. Specifically, a Licensed Vocational Nurse (LVN) did not don a gown when entering a resident's isolation room to provide care. The resident, a cognitively intact male with a history of pressure ulcers and cellulitis, was on contact isolation precautions due to a multidrug-resistant organism (MDRO). Despite being in-serviced on proper PPE use, the LVN entered the room wearing only a mask and gloves, neglecting to wear a gown as required by the facility's policy and the resident's care plan. This oversight was observed during the administration of IV medication and other care activities, such as handling the resident's urine bag and providing water. Interviews with the LVN and the Director of Nursing (DON) confirmed that full PPE, including a gown, should have been worn when entering the resident's room. The LVN admitted to forgetting to wear the gown due to being busy, acknowledging the risk of infection spread. The DON reiterated the importance of adhering to contact isolation precautions to prevent contamination. The facility's policy on isolation precautions, which mandates the use of gowns for interactions involving contact with the resident or potentially contaminated items, was not followed in this instance.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify and consult with the resident's physician regarding a significant change in the resident's physical status, specifically a deterioration in health due to a pressure ulcer. Resident #1, a female with severe cognitive impairment and multiple health issues, was under hospice care and had existing pressure ulcers. On January 11, 2024, an open area was discovered on her sacrum, which was not reported to the wound physician until January 23, 2024. This delay resulted in the wound developing into an unstageable pressure ulcer, which later required surgical debridement and was categorized as a Stage 4 pressure wound. Interviews and record reviews revealed that the facility's staff, including LVN C and ADON A, did not follow proper procedures for notifying the wound physician. LVN C, who was responsible for implementing care to prevent skin breakdown, assumed that ADON A had informed the wound physician about the open area. However, there was no documentation to confirm this communication. The wound physician was only informed during a routine visit on January 23, 2024, leading to a delay in appropriate wound care and management. The facility's policy on Change of Condition and Physician/Family Notification was not adhered to, as there was no documentation of the communication with the primary physician or the ADON. The lack of documentation and follow-up on the wound consultation request contributed to the delay in addressing the resident's deteriorating condition. This failure placed the resident at increased risk of complications, including pain, infection, and worsening of the existing wound.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development and worsening of pressure ulcers. The resident, who had severe cognitive impairment and was frequently incontinent, was at risk for pressure ulcers and had existing Stage 4 and unstageable pressure injuries. Despite having a care plan in place that included pressure-reducing devices and a turning/repositioning program, the facility did not consistently perform weekly skin assessments as required by the physician's orders. On one occasion, a Licensed Vocational Nurse (LVN) identified a dime-sized open area on the resident's sacrum and notified the primary physician, who ordered treatment and a consultation with a Wound Management Doctor (WMD). However, the facility failed to consult the WMD for 12 days, during which time the wound progressed to an unstageable pressure ulcer with necrotic tissue. The WMD eventually assessed the wound and performed surgical debridement, categorizing it as a Stage 4 pressure ulcer. The facility's documentation and communication were inadequate, as evidenced by discrepancies in skin assessment records and a lack of follow-up on the WMD consultation. Staff interviews revealed confusion and miscommunication regarding the resident's wound care needs, with some staff members unaware of the severity of the sacral wound. This lack of coordination and adherence to professional standards of practice placed the resident at increased risk of complications from pressure ulcers.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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