Navasota Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Navasota, Texas.
- Location
- 1405 E Washington, Navasota, Texas 77868
- CMS Provider Number
- 675399
- Inspections on file
- 40
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Navasota Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, gait abnormalities, bipolar disorder with psychotic features, generalized muscle weakness, and severely impaired decision-making repeatedly lay on a mattress placed on the floor beside the bed and crawled off the mattress toward a roommate’s bed, as documented in multiple nurse notes. Despite these documented behaviors and the use of the floor mattress, the comprehensive care plan was not updated to include this intervention or the resident’s crawling behavior, so it did not appear on the CNA Kardex. Interviews with the MDS coordinator, DON, CNA, LVNs, Administrator, and Nurse Consultant confirmed that such behaviors and interventions were expected to be care planned, that the Kardex information is derived from the care plan, and that there were inconsistencies and gaps in staff training and documentation practices related to care plan revisions.
The facility did not provide or document group, individual, or independent activities for all residents over a two-month period, as confirmed by record review, resident interviews, and staff admission. Several residents with mental health diagnoses reported boredom and lack of engagement during this time, and the Activity Director acknowledged the lapse in both activity provision and documentation.
Three residents with mental health diagnoses and behavioral challenges did not receive adequate psychiatric services, as psychiatric visits focused mainly on medication management and lacked individualized counseling or assessment of emotional well-being. Residents reported that their emotional needs and recent behavioral incidents were not addressed during psychiatric visits, and care plans were not fully implemented to meet their psychosocial needs.
Two residents with intact cognition and behavioral health diagnoses were involved in escalating arguments over hygiene, culminating in one physically assaulting the other in the therapy room. Staff present attempted verbal de-escalation but did not physically intervene, resulting in the assaulted resident sustaining a nose injury. The staff were unaware of prior conflicts and did not implement effective interventions to prevent the abuse.
Staff failed to keep a shower room door closed and locked, leaving hazardous chemicals accessible and unsupervised. Interviews with a CNA, DON, and Administrator confirmed that the expectation was for the door to remain locked, but the door was left open and staff could not recall the last in-service on this policy. The facility also lacked a formal protocol for accidents and hazards, and was unable to provide all required Safety Data Sheets for chemicals found in the shower room.
A resident with severe cognitive impairment and cervical fractures developed unstageable pressure ulcers under a C-collar due to staff failing to remove the collar for regular skin assessments, improper application and maintenance of the collar (including excessive taping and soiling), and lack of appropriate care planning and documentation. Staff interviews and record reviews confirmed that required skin checks and interventions were not performed, leading to the discovery of severe wounds and an Immediate Jeopardy finding.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
A medication cart was found unlocked and unattended near a nurse's station, with medications and biologicals accessible. An RN admitted to leaving the cart unsecured while assisting a resident, and both the DON and Administrator confirmed that staff had been in-serviced on the requirement to keep carts locked when not in use. Facility policy requires secure storage of all medications, accessible only to authorized personnel.
The facility did not ensure that information about the grievance process was accessible to residents, with postings placed out of reach and residents reporting they were unaware of how to file grievances or where to find forms. Interviews confirmed that most residents had not received information about voicing concerns, and the facility's policy requiring prominent postings and access to grievance forms was not followed.
Three residents who were unable to perform ADLs did not receive necessary assistance with hygiene, including regular bathing, nail care, and clothing changes. One resident had long, dirty fingernails and was not provided with proper nail care, another did not consistently receive scheduled baths or nail trimming, and a third wore the same stained clothing for days and missed multiple scheduled baths. Staff interviews revealed gaps in training and awareness regarding their responsibilities for providing personal hygiene care.
A resident with severe dementia and hypertension did not receive daily vital sign monitoring as ordered by a physician and required by a QAPI initiative. Over a 68-day period, vital signs were not recorded for 58 days, despite the resident being on antihypertensive medications. Staff interviews revealed confusion about responsibility for obtaining vital signs, and system setup issues prevented proper tracking. Nursing and administrative staff acknowledged the failure to follow physician orders for daily monitoring.
A Dietary Aide was observed preparing dessert and washing dishes in the kitchen without a hair restraint, despite being aware of the requirement and having received training. The Dietary Manager and Administrator confirmed that all dietary staff were expected to wear hair nets, and facility policy mandated their use to maintain sanitary food preparation.
A loose Tramadol pill, a controlled substance, was discovered unsecured in an RN medication cart. Nursing staff confirmed the medication was not properly secured, administered, or disposed of per facility policy. Audits showed the narcotic counts for two residents prescribed Tramadol were correct, and leadership indicated the pill may have fallen out during preparation. Facility policy requires strict handling of controlled substances, and the incident indicated a failure to ensure proper medication security and administration.
A resident with Parkinson's disease, malnutrition, and no natural teeth experienced pain when eating and had not seen a dentist during her stay, despite a care plan and physician order for dental consult. Staff interviews revealed confusion over referral responsibilities, and records showed no dental consult was arranged. The facility's policy required coordination between nursing and social services for dental care, but this was not followed, resulting in unmet oral health needs.
A nurse failed to wear gloves while opening oral medication capsules for a resident with severe dementia and other health conditions, despite facility policy and infection control standards requiring glove use. Multiple staff confirmed that gloves should have been used to prevent cross contamination during medication administration.
The facility did not ensure that survey results and plans of correction were accessible and visible to residents, their legal representatives, or visitors. The survey book was hidden behind a plant stand and only contained one survey report, while several residents reported not knowing how to access the information. The ADM was unaware of the full requirements for maintaining and updating the survey book.
The facility did not maintain sufficient numbers of nurse aides and licensed nurses on several shifts, resulting in missed care such as delayed call light response and incomplete assistance with activities of daily living. Residents and staff reported chronic understaffing, frequent call-ins, and high turnover due to low pay and overwork. Facility records and interviews confirmed that posted staffing requirements were not met, and staff from other departments had to assist with resident care to compensate for the shortages.
The facility failed to ensure that call lights were within reach for three residents, affecting their ability to request assistance. A resident with Alzheimer's had her call light behind her bed, another with hemiplegia found his call light inaccessible, and a third with dementia had her call light on the floor. Staff interviews confirmed the expectation for call lights to be within reach, but this was not consistently maintained.
A facility failed to include psych services in a resident's care plan, despite the resident receiving these services as per physician orders. The resident, with dementia and major depressive disorder, was seen by psych services, but this was not reflected in the care plan. Interviews with the DON and RCN confirmed the oversight, citing the absence of an MDS coordinator and the responsibility of the IDT to ensure accurate care plans.
A resident with severe cognitive impairment experienced multiple falls, but the facility failed to update the care plan to reflect these incidents. Interviews with the DON and RCN confirmed that the care plan should have been revised to ensure appropriate care. The facility's policy requires care plans to be updated based on changing needs, which was not followed in this case.
The facility failed to post daily nurse staffing information for seven consecutive days, as the new DON was unaware of this requirement and the facility lacked a policy. The administrator, who usually posted the information, was out sick, leading to the oversight. The RCN confirmed the posting responsibility was not communicated, and the weekend supervisor also did not post the information.
A resident with a history of stroke and diabetes experienced severe pain and swelling in her left arm, but the facility failed to notify her physician immediately. Despite the resident's complaints and visible symptoms, the physician was only informed during routine rounds, leading to a delayed diagnosis of a ruptured bicep tendon. The lack of timely communication and adherence to notification policies was acknowledged by the facility's DON.
A resident with PTSD was placed in a shared room, contrary to their care plan, which specified the need for a private room to prevent PTSD triggers. Facility staff, including an LVN, MDS Coordinator, and DON, were unaware or did not adhere to the care plan, leading to a deficiency in trauma-informed care. The facility's policy on trauma-informed care was not effectively implemented, placing the resident at risk for psychological distress.
A resident with severe cognitive impairment and dependent on staff for all ADLs was left in the same position in a Geri-chair for over six hours without being turned or provided incontinent care, leading to the development of two DTIs. The facility failed to follow its own care plan and policies for pressure injury prevention, resulting in skin breakdown.
The facility failed to provide a private space for resident council meetings, holding them in an open dining area without doors, compromising residents' ability to voice grievances confidentially. Residents expressed discomfort with the lack of privacy, and the facility could not provide Resident Council minutes or policy when requested.
The facility failed to provide necessary assistance for ADLs, including repositioning and incontinent care, for two residents, and did not maintain proper nail hygiene for three residents. Observations revealed saturated briefs and blackish substances under fingernails, indicating a lack of care. Staff interviews highlighted confusion over responsibilities and a failure to seek help, placing residents at risk for health issues.
A facility failed to provide resident-centered activities for four residents, leading to a lack of engagement in both one-on-one and group activities. Residents with various diagnoses, including dementia, multiple sclerosis, and sensory impairments, were observed spending significant time in their rooms with minimal stimulation, such as television. Staff interviews confirmed the absence of appropriate activities, and the facility's administrator acknowledged the deficiency.
The facility failed to properly prepare pureed food, specifically meatloaf, by using water instead of broth or thickener, contrary to the facility's recipes. Staff did not have recipes available during preparation, and interviews revealed a lack of understanding of the negative outcomes of using water, which can dilute nutritional content. The Administrator confirmed that staff were trained and recipes were available, but they were not being followed, leading to the deficiency.
The facility failed to label and date food items in storage and did not maintain proper food temperatures before serving. Observations revealed unlabeled milk, juices, dough, and sausage patties, and improper temperatures for pureed meatloaf and peas. Staff interviews confirmed awareness of the risks associated with these deficiencies.
A resident with a history of behavioral issues was left without a meal for 20 minutes while his tablemate ate, leading to feelings of frustration and anger. The delay was due to a lack of communication between nursing and dietary staff about the resident's dining location, violating the facility's dining room etiquette policy.
The facility failed to ensure call lights were within reach for two residents, leading to potential risks of falls and unmet needs. One resident with essential tremor and dementia could not reach his call light, while another with lymphedema and depression found hers behind her recliner. Staff interviews confirmed the responsibility to ensure call light accessibility, but training dates were not recalled, and the facility's policy was not provided.
A facility failed to include a resident's indwelling urinary catheter in their care plan, incorrectly noting bladder incontinence instead. The resident, with severe cognitive impairment and multiple diagnoses, was observed with the catheter drainage bag on the floor. The DON acknowledged the oversight, noting the lack of a dedicated person for care plans.
The facility failed to provide necessary interventions for two residents with hand contractures, leading to a risk of decreased mobility. One resident was observed without prescribed splints and had untrimmed nails, while another lacked consistent use of a therapy carrot. Staff cited short staffing as a reason for not implementing care plans, and the DON acknowledged the need for regular monitoring.
A resident with severe cognitive impairment and an indwelling urinary catheter was observed with the catheter drainage bag placed on the floor, increasing the risk of UTIs. The facility's care plan did not address this issue or include the use of a catheter secure device. Staff interviews confirmed the lack of consistent monitoring and intervention, and the facility's policy did not cover the use of secure devices.
A resident with dementia and an indwelling urinary catheter exhibited behaviors such as placing the catheter bag on the floor and attempting to hit staff with it. The facility failed to develop a comprehensive care plan addressing these behaviors, leading to potential risks of urinary tract infections and traumatic catheter removal. Observations and interviews revealed a lack of staff awareness and documentation regarding interventions for the resident's behaviors.
An LVN failed to sanitize a common glucometer between blood sugar checks for two residents, potentially leading to contamination and disease spread. One resident was cognitively intact with Diabetes Mellitus Type II and a history of sepsis, while the other had severe cognitive impairment and Diabetes Mellitus Type II. The facility's infection control policy requires cleaning of equipment to prevent disease transmission, which was not followed.
Failure to Care Plan Mattress Use and Crawling Behavior for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with measurable objectives and timeframes that reflected a resident’s identified needs and behaviors. The resident was an elderly male with Alzheimer’s disease with late onset, abnormalities of gait and mobility, bipolar disorder with severe depressive episode and psychotic features, generalized muscle weakness, and a prior cerebral infarction. His Quarterly MDS showed he was unable to complete the BIMS, had poor short- and long-term memory, severely impaired decision-making, difficulty focusing, and disorganized thinking. He required at least supervision or touching assistance for eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers. Despite these needs and cognitive impairments, his Comprehensive Care Plan dated 01/19/2026 and revised on 02/05/2026 did not include that he had a mattress beside his bed, that he lay on this mattress, or that he crawled off the mattress toward his roommate’s bed. Nursing documentation showed repeated observations of the resident lying on a mattress on the floor next to his bed and engaging in crawling behavior toward his roommate’s bed, but these observations were not incorporated into the care plan. Nurse notes on 01/31/2026 at multiple times documented the resident lying on a mattress on the floor parallel to his bed. Additional nurse notes on 02/02/2026 documented that the resident was not staying on the mattress, crawled off it twice, and was observed crawling toward his roommate’s bed, and later that he rolled off the mattress onto the floor and toward the roommate’s bed, awakening the roommate. None of these behaviors or the use of the mattress on the floor were reflected in the resident’s care plan, and therefore were not communicated through the care plan to guide staff interventions. Interviews with facility staff confirmed that the behavior and mattress use should have been care planned and that the care plan is the source of information for the CNA Kardex. The MDS Coordinator stated that if a resident had a mattress beside the bed and was crawling off it toward a roommate’s bed, this behavior was expected to be care planned, and acknowledged that the care plan is used to inform staff how to provide needed care and interventions. The DON and Administrator both stated their expectation that such a mattress and related behaviors be included on the care plan, and that CNA Kardex information comes from the care plan. A CNA/MA reported that the resident had a mattress on the floor by his bed for approximately two weeks before he died, that he preferred lying on the mattress, and that he began to crawl toward his roommate’s bed, but she did not recall seeing this on the Kardex. An LVN reported she had not been trained on how to document or revise care plans despite working at the facility for over a year, while another LVN stated she had been trained at a different facility owned by the same company. The Nurse Consultant stated all nursing staff had been in-serviced on documenting care plans but could not provide dates or documentation of such training. The facility’s written policy stated that care plans would be reviewed and revised based on changing goals, preferences, and needs, but the resident’s mattress use and crawling behavior were not added to the care plan despite repeated documentation in the nurse notes.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to provide an ongoing activity program to support residents' choices and needs for both group and individual activities, as well as independent activities, for the entire months of August and September 2025. Record review showed there were no activity participation records for these two months, and the Activity Director confirmed that there was no documentation of any activities provided during this period. The absence of activities was also corroborated by resident interviews, with multiple residents reporting a lack of activities and expressing feelings of boredom during this time. Three residents were specifically reviewed in relation to this deficiency. One resident, with diagnoses including major depressive disorder and other depressive disorders, reported feeling bored and stated that there were approximately two or three months with very few activities, except for reading and watching TV. Another resident, with mild intellectual abilities and major depressive disorder, stated that there were months with no activities except for occasional church services, though he did not get bored due to personal activities and family support. A third resident, diagnosed with bipolar disorder and generalized anxiety disorder, also reported periods without visible activities and occasional boredom, though he preferred solitary activities and sometimes attended music events or parties. The Activity Director, who had been certified and in her role for over ten years, admitted to not providing or documenting activities during the deficient months and did not request assistance. The Administrator was unaware of the lack of documentation until October 2025, as she had not yet monitored the activity department. The facility's job description for the Activity Director included maintaining detailed records of activity programs and participation, which was not fulfilled during the months in question.
Failure to Provide Appropriate Psychiatric Services for Residents with Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that residents diagnosed with mental illness, psychosocial adjustment difficulties, or a history of trauma and/or post-traumatic stress disorder received appropriate treatment and services to address their assessed problems and attain the highest practicable mental and psychosocial well-being. Specifically, three residents with significant behavioral health needs did not receive adequate psychiatric services. The deficiency was identified through interviews and record reviews, which revealed gaps in the provision of individualized psychiatric care and counseling. One resident with severe dementia, anxiety disorder, alcohol-induced persisting dementia, and a history of trauma exhibited multiple behavioral issues, including wandering, aggression, inappropriate exposure, and self-injurious behaviors. Although the care plan included interventions such as arranging for a licensed mental health provider and monitoring for escalating symptoms, documentation showed ongoing behavioral challenges and repeated psychiatric notes that primarily focused on medication management. The psychiatric provider's notes often indicated that non-pharmacologic interventions had been ineffective, but there was little evidence of ongoing, individualized psychiatric counseling or assessment of the resident's emotional state in relation to recent incidents. Another resident with major depressive disorder and chronic diarrhea reported feeling that psychiatric visits were superficial and did not address his emotional needs or recent conflicts with a roommate. He stated that the psychiatrist did not inquire about his feelings or the impact of recent altercations, and that visits were conducted in the presence of his roommate, making him uncomfortable to share openly. A third resident with mild intellectual disabilities, major depressive disorder, and generalized anxiety disorder also reported that psychiatric visits did not address his behavioral outbursts or emotional well-being, with interactions focusing on casual topics rather than his mental health needs. These findings demonstrate a lack of comprehensive psychiatric assessment and individualized counseling for residents with behavioral health needs.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, specifically failing to prevent one resident from physically assaulting another. One resident, who had a history of major depressive disorder and chronic diarrhea, was involved in a conflict with his roommate, who had diagnoses of bipolar disorder with psychotic features and generalized anxiety disorder. The conflict escalated due to ongoing arguments about hygiene and odor related to the first resident's medical condition. Despite both residents having intact cognition, their interpersonal issues were not identified or addressed by staff prior to the incident. On the day of the incident, the resident with chronic diarrhea exited the bathroom and discussed showering with a CNA, while his roommate overheard the conversation and became increasingly agitated. The agitated resident followed his roommate to the therapy room, where he began yelling and cursing. Therapy staff attempted to verbally de-escalate the situation by asking the agitated resident to calm down and go for a walk, but these interventions were ineffective and further escalated his anger. The resident then approached his roommate, who was seated, and struck him in the nose. Staff present in the therapy room did not physically intervene to prevent the assault, and the assaulted resident later expressed that if someone had stepped in front of him, he would not have been hit. Interviews with staff revealed that they were unaware of any prior arguments between the two residents and did not anticipate the escalation. The Director of Therapy acknowledged that the interventions used were not appropriate and that removing the assaulted resident from the situation would have been a better response. The facility's policy on abuse and neglect emphasizes the responsibility of staff to recognize and promptly intervene in situations that may constitute abuse, but in this case, staff failed to protect the resident from physical harm.
Failure to Secure Shower Room and Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards by not keeping the shower room door on one hallway closed and locked as required. During an observation, the shower room door was found propped open with no staff or residents nearby, and various potentially hazardous items such as no-rinse cleanser, shampoo, body wash, and shaving cream were accessible on top of a clothes barrel. Staff interviews confirmed that the expectation was for the shower room door to be locked at all times, and that staff had been in-serviced on this requirement, though the last in-service date could not be recalled. The CNA involved admitted to leaving the door unlocked and acknowledged the risks associated with residents accessing the chemicals inside. Further interviews with the DON and Administrator confirmed that all shower doors were expected to be closed and locked at all times to prevent residents from entering unsupervised, potentially ingesting chemicals, or being unable to call for help if they fell. The Administrator also stated that there was no formal protocol in place for accidents and hazards. A review of the Safety Data Sheet for one of the cleansers indicated that ingestion could be harmful, and the facility was unable to provide Safety Data Sheets for other chemicals present in the shower room.
Failure to Prevent Pressure Ulcers Under Cervical Collar
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice to prevent pressure ulcers for a resident with a cervical collar (C-collar). The resident, who had diagnoses including dementia, vertebral artery dissection, and cervical vertebra fractures, was admitted and readmitted to the facility without any initial evidence of pressure ulcers. Physician orders specified that the C-collar should be worn at all times except during showers, with a soft collar to be used for bathing. However, there were no orders or documented interventions for regular removal of the collar to perform skin checks, and the care plan did not address brace removal for skin assessment. Observations and interviews revealed that staff did not consistently remove the C-collar to assess the skin underneath, as required by facility policy and professional standards. The collar was found to be taped in place, with excessive tape wrapped around it, and was soiled with fecal matter and food. Nursing staff, including the treatment nurse and LVNs, reported not removing the collar for thorough skin assessments, and some staff were unaware of the presence or purpose of the tape. The resident was only documented as receiving baths on two occasions, and during these times, the collar was not always removed. When the resident was sent to the emergency room, hospital staff discovered unstageable pressure ulcers, wounds behind the ear and on the chin, and noted a strong odor and signs of infection under the collar. Interviews with facility staff and the resident's physician confirmed that proper procedures for skin assessment under immobilization devices were not followed. The physician stated that the collar should be fitted correctly and removed for skin checks as appropriate, and the facility's own policies required periodic removal of immobilization devices for skin assessment and cleanliness. Despite these requirements, staff failed to perform adequate skin checks, did not document concerns about the tape or soiling, and did not follow up with appropriate interventions to prevent pressure ulcers. These failures resulted in the development of unstageable pressure ulcers and an Immediate Jeopardy situation.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Unattended Unlocked Medication Cart Found in Hallway
Penalty
Summary
A deficiency occurred when a medication cart on [NAME] Hall was found unlocked and unattended near the nurse's station and hallway entrance. The state surveyor observed that the locking mechanism was protruding outward, and the drawers containing medications and biologicals could be opened. No nursing or other staff were present in the area at the time of observation. RN A later confirmed that he had left the cart unlocked while assisting with a resident transfer in a room where the cart was not visible. He acknowledged that the cart should have been locked at all times except when dispensing medications and that it was his responsibility to ensure its security. The key to the cart was in his pocket, and he stated that narcotics, PRN medications, a glucose monitor, and a blood pressure cuff were stored in the cart. Interviews with the Director of Nurses and the Administrator confirmed that their expectation was for all medication carts to be locked when not in use and that staff had been in-serviced on this policy, though neither could recall the specific date of the in-service. Both acknowledged that leaving the cart unlocked could allow residents, staff, or visitors access to medications. Review of the facility's policy indicated that medications and biologicals are to be stored securely and only accessible to authorized personnel, with medication carts to be locked or attended at all times.
Failure to Provide Accessible Grievance Process Information
Penalty
Summary
The facility failed to ensure that residents had accessible and adequate information regarding their right to voice grievances without discrimination or reprisal. Observations revealed that the grievance procedure was posted in only two locations: one near the front entrance, affixed approximately nine feet above the floor, making it difficult for residents—especially those in wheelchairs or of shorter stature—to read, and another behind the nurse's station desk, in an area not accessible to residents. A walkthrough of the facility confirmed that these postings were not positioned in a way that supported easy viewing or access by residents, their representatives, staff, or visitors. Additionally, there was no evidence that grievance forms or instructions for filing anonymous grievances were readily available to residents. Interviews with five of six residents indicated that they had not received information about the process for filing grievances or concerns within the facility. These residents reported being unaware of their right to formally voice concerns or complaints and did not know who to contact or where to find grievance forms or related resources. The facility's Grievance Policy required that residents be notified on how to file a grievance orally, in writing, or anonymously, with postings in prominent locations, but this was not being met in practice.
Failure to Provide Necessary ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. One male resident with Alzheimer's disease and cerebral infarction, who was on hospice care, was observed to have long, jagged fingernails with brown debris underneath. His care plan indicated a need for supervision or assistance with personal hygiene, but staff were unaware of their responsibility to provide this care. A female resident with type 2 diabetes, morbid obesity, and a history of stroke was dependent on staff for personal hygiene. Documentation showed that she did not consistently receive scheduled baths, with five missed or undocumented baths in one month. She also reported that her nails were not trimmed as requested, and staff were not aware of the need to provide this care. Another female resident with dementia and psychotic disturbance was also dependent on staff for personal hygiene. She was observed wearing the same stained clothing for three consecutive days and had long, dirty, jagged fingernails. Bathing records indicated that eight scheduled baths were not documented as given in one month. Staff interviews confirmed a lack of training and awareness regarding the importance of regular hygiene, nail care, and clothing changes for residents who are unable to care for themselves.
Failure to Monitor and Record Daily Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that a resident received daily vital sign monitoring as ordered by a physician and as part of a QAPI initiative to prevent rehospitalization. The resident, an elderly female with severe dementia, hypertension, and generalized anxiety disorder, had physician orders for daily vital signs, including blood pressure, pulse, temperature, respiration, and oxygen saturation, starting from late March. Despite these orders, there were 58 days within a 68-day period where no vital signs were recorded for the resident. Record reviews confirmed that the resident's care plan included monitoring for abnormal blood pressure due to cardiac disease, and medication orders for antihypertensive drugs were in place. However, documentation showed that vital signs were not consistently obtained or recorded, and direct observation revealed that staff did not take blood pressure or pulse prior to administering blood pressure medication. Interviews with nursing staff and medication aides indicated confusion regarding responsibility for obtaining vital signs, with some staff believing the order was no longer valid or that it was the nurse's responsibility rather than the medication aide's. Further interviews with nursing leadership revealed that the QAPI order for daily vital signs was not set up correctly in the system, which prevented proper tracking and auditing. The responsible nurse who initiated the order was no longer employed at the facility, and there was no specific policy for vital signs beyond following physician orders. The lack of daily vital sign monitoring as ordered was acknowledged by both nursing and administrative staff, who recognized the potential for unacknowledged changes in condition and possible hospitalization.
Failure to Ensure Dietary Staff Wore Hair Restraints During Food Preparation
Penalty
Summary
A deficiency was identified when a Dietary Aide was observed in the kitchen preparing dessert and washing dishes without wearing a hair restraint. The aide acknowledged during an interview that she was aware of the requirement to always wear a hair net, as she had been trained by a previous Dietary Manager and held a food handler certificate. She explained that she found a hair net on the floor but did not realize her own had fallen off. The Dietary Manager confirmed that it was expected for all dietary staff to wear hair restraints before entering the kitchen and noted that the aide's hair net often fell off due to its size. The facility had signage at the kitchen entrance reminding staff to wear hair nets, and the infection control policy required clean hair to be covered with an effective hair restraint. Interviews with both the Dietary Manager and the Administrator confirmed the expectation that all dietary staff must wear hair nets in the kitchen. The facility's infection control policy, dated 04/09/2025, specified that personal cleanliness and the use of hair restraints were required to maintain sanitary food preparation. The failure to ensure the Dietary Aide wore a hair net while handling food and dishes constituted a breach of professional standards for food service safety.
Loose Controlled Medication Found in RN Medication Cart
Penalty
Summary
A deficiency occurred when a loose Tramadol 50 mg pill, a controlled medication, was found unsecured in the bottom drawer of a locked RN medication cart during an observation. The pill was identified by an RN, who confirmed it was not properly secured, administered, or disposed of according to facility policy. The RN stated that it was the responsibility of staff administering medications to check their carts before use, and that all medication counts had been correct that morning. There were no previous discrepancies reported with the narcotics count, including Tramadol, and the RN indicated she would complete an incident report regarding the loose medication. Interviews with nursing leadership, including the RCN, ADON, and Traveling DON, confirmed that the presence of a loose controlled medication in the cart could mean a resident did not receive their prescribed pain medication, and there was potential for diversion. An audit was performed for the two residents prescribed Tramadol, and the counts were found to be correct, suggesting the pill may have fallen out during preparation. The facility's policy requires controlled substances to be handled in accordance with federal and state laws, with only authorized personnel having access. The ADM stated that controlled medications should be kept in a lock box and that the loose pill in the cart indicated a resident may not have received their ordered medication.
Failure to Provide Dental Services for Resident with Oral Health Needs
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident with significant oral health needs. The resident, a 69-year-old woman with diagnoses including Parkinson's disease, protein-calorie malnutrition, and rhabdomyolysis, had no natural teeth and experienced pain when eating certain foods. Despite a care plan identifying her risk for oral health problems and a physician order for a dental consult as needed, there was no evidence that a dental consult was arranged or that the resident was seen by a dentist during her stay. Record reviews showed that the resident's quarterly MDS assessment did not reflect mouth or facial pain, but the resident herself reported difficulty chewing and pain with hard foods during an interview. She stated she had not seen a dentist in three years, including the duration of her stay at the facility. Staff interviews revealed a lack of clarity and follow-through regarding the process for dental referrals, with social services, nursing, and administration each describing different responsibilities for ensuring dental care was provided. The resident was not added to the list for the mobile dental service, and there was no documentation of a dental exam or consult in her records. The facility's policy required that oral health services be available and that social services assist with dental appointments and transportation, following notification from nursing. However, the breakdown in communication and lack of action resulted in the resident not receiving the dental care outlined in her care plan and physician orders. This failure was identified through observation, interviews, and record review, and directly affected the resident's ability to eat comfortably and maintain oral health.
Failure to Use Gloves During Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use gloves while opening Depakote Sprinkles capsules for a resident during medication administration. The resident involved was an elderly female with severe dementia, essential hypertension, and cognitive communication deficits, who required supervision with eating and drinking. The resident's care plan included interventions for medication administration and monitoring for signs and symptoms of dysphagia. Despite facility policy and accepted infection control standards requiring glove use to prevent cross contamination, the LVN did not wear gloves when opening the capsules. Multiple staff interviews, including those with a medication aide, the LVN involved, the registered charge nurse (RCN), the director of nursing (DON), and the administrator (ADM), confirmed that the expected practice was to wear gloves during this procedure. The facility's infection control policy also specified glove use to reduce the risk of transmitting microorganisms. The failure to follow these procedures was observed directly and acknowledged by staff as a breach of infection control practices, potentially exposing the resident to cross contamination.
Failure to Provide Accessible Survey Results to Residents and Representatives
Penalty
Summary
The facility failed to ensure that residents had the right to examine the results of the most recent survey conducted by Federal or State surveyors, as well as any plan of correction in effect. During an observation, the survey results book was found placed behind a plant stand, making it difficult to locate or access. The book was not readily accessible or visible to residents, their legal representatives, or visitors. Additionally, the survey book only included the results from one survey and did not contain reports or plans of correction for the three preceding years as required. During a confidential group interview, six residents stated they were unaware of the existence of the survey book or how to access the survey results. The Administrator (ADM) confirmed it was her responsibility to maintain and update the survey book but was unaware of the requirement to include survey, certification, and complaint investigation reports, as well as plans of correction for the past three years. The ADM also stated she could not find a written policy regarding the maintenance and accessibility of the survey book.
Failure to Maintain Sufficient Nurse Staffing on Multiple Shifts
Penalty
Summary
The facility failed to provide sufficient numbers of nurse aides and licensed nurses on a 24-hour basis to meet the needs of all residents, as required by posted nurse staffing levels and resident care plans. Over a period of several days, staffing schedules and time punches revealed repeated shortfalls in both nurse aides and licensed nurses on multiple shifts, with the facility consistently missing the required number of staff as indicated by their own posted staffing requirements. The resident census during this period was 58, and the facility assessment confirmed this average census. Despite the posted requirements, actual staffing often fell short, with some shifts missing up to two nurse aides and one LVN. Resident council minutes and interviews with residents indicated that call lights were not answered in a timely manner and that scheduled showers were sometimes missed. Multiple residents reported delays in receiving assistance and noted that staff were overworked, with some residents stating they had to remain in bed due to insufficient staff to assist them. Staff interviews corroborated these findings, with several staff members reporting chronic understaffing, frequent call-ins, and high turnover due to low pay and overwork. Staff also reported that nurses and therapy staff had to assist with direct care tasks to compensate for the lack of nurse aides, which in turn prevented them from completing their own duties, such as charting. The facility's own policy and facility assessment required staffing decisions to be informed by resident needs and census, and to include contingency planning for staffing shortages. However, interviews with the Director of Rehabilitation, acting administrator, and multiple staff members confirmed that the facility was unable to maintain adequate staffing, particularly when scheduled staff called in or did not show up. The issue was widely known among staff and residents, and the facility struggled to recruit and retain staff, with sign-on bonuses and pay rates cited as contributing factors. Observations during the survey period showed that, while care was being provided and call lights were answered promptly during the survey, this was not representative of typical staffing levels, as staff reported that the facility was only fully staffed due to the presence of surveyors.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodations for their needs, specifically regarding the accessibility of call lights. Three residents were affected by this deficiency. Resident #1, a female with Alzheimer's Disease and severe cognitive impairment, was found with her call light behind her bed and out of reach. She was unaware of its location and unable to reach it, despite her care plan indicating that the call light should be within reach due to her communication problems and cognitive deficits. Similarly, Resident #2, a male with hemiplegia and moderate cognitive impairment, had his call light positioned behind his bed, making it inaccessible. He expressed that he often had to wait for staff to pass by for assistance. Resident #3, a female with unspecified dementia and aphasia, also had her call light out of reach, as it was found on the floor beside her recliner. She was unaware of its location and unable to reach it. Interviews with staff, including a CNA and the DON, confirmed that call lights should always be within reach, yet this was not consistently ensured, leading to the deficiency.
Failure to Include Psych Services in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not include the psych services the resident was receiving. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, an elderly female with diagnoses including unspecified dementia, major depressive disorder, and aphasia, had a physician order for psych services to evaluate and treat as needed. Despite this, the resident's care plan did not reflect these services, which were documented in psych service notes indicating the resident was seen on two occasions. Interviews with the Director of Nursing (DON) and the Registered Nurse Coordinator (RCN) confirmed that the resident was receiving psych services and that these should have been included in the care plan. Both the DON and RCN acknowledged the absence of a Minimum Data Set (MDS) coordinator and stated that it was the responsibility of the Interdisciplinary Team (IDT) to ensure the care plan was accurate. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes to meet residents' needs, but this was not adhered to in this case.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan was not updated to reflect the resident's recent falls on three separate occasions. The resident, who has severe cognitive impairment and is dependent on assistance for various activities of daily living, experienced falls on 12/20/2024, 01/24/2025, and 01/26/2025. Despite these incidents, the care plan did not include these falls, which could potentially impact the resident's care. Interviews with the Director of Nursing (DON) and the Registered Charge Nurse (RCN) revealed that the care plan should have been updated after each fall to ensure the resident received the most efficient care. The RCN noted that without a current MDS coordinator, it was the responsibility of the interdisciplinary team to update the care plan. The facility's Comprehensive Care Planning policy requires that care plans be reviewed and revised based on changing needs and interventions, but this was not adhered to in the case of the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily and was readily accessible to residents and visitors, as required. This deficiency was observed over a period of seven days, from January 24, 2025, to January 30, 2025. During this time, the nursing staffing information was not updated and remained dated January 23, 2025. The Director of Nursing (DON), who was new to long-term care, was unaware of the requirement to post this information. The facility also lacked a policy regarding the posting of nursing staff information, contributing to the oversight. Interviews with the DON and the RCN revealed that the responsibility for posting the staffing information was not clearly communicated, especially during the absence of the administrator due to illness. The RCN indicated that the administrator had been responsible for posting the information, and with the administrator out sick, the DON, who was not informed of this duty, did not ensure the information was posted. The RCN also mentioned that the weekend supervisor was responsible for posting on weekends, but this was not done. Both the DON and RCN stated that the lack of posted information would not adversely affect residents, although it was meant to demonstrate staffing transparency.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately inform a resident's physician and notify the resident's representative when there was a significant change in the resident's physical status. The resident, a female with a history of cerebral infarction, type II diabetes, muscle weakness, and lack of coordination, experienced swelling and pain in her left arm. Despite the resident's complaint of severe pain and visible swelling, the physician was not notified until several days later when the physician was on-site for rounds. On November 16, the resident reported a pain level of 10 out of 10, and interventions such as Tylenol and Voltaren Gel were administered, providing temporary relief. However, the physician was not informed of this significant change. It was only on November 20, when the physician was present at the facility, that an x-ray was ordered. The x-ray results, which showed no significant findings, were not communicated to the physician. The resident's condition worsened, leading her to request an emergency room visit on November 26, where she was diagnosed with a ruptured left bicep tendon. Interviews with the staff revealed a lack of communication and adherence to the facility's policy on notifying physicians of significant changes in a resident's condition. The Director of Nursing acknowledged that the physician should have been notified immediately about the swelling and increased pain. The physician expressed that had she been informed earlier, she would have sent the resident to the emergency room sooner. This oversight in communication and notification could have placed the resident at risk of further complications.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident diagnosed with PTSD, as outlined in the resident's care plan. The resident, who has a history of military service-related PTSD, was placed in a shared room with another resident, despite the care plan explicitly stating that having a roommate triggers the resident's PTSD. This oversight was identified during a review of the resident's care plan, which had been revised to include the need for a private room to prevent re-traumatization. Interviews with facility staff, including an LVN, the MDS Coordinator, the Social Worker, the DON, and the Regional Compliance Nurse, revealed a lack of awareness and adherence to the resident's care plan. The LVN was unaware of the resident's PTSD diagnosis and the associated care plan requirements. The MDS Coordinator acknowledged the failure to follow the care plan, which could lead to adverse effects, including potential physical altercations or re-traumatization. The Social Worker and the DON also confirmed that the resident's PTSD and triggers should have been care planned and followed through with, emphasizing the importance of adhering to the care plan to prevent negative outcomes. The facility's Trauma-Informed Care Policy mandates the identification and mitigation of triggers for residents with a history of trauma. However, the policy was not effectively implemented in this case, as evidenced by the resident's continued placement in a shared room. The facility's failure to adhere to the care plan and policy guidelines placed the resident at risk for psychological distress and re-traumatization, highlighting a significant deficiency in the provision of trauma-informed care.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide appropriate care to prevent pressure ulcers for a resident who was at risk for skin breakdown. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was left in the same position in a Geri-chair for six and a half hours without being turned or provided with incontinent care. This neglect led to the development of two deep tissue injuries (DTIs) on the resident's coccyx, which were previously unidentified by the facility. The resident's care plan included interventions to prevent skin breakdown, such as checking the resident every two hours and assisting with toileting as needed, as well as repositioning to prevent pressure on body parts. However, these interventions were not followed, as evidenced by the resident being left in the same position for an extended period. The facility's policy on pressure injury prevention and perineal care was not adhered to, resulting in the resident's skin breakdown. Interviews with staff revealed that the certified nursing assistant (CNA) responsible for the resident did not perform the necessary care due to being alone on the hall and not seeking assistance. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the resident's prolonged time in the chair, and the facility's monitoring systems failed to identify and address the issue in a timely manner.
Lack of Privacy for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for residents' monthly resident council meetings, which compromised the residents' ability to voice their grievances in a confidential setting. The meetings were initially held in the dining area, an open room next to the nurses' station without doors, which did not ensure privacy. This arrangement was confirmed by the Administrator during an interview, who acknowledged the lack of privacy in the current meeting location. A confidential resident group meeting was later held in the Activity Director's office, where residents expressed their discomfort with the usual meeting space in the dining room due to its lack of privacy. The residents indicated that they do not meet regularly and would prefer a private setting. The newly appointed Activity Director also confirmed that meetings should be held in a room with a door, such as the activity room, to ensure privacy. Additionally, the facility was unable to provide Resident Council minutes or a copy of the Resident Council Policy when requested by the surveyors.
Deficiencies in ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADLs) to residents who were unable to perform them independently. Specifically, the facility did not ensure that two residents received repositioning and incontinent care every two hours as required. Observations revealed that these residents were left in the same position for extended periods, resulting in saturated briefs with a strong urine odor. Interviews with staff indicated that the care was not provided due to a lack of assistance, and the staff did not seek help to perform the necessary care. Additionally, the facility failed to maintain proper nail hygiene for three residents, resulting in a blackish substance accumulating under their fingernails. These residents required assistance with personal hygiene due to cognitive and physical impairments. Despite requests from one resident to have their nails cleaned, the care was not provided. Interviews with staff revealed a lack of awareness and responsibility for nail care, with confusion over whether CNAs or nurses were responsible for cleaning the nails of diabetic residents. The deficiencies in providing ADL assistance and nail care placed residents at risk for health-related issues, including potential infections and skin breakdown. The facility's policies on perineal and nail care were not followed, leading to a decline in the quality of care provided to the residents. The observations and interviews highlighted a lack of communication and accountability among staff, contributing to the failure to meet the residents' needs.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the comprehensive assessment and care plan of each resident, as well as their preferences. This deficiency was observed in four residents who were not receiving one-on-one activities or participating in group activities over a four-month period. The lack of engagement in activities could potentially lead to a decline in their social, mental, and psychosocial well-being, as well as a diminished quality of life. Resident #4, a female with diagnoses including unspecified dementia, hemiplegia, cerebrovascular disease, and aphasia, was not receiving the one-on-one sensory stimulation activities outlined in her care plan. Observations showed that she spent significant time in her room with minimal stimulation, such as a television being on. Similarly, Resident #20, who had multiple sclerosis, dementia, major depressive disorder, and anxiety, was not engaged in activities that matched her interests, such as listening to music or participating in religious activities. Observations confirmed that she was often in her room with the television on, without any other form of stimulation. Resident #21, diagnosed with depression, anxiety, and dementia, also did not receive the one-on-one activities or group engagement specified in her care plan. She was observed in her room with the television on, lacking the socialization and sensory stimulation needed. Resident #61, who was legally blind, deaf, and non-verbal, was not provided with appropriate tactile sensory activities, as she consistently rejected the cloth activity item given to her. Staff interviews revealed a lack of alternative activities being offered to her, and she was often seen pacing or sitting without engagement. The facility's administrator acknowledged the absence of documented activities for these residents and recognized the potential negative impact on their well-being.
Deficiency in Puree Food Preparation
Penalty
Summary
The facility failed to prepare pureed food by methods that conserve nutritive value, flavor, and appearance, specifically in the preparation of pureed meatloaf. Observations revealed that staff members were using water instead of broth or thickener to puree meatloaf, which is against the facility's puree diet recipes. Staff members did not have the recipes available during food preparation, and one staff member admitted to forgetting to use them. Interviews with staff indicated a lack of understanding of the negative outcomes of using water, which can dilute the nutritional content of the food. The facility's Administrator confirmed that staff were trained on puree preparation and that recipes were available, but they were not being utilized. The Administrator acknowledged that using water instead of broth or thickener could result in residents not receiving the necessary nutrition. Despite the availability of recipes and training, staff members were not following the correct procedures, leading to the deficiency in food preparation. The facility was unable to provide the puree policy upon request during the survey, indicating a possible gap in policy enforcement or availability.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation, as observed during a survey of the kitchen. Specifically, food items in the walk-in cooler, freezer, and dry storage were not labeled or dated, which is a critical step in ensuring food safety. Milk, apple juice, and orange juice in the cooler, as well as dough and sausage patties in the freezer, lacked proper labeling. Additionally, a container of flour in the dry storage area was not dated. This oversight was confirmed through interviews with staff members, who acknowledged the importance of labeling and dating food items to prevent the risk of foodborne illness. Furthermore, the facility did not maintain proper food temperatures before placing items on the steam table. During an observation, the temperature of pureed meatloaf was recorded at 120 degrees Fahrenheit, and pureed peas at 142 degrees Fahrenheit, both below the required temperatures for safe consumption. Staff members, including the dietary aide and food service supervisor, were aware of the correct temperature requirements but failed to ensure compliance. The administrator and other staff members recognized the potential risk of bacterial growth and illness due to improper food labeling and temperature control.
Resident Dignity Compromised During Meal Service
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident during a meal service in one of the dining rooms. The incident involved a resident who was not served his lunch tray for 20 minutes after his tablemate had already begun eating. This delay in service led to the resident expressing feelings of hunger and frustration, as he repeatedly asked for food and questioned why he had not been served. Observations noted that staff were present in the vicinity but did not address the resident's needs promptly, contributing to the resident's agitation. The resident in question had a history of intermittent explosive disorder and was assessed to have poor short- and long-term memory recall. His care plan indicated a potential for verbally and physically abusive behaviors, with interventions in place to assess and anticipate his needs to prevent agitation. Despite these measures, the resident was left to watch his tablemate eat, which led to visible signs of anger and distress, such as clenched fists and tense facial expressions. The staff's inaction in serving the resident in a timely manner was a direct violation of his right to dignity and respect. Interviews with staff revealed a lack of communication and coordination between the nursing and dietary departments regarding meal service. The staff were expected to serve all residents at one table before moving to another, but this protocol was not followed. The failure to communicate the resident's dining location to the dietary staff resulted in the delay of his meal service. The facility's policy on dining room etiquette was not adhered to, leading to the resident feeling ignored and potentially isolated, which could have exacerbated his behavioral issues.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident #45 and Resident #46, were within their reach, which is a deficiency in accommodating the needs and preferences of residents. Resident #45, a male with essential tremor, unspecified dementia, and other conditions, was observed lying in bed without access to his call light, which was placed on a nightstand 3-4 feet away. He expressed difficulty in reaching the call light and fear of injury if he attempted to do so. His care plan indicated a need for assistance with activities of daily living (ADLs) and communication problems. Resident #46, a female with lymphedema, major depressive disorder, and other health issues, was found sitting in her recliner without her call light in reach, as it was positioned behind the recliner. She expressed reliance on the call light for assistance and concern about falling if she attempted to get up without help. Her care plan highlighted her risk for falls and poor safety awareness, requiring staff assistance with ADLs and ensuring the call light was within reach. Interviews with staff, including an LVN, ADON, CNA, and the Administrator, revealed a consensus that it was the responsibility of all staff to ensure call lights were accessible to residents. They acknowledged the potential risks of falls and injuries if residents attempted to reach for call lights that were not within reach. Despite being in-serviced on the importance of call light placement, staff could not recall the last training date, and the facility's policy on call lights was not provided upon request.
Failure to Include Indwelling Urinary Catheter in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter. The care plan did not reflect the resident's use of the catheter, instead incorrectly noting bladder incontinence. This oversight was identified during a review of the resident's records, which included a physician's order for a urinary catheter and a quarterly MDS assessment indicating the presence of the catheter. The resident, who has severe cognitive impairment and multiple diagnoses including dementia and benign prostatic hyperplasia, was observed with the catheter drainage bag improperly placed on the floor. The Director of Nursing (DON) acknowledged the omission in the care plan, stating that the care plan should have addressed the catheter and not mentioned bladder incontinence. The DON admitted that the facility did not have a dedicated person for care plans, and the responsibility fell on her and the Assistant Director of Nursing (ADON). The facility's policy on comprehensive care planning emphasizes the need for person-centered care plans with measurable objectives and timeframes, which was not adhered to in this case.
Failure to Implement Contracture Management Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion for two residents with hand contractures. Resident #4, a female with severe cognitive impairment and multiple medical conditions including dementia and hemiplegia, was observed without the necessary splints or palm guards for her bilateral hand contractures. Her care plan included interventions such as applying a right wrist cock-up splint and a left padded palm guard, as well as providing gentle stretching and range of motion exercises. However, observations revealed that these interventions were not in place, and her fingernails were long and untrimmed. Interviews with staff indicated that due to short staffing, these care interventions were not consistently implemented. Resident #20, another female with severe cognitive impairment and conditions such as multiple sclerosis and hemiplegia, was also found without the necessary contracture management devices. Her care plan did not include specific interventions for her contracted right hand, although she was receiving skilled occupational therapy services. Observations showed that her therapy carrot, a device meant to aid in contracture management, was not consistently placed in her hand. Staff interviews revealed that the therapy carrot was often removed by the resident and not promptly replaced by the staff. The facility's failure to ensure the implementation of prescribed interventions for residents with contractures placed them at risk for decreased mobility and worsening of their condition. The Director of Nursing acknowledged the expectation for staff to perform range of motion exercises and ensure the use of devices to prevent further decline. The facility's policy on immobilization devices emphasized the need for regular monitoring and documentation, which was not adhered to in these cases.
Inadequate Catheter Care Leading to UTI Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to potential risks for urinary tract infections. The resident, who has severe cognitive impairment and multiple medical conditions including dementia and benign prostatic hyperplasia, was observed with his catheter drainage bag placed on the floor on multiple occasions. The facility's care plan did not address the issue of the urine collection bag being placed on the floor or provide staff interventions to prevent this. Additionally, the care plan lacked instructions for using a catheter secure device to prevent dislodgment or traumatic removal of the catheter. Interviews with staff revealed that the resident's catheter bag was frequently found on the floor, and there was no catheter secure device in place. The Director of Nursing acknowledged that catheter bags should not be on the floor due to the risk of UTIs and expected all residents with catheters to have secure devices. The facility's policy on catheter care emphasized keeping the catheter and drainage bag off the floor but did not address the use of catheter secure devices. Observations and interviews indicated a lack of consistent monitoring and intervention to ensure the resident's catheter care was managed according to best practices.
Failure to Address Dementia-Related Behaviors in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, who also had an indwelling urinary catheter. The resident, identified as having severe cognitive impairment, exhibited behaviors such as placing his catheter collection bag on the floor and attempting to hit staff with it. Despite these behaviors, the resident's care plan did not address the management of his indwelling catheter or provide interventions to prevent the catheter bag from being placed on the floor, which could lead to urinary tract infections and other complications. Observations and interviews revealed that the resident frequently placed his catheter bag on the floor and on the nurses' station desk, despite staff attempts to redirect him. The Director of Nursing (DON) acknowledged that the care plan should have addressed the resident's behaviors and the use of a catheter secure device to prevent traumatic removal. However, the care plan inaccurately reflected bladder incontinence instead of addressing the indwelling catheter and associated behaviors. Staff interviews indicated a lack of awareness regarding interventions for the resident's behaviors and the absence of documentation on monitoring the drainage bag. The facility's policy on catheter care emphasized keeping the catheter and tubing off the floor but did not address the use of catheter secure devices. The facility's policy on dementia and behavioral health highlighted the need for individualized, person-centered interventions, but these were not implemented for the resident in question.
Failure to Sanitize Glucometer Between Resident Use
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN A, who did not sanitize the common glucometer between blood sugar checks for two residents. This oversight was observed during a survey, where LVN A was seen using the glucometer on Resident #22 and then on Resident #32 without cleaning it in between uses. This failure to sanitize the glucometer could potentially lead to contamination and the spread of blood-borne diseases among residents. Resident #22, a cognitively intact male with Diabetes Mellitus Type II and a history of sepsis due to Methicillin Susceptible Staphylococcus Aureus, was subjected to a finger stick blood sugar test without the glucometer being sanitized. Similarly, Resident #32, who has severe cognitive impairment and Diabetes Mellitus Type II, also underwent a blood sugar test with the same unsanitized glucometer. The facility's policy on infection control mandates the cleaning of resident care equipment to prevent disease transmission, which was not adhered to in this instance.
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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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