Nazareth Living Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 1475 Raynolds St, El Paso, Texas 79903
- CMS Provider Number
- 675723
- Inspections on file
- 36
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Nazareth Living Care Center during CMS and state inspections, most recent first.
The facility failed to ensure oxygen concentrators were properly maintained and that continuous oxygen therapy was administered as ordered. Multiple concentrators in use and in storage lacked current QA or maintenance tags, one known non‑working concentrator was stored under a sink without an "out of order" label, and leadership confirmed there was no contract in place for vendor maintenance. A resident with severe pulmonary disease and recent ICU stay experienced worsening hypoxia while on oxygen, with family reporting that the concentrator was not delivering enough oxygen and EMS documenting low O2 saturation on 6 L/min via nasal cannula. Another resident with COPD and an order for continuous oxygen at 1 L/min was observed at the nurse’s station without her oxygen in place until an LVN was prompted by the surveyor. A further resident with pneumonia and dependence on supplemental oxygen had an order for 2–3 L/min, but the concentrator was set at 1.5 L/min, which the DON confirmed was below the ordered rate. A resident with asthma and pulmonary embolism was using a concentrator bearing a maintenance tag from several years prior, and the facility’s oxygen policy did not address concentrator maintenance, contributing to inconsistent and potentially inadequate oxygen delivery.
A resident with multiple chronic pain-related conditions, including fibromyalgia, rheumatoid arthritis, and multiple sclerosis, had a physician order for Pregabalin (Lyrica) 50 mg PO TID for pain, but the medication was not administered over multiple consecutive days because it was not available. The MAR documented missed doses with a code directing staff to progress notes, and nursing notes repeatedly stated the drug was not available or pending from the pharmacy. The medical director reported he was not notified that the resident was not receiving the ordered medication, and pharmacy staff stated they never received a faxed order needed to obtain physician confirmation and dispense this controlled substance. The DON and ADON confirmed that licensed staff were responsible for faxing controlled substance orders to the vendor pharmacy, and records showed the Pregabalin was not administered as ordered during this period.
Surveyors identified that the facility failed to maintain a functional nurse call system in multiple rooms, including bathrooms and bathing areas, when call lights showing as active on the nurse’s station panel did not ring or illuminate in the rooms or hallway domes. In one room, a confused resident’s call light was found unplugged on the bed, with a loose, taped wall plate that would not securely hold the cord, and staff had not ensured a work order was submitted. Dual call light systems in two rooms did not activate when tested, and staff, including an LVN, CNA, and the Director of Support Services, acknowledged that confused residents did not use the call lights, that call lights had been pulled out and stored in furniture, and that there was no documentation of the claimed routine call light testing or an existing call light policy.
A resident with multiple chronic conditions, depression, prior CVA with hemiplegia, and moderately impaired cognition repeatedly yelled, expressed a desire to leave, and made explicit threats to throw herself on the floor and out of bed and her wheelchair. Multiple LVNs documented these behaviors over several days but did not notify the physician or NP, despite facility policy and training requiring immediate consultation for significant mental status changes and self-harm threats. The resident was later found on the floor near her bed after reporting she fell while leaning forward in her wheelchair to reach the call light, and leadership and the Medical Director confirmed they had not been informed of the earlier threats or behavioral escalation.
A resident with Parkinson’s disease, dysphagia, and a PEG/G-tube had physician orders and MAR entries for continuous enteral feeding at 50 ml/hr with 50 ml free water flush every hour. During observation, the feeding pump was alarming, the attached water bag was empty, and the formula bottle was still half full, indicating that ordered water flushes were not being provided as prescribed. The assigned LVN stated she checked the resident every two hours and last checked about an hour earlier, when there was still water in the bag, but she could not recall the amount. The DON stated that licensed staff were trained and expected to follow enteral feeding orders and check feedings and hydration during rounds, and facility policy required adherence to physician orders for enteral feedings and flushes.
A resident with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, and COPD was admitted with orders for continuous O2 and bronchodilator therapy. On the day of admission, the resident experienced worsening hypoxia and SOB, with low O2 saturation and abnormal vital signs, leading to EMS transfer to the hospital after physician notification. One LVN acknowledged she did not document her full assessment of the resident’s change in condition or the presence of a family member at the time of transfer, and another LVN reported making two calls to the physician to confirm admission medication orders and to report the resident’s transfer but did not document either call. The DON and facility policy confirmed that licensed staff were expected to document assessments and physician communications in the electronic record, but this did not occur, resulting in incomplete and inaccurate medical records for the resident.
Staff failed to assist two residents with severe cognitive and physical impairments at eye level during meals, despite facility policy and training requiring this practice. Staff were observed standing while providing eating assistance, and interviews confirmed awareness of the expectation to sit at eye level for proper monitoring and resident comfort. The facility's procedures also specified that staff should be seated when assisting with feeding.
A resident with severely impaired cognition and a history of wandering was not provided with a comprehensive care plan addressing wandering behaviors, despite being listed as a wanderer. Facility records and staff interviews confirmed that the care plan lacked focus, goals, and interventions for wandering, and that this omission was contrary to facility policy and staff responsibilities.
A resident with severe cognitive impairment was admitted without a completed personal inventory sheet, as required by facility policy. The inventory form remained blank and was not updated, and staff interviews confirmed that the process for documenting personal belongings was not followed. Facility policy required a personal inventory list to be completed and included in the medical record, but this was not done.
A resident with an arterial ulcer on her right big toe did not receive scheduled wound care as per her care plan. The facility failed to perform the necessary wound care on one occasion, leading to a grievance from the resident. Interviews with staff revealed confusion about responsibility for the wound care, and the facility's policy on dressing changes was not followed.
A resident at an LTC facility, diagnosed with dementia and bipolar disorder, was at risk for falls due to a torn fall mat. The mat, intended to prevent injuries, was found to be in poor condition, exposing internal materials. Staff interviews revealed a lack of awareness and responsibility for replacing the mat, with no clear policy in place to address such hazards.
A resident with severely impaired cognition received oxygen therapy without a physician's order, despite facility policy requiring such orders for medications. The resident, who acquired COVID-19, was observed with a nasal cannula, but no orders were documented. Staff interviews confirmed the absence of orders, highlighting the risk of inadequate oxygen support.
The facility did not ensure residents and families could access the latest survey results. An empty storage bin meant to hold these documents was found, and staff were unaware of their location. Residents were also uninformed about their right to review these reports.
A facility failed to meet professional standards in administering nebulizer treatments to a resident. The staff did not assess or document the resident's respiratory status before and after treatment, as required by facility policy. The resident, on oxygen therapy for shortness of breath, received Pulmicort via nebulizer without proper pre- and post-treatment checks. Interviews revealed a lack of training and awareness among staff regarding nebulizer administration protocols.
The facility failed to maintain clean oxygen equipment and conduct necessary respiratory assessments for two residents. One resident's oxygen machine had a dirty filter, and nebulizer treatments were administered without pre- and post-assessment of respiratory status. Additionally, the facility did not post required oxygen signs on another resident's door, posing safety risks. Staff interviews revealed a lack of clarity and adherence to facility policies.
The facility failed to administer medications accurately and securely store them, affecting two residents. One resident did not receive the correct dosage of Gabapentin, while another's medications were improperly stored when not administered. Additionally, an LVN failed to sign the controlled drugs count record at shift change, risking drug diversion.
A LTC facility reported a 14% medication error rate involving three residents. Errors included incorrect dosage and failure to administer medication with food as per physician's orders. LVNs were observed making these errors, which involved a resident with diabetes, another with cerebral arteritis, and a third with end-stage renal disease.
The facility failed to properly store and handle medications, with issues observed in medication carts and the medication room. Medications were stored inappropriately after being poured, and controlled substances were not properly accounted for at shift changes. Glucose control solutions were not dated according to manufacturer guidelines, and the medication room was disorganized, with improper storage of IV bags and over-the-counter drugs.
The facility failed to provide food at an appetizing temperature, as CNAs left insulated meal cart doors open during tray distribution, leading to cold meals. Residents reported ongoing dissatisfaction with meal temperatures, and test trays confirmed food was below required temperatures. The Dietary Manager acknowledged the issue, but no system was in place to ensure cart doors remained closed, and the Administrator was unaware of the problem.
The facility was cited for multiple deficiencies in kitchen sanitation and food safety, including unclean floors, equipment, and storage areas, improper food handling practices, and failure to maintain equipment. Ongoing construction contributed to dust accumulation, and staff did not consistently use protective gear or follow proper procedures. These issues could pose a risk of foodborne illnesses to residents.
The facility failed to maintain accurate medical records for two residents regarding their restorative therapy care. One resident's care plan lacked documentation for therapy intended to maintain range of motion and facilitate ADLs, with no completion dates or progress notes. The second resident's family reported a lack of progress and questioned therapy provision, with the ADON unaware of therapy approval status. The DON could not find necessary documentation, highlighting a failure in maintaining complete and accurate records.
The facility's QAPI committee failed to address ongoing issues with meals being served cold to residents. CNAs were observed leaving insulated meal cart doors open during tray distribution, leading to cold meals. Residents reported this as a persistent problem, and test trays confirmed food temperatures were below required levels. The facility lacked documentation of actions taken to address these concerns.
The facility failed to address dietary concerns and complaints about cold food being served to residents. CNAs left insulated meal cart doors open, causing food to become cold. Despite resident complaints and discussions in meetings, no effective corrective actions or monitoring systems were implemented to resolve the issue.
The facility failed to maintain an effective Infection Prevention and Control Program, with staff not performing proper hand hygiene between resident interactions and during medication administration. An LVN did not use gloves or assess a resident's respiratory status during nebulizer treatment. Additionally, improper storage of medical supplies and equipment was observed, contributing to potential cross-contamination.
The facility failed to maintain essential kitchen and laundry equipment in safe operating condition. In the kitchen, the stove was missing control knobs and oven door handles, and the Robot Coupe's blade was broken. In the laundry room, dryers were missing control panel covers, and washers were leaking with rust and substance build-up. The Maintenance Director, new to the facility, was unaware of maintenance policies and was addressing the issues as quickly as possible.
The facility failed to maintain a safe and sanitary environment, with dust from construction affecting the kitchen and halls, and a lack of paper towels in the medication room. The kitchen had dust-covered equipment, a hole in the ceiling, and uncovered food pots. Plastic barriers were ineffective in containing dust, and the medication room lacked paper towels, as confirmed by the DON.
Two residents in the facility were not administered their medications with meals as ordered by their physicians, leading to a deficiency in care. One resident with cerebral arteritis received medication without food, while another with end-stage renal disease did not receive medications during meal times. The facility's policies require adherence to physician orders, but these were not followed, placing residents at risk of adverse drug effects.
A resident with urinary incontinence did not receive proper catheter care, as the catheter tubing was improperly placed and not secured with a leg strap, leading to potential risks of urinary tract infections and injury. Staff interviews revealed a lack of training and awareness regarding catheter care, and the facility's policy did not address the use of leg straps.
Failure to Maintain Oxygen Equipment and Administer Ordered Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care, including proper oxygen administration and equipment maintenance, for multiple residents requiring continuous oxygen therapy. Surveyors identified that the facility did not have a system or contract in place to ensure oxygen concentrators were serviced and maintained to deliver prescribed flow rates. Several concentrators in storage areas and in use lacked QA or maintenance stickers, and one concentrator stored under a hand sink was known by the DON to be non‑functional but was neither labeled as out of order nor stored separately. The ADON reported she did not know if there was a contract with an oxygen supplier for maintenance, and the Administrator, DON, and ADON confirmed there was no such contract at the time of the survey. One resident with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, COPD, and recent ICU hospitalization was admitted with orders for continuous oxygen at 2–6 L/min via nasal cannula and had a history of hypoxia and altered mental status. Facility documentation showed that upon arrival his oxygen saturation was low (around 73–80%) while on oxygen via nasal cannula, and staff reported he was placed on 6 L/min. A family member reported to staff and later to the Administrator that the oxygen equipment was not delivering enough oxygen, and an SBAR noted worsening hypoxia with oxygen saturation at 74% on nasal cannula and a family request to send the resident out because he was not receiving enough oxygen through the concentrator. EMS documentation indicated that nursing home staff reported the resident had been discharged from the hospital for hypoxia and that his oxygen saturation was 75% on 6 L/min via nasal cannula at the facility, prompting EMS activation. Another resident with COPD and an order for continuous oxygen at 1 L/min via nasal cannula was observed sitting at the nurse’s station without her oxygen in place, despite an order and care plan specifying continuous oxygen. The LVN at the nurse’s station stated she had not noticed the missing cannula until the surveyor pointed it out, and only then checked the resident’s oxygen saturation and returned her to her room to reapply the cannula and set the concentrator. A further resident with pneumonia, dependence on supplemental oxygen, acute and chronic respiratory failure with hypoxia, and Parkinson’s disease had an order for continuous oxygen at 2–3 L/min via nasal cannula, but was observed with the concentrator set at 1.5 L/min. The DON confirmed at the bedside that the concentrator was set below the ordered 2 L/min and stated the resident should be on 2 L/min as ordered. A fourth resident with asthma, pulmonary embolism with acute cor pulmonale, and shortness of breath had an order for continuous oxygen at 2–4 L/min via nasal cannula. During observation, the ADON demonstrated that the oxygen concentrator in use for this resident had a maintenance service tag dated 10/04/2019. The ADON stated the resident had just been changed to a different concentrator because her oxygen was changed to 5 L/min, and it was observed that the regulator was set at 5 L/min via nasal cannula. The facility’s written policy on oxygen therapy addressed reviewing physician orders and emergency use of oxygen for low saturations but did not include any policy or procedure for maintenance of oxygen concentrators, contributing to the lack of a structured system to ensure concentrators were functioning properly and delivering ordered flow rates. Interviews with the Medical Director confirmed awareness of standing orders for oxygen at 2–6 L/min via nasal cannula with shift oxygen saturation monitoring and that nurses could adjust liters within that range, but he was not aware that the facility lacked a system for vendor maintenance of concentrators. A vendor representative later described the type of maintenance required for concentrators, including filter care and oxygen concentration testing, underscoring that such maintenance had not been in place at the time of the identified events. Overall, the deficiency centers on the facility’s failure to maintain and monitor oxygen equipment and to consistently administer oxygen as ordered, as evidenced by unmaintained concentrators, lack of labeling of non‑functional equipment, and residents not receiving oxygen continuously or at the prescribed flow rates.
Failure to Timely Obtain and Administer Ordered Pregabalin for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely acquisition and administration of a prescribed controlled medication for pain. A resident with an original admission date of 12/24/25 and a readmission date of 01/22/26 had multiple chronic conditions, including fibromyalgia, rheumatoid arthritis, multiple sclerosis, COPD, and osteoporosis. The admission MDS showed moderately impaired cognition (BIMS score 12), frequent pain with interference in sleep and daily activities, and a reported pain level of 7/10. The physician’s order, reflected on the Order Summary Report dated 01/23/26, prescribed Pregabalin (Lyrica) 50 mg orally three times daily for pain. Review of the January 2026 MAR showed that Pregabalin doses scheduled for 7:00 a.m., 1:00 p.m., and 7:00 p.m. on 01/21/26, 01/22/26, and 01/23/26 were not administered, with code 8 entered directing staff to see progress notes. Nursing progress notes on 01/22/26 and 01/23/26, documented by LVNs and a medication aide, repeatedly stated that the Pregabalin was “med not available” or “pending.” A note on 01/24/26 at 7:43 a.m. again documented that the Pregabalin was not available from the pharmacy. Despite these repeated notations of unavailability over several days, the medication was not obtained and administered as ordered. Interviews and record reviews identified that the failure to obtain the medication was related to breakdowns in the ordering process for controlled substances. The medical director, who was the attending physician, stated he was not notified that the resident had not received Pregabalin for several days and noted that a designated agent at the facility could order controlled substances once a physician order was received. Pharmacy customer service staff reported that the Pregabalin order had not been faxed to the pharmacy and that narcotics are not dispensed without physician confirmation, which they obtain after receiving a faxed order from nursing that includes the physician’s contact information. The DON and ADON confirmed that licensed staff were responsible for faxing controlled substance orders to the vendor pharmacy so the pharmacy could obtain authorization and dispense the medication, and the MAR confirmed that Pregabalin was not administered as ordered on 01/21/26, 01/22/26, 01/23/26, and 01/24/26.
Failure to Maintain Functional Nurse Call System in Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a properly functioning nurse call system in multiple resident rooms, including bathrooms and bathing areas, and to ensure that call lights were operational and able to alert staff at the nurse’s station. During observation, the call light panel at the nurse’s station showed active call lights for several rooms, but the corresponding call lights did not ring or illuminate in the rooms or hallway light domes. In one room, the call light cord was found disconnected and lying on the resident’s bed, and the wall plate for the call light was taped to the wall and loose. When the LVN attempted to plug the call light back in, it would not stay in the socket and slipped out. Staff reported that the resident in that room was confused, did not use the call light, and that the resident’s son used the call light when present. Further observations and interviews showed that dual call light systems in two rooms did not activate in the rooms or on the hallway light domes when tested. The Director of Support Services acknowledged that the wall plate was loose and that nursing staff should have submitted a work order, but there was no indication that such a work order had been made. A CNA confirmed that a confused resident had pulled the call light off the wall and stored it in a nightstand drawer, and that the wall plate had been taped but she was unaware of any work order and had not noticed that the call lights showing on the panel were not ringing. The Director of Support Services stated he conducted call light tests every two weeks but was unable to provide any documentation of these tests when requested, and later stated that one of the dual call light cords was not working, which explained why the dome light and nurse’s station alarm did not activate. The Administrator reported that corporate staff had informed her there was no policy and procedure on call lights.
Failure to Notify Physician/NP of Resident’s Self-Harm Threats and Mental Status Change
Penalty
Summary
The deficiency involves the facility’s failure to consult with the resident’s physician or NP when there was a significant change in a resident’s mental status and when the resident voiced threats to harm herself. The resident was an older female with a complex medical history including fibromyalgia, rheumatoid arthritis, multiple sclerosis, COPD, osteoporosis, prior CVA with hemiplegia, depression, arthritis, and UTI. Her admission MDS showed moderately impaired cognition (BIMS 12), dependence in most ADLs and mobility, and a history of verbal behavioral symptoms such as screaming and cursing. Facility policy on change in condition required assessment, completion of SBAR, and timely physician notification for changes in physical or mental status. On multiple occasions, nursing notes documented that the resident was yelling and making threats to throw herself on the floor or out of bed and out of her wheelchair, and repeatedly stating she did not want to remain in the facility and wanted to call 911. On one date, an LVN documented that the resident was yelling and threatened to throw herself on the floor. Later that same day, another LVN documented that the resident continuously yelled and screamed throughout the shift, repeatedly stating her intent to throw herself out of bed and out of her wheelchair, expressing a desire to go home, and wanting to call 911. On a later date, another LVN documented that the resident was again making threats to throw herself on the floor and yelling. These behaviors represented a change in mental/psychosocial status and included explicit threats of self-harm. Despite these documented threats and behavioral changes, the involved LVNs acknowledged in interviews that they did not notify the physician or NP of the resident’s threats to hurt herself or her increased anxiety and agitation. They also acknowledged they had been trained to immediately report such threats to the physician or NP but did not provide a reason for failing to do so. The Medical Director, who was also the attending physician, confirmed that nursing staff had not reported the resident’s anxiety and threats to throw herself on the floor on the identified dates and stated he expected immediate notification when residents voiced threats to hurt themselves so that the situation could be evaluated. The DON and ADON similarly stated that nurses had been trained to immediately report such threats, but the notifications did not occur as required by facility policy and physician expectations. Subsequently, the resident was found on the floor next to her bed by an LVN, who reported that the resident stated she had been leaning forward in her wheelchair to reach her call light and fell, and that she promised she did not throw herself on purpose. The call light was documented as clipped to the resident’s gown within reach. The resident complained of pain and requested transfer to the hospital, and the POA requested hospital transfer. The DON and ADON reported that the LVN who found the resident on the floor did not inform them that the resident had previously threatened to throw herself from the wheelchair. The Medical Director and facility leadership confirmed that they had not been notified of the earlier threats and behavioral changes, which constituted a failure to follow the facility’s change in condition communication policy and to immediately consult with the physician/NP when the resident experienced a significant change in mental status and voiced threats of self-harm.
Failure to Administer Ordered Free Water Flushes With Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via G-tube received water flushes as ordered by the physician. The resident, an older male with Parkinson’s disease, dysphagia, and a history of PEG tube placement, had physician orders for continuous enteral feeding of Nutritional Formula 1.2 at 50 ml/hr with 50 ml free water flush every hour via G-tube. Review of the physician order summary and the January medication administration record confirmed these orders. During observation, the resident was in bed, awake and moaning, with the head of bed elevated and the enteral feeding pump alarming. The water bag connected to the enteral pump was empty, while the formula bottle was still half full. The water bag and formula bottle were both dated for the early morning of the same day by the night-shift nurse. During interview, the LVN assigned to the resident for the 6 AM–2 PM shift stated she was unaware that the feeding pump alarm was sounding and acknowledged that the alarm was due to the empty water bag. She reported that she checked the resident every two hours to ensure the enteral feeding was being administered according to physician orders and stated that the last time she checked the resident was at 1:20 p.m., at which time there was still water in the bag, though she could not recall the amount. The DON reported that licensed staff had been trained to administer enteral feedings according to physician orders and were expected to check enteral feedings during rounds to ensure feedings and hydration were being administered as ordered. The facility’s enteral feeding policy stated that the facility would follow physician orders and document feedings on the electronic MAR, but the observation of an empty water bag and active pump alarm demonstrated that the ordered free water flushes were not being administered as prescribed.
Failure to Accurately Document Resident Assessment and Physician Communication During Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation in accordance with its own policy and accepted professional standards for one resident. The resident, an older male with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, and COPD, was admitted from the hospital with ongoing respiratory issues, including shortness of breath, worsening hypoxia, and confusion. On admission, he had orders for continuous oxygen at 2–6 L/min via nasal cannula with oxygen saturation monitoring each shift, and scheduled Ipratropium-Albuterol inhalation for shortness of breath. An IDT nursing note documented that he was admitted following episodes of altered mental status, hypoxia, pulmonary fibrosis, and COPD, and that he was on 4–6 L/min of oxygen. On the day of admission, the resident experienced a change in condition with worsening hypoxia. An SBAR form documented that his oxygen saturation was 74% via nasal cannula and that his son reported the resident was not receiving enough oxygen through the concentrator and requested that he be sent out. An IDT nursing note by an LVN recorded that the resident complained of hypoxia and shortness of breath, with vital signs including BP 157/83, HR 122, respirations 30, and oxygen at 6 L/min, and that the physician was notified and ordered transfer to the ER via EMS, with the resident transferred to the hospital and a family member at bedside. However, during interview, this LVN stated she had assessed the resident when he was yelling that he could not breathe and arranged transfer to the ER, but she acknowledged she had not documented her assessment in the clinical record on that day and had not documented that the family member was in the room when the resident was transported. Another LVN reported that she made two telephone calls to the resident’s attending physician on the day of admission: one to confirm medication orders upon admission and a second to report that the resident had been sent to the hospital via EMS due to a change in condition. She stated that licensed staff had been trained to document in the clinical record when they called the physician to obtain orders or report changes in condition, but she did not document either of these calls in the resident’s record, citing multiple admissions that day and lack of time. The DON confirmed that licensed staff were trained to document resident assessments and physician or NP communications in the electronic record. Review of the facility’s Clinical Documentation policy showed that documentation was to be accurate, timely, reflective of care provided, and completed as close to the time of care as possible, including documentation of assessments and exceptions when care does not occur as planned, which was not followed in this case.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance with eating were treated with dignity and respect, specifically by not assisting them at eye level during mealtimes. Observations revealed that two residents with significant cognitive impairments and physical limitations were assisted with eating by staff who remained standing rather than sitting at eye level, contrary to facility policy and training. One resident, a male with COPD, dementia, and altered mental status, required supervision and set-up help for eating, while another, a female with cognitive communication deficits and generalized weakness, required supervision during meals. During meal observations, staff members, including a CNA and a staff person (SP), were seen assisting these residents while standing, which did not align with the facility's established procedures for dining assistance. Interviews with staff confirmed that they were aware of the expectation to be seated at eye level when assisting residents with eating, and that this practice was part of their training and competencies. One CNA, who was in training, brought chairs to the staff after noticing they were standing, and acknowledged the importance of being at eye level for proper monitoring and resident comfort. Further interviews with the DON and other staff reiterated that sitting at eye level was a standard practice intended to promote resident comfort and allow for better observation during feeding. The facility's written procedure also specified that qualified nursing staff should sit down when assisting residents with eating. Despite this, the observed failure to follow these procedures resulted in a lack of dignity and potentially inadequate monitoring for the residents involved.
Failure to Develop and Implement Care Plan for Resident's Wandering Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's history of wandering. Record reviews showed that although the resident was listed as a wanderer on the facility's list, there was no corresponding focus, goal, or intervention for wandering in the resident's care plan. The resident had a severely impaired cognition as indicated by a BIMS score of 3, and was diagnosed with altered mental status and UTI. However, the clinical risk assessment and MDS did not code for wandering, and the care plan did not reflect this behavior. Interviews with the DON, MDS, and Administrator confirmed that the resident's wandering behavior should have been care planned, and that it was the responsibility of the MDS department to ensure care plans were accurate and complete. The lack of a care plan for wandering was acknowledged as an oversight, with staff stating that care plans are necessary to inform staff of resident needs and to provide appropriate care. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident, but this was not followed in this case.
Failure to Complete Resident Personal Inventory on Admission
Penalty
Summary
The facility failed to maintain complete and accurate records for a resident upon admission, specifically by not completing a personal inventory sheet as required by facility policy. The resident, an elderly female with severe cognitive impairment as indicated by a BIMS score of 02, was admitted with age-related cognitive decline. Review of her admission documents showed that the inventory form, which should have listed her personal belongings, was left blank and was not updated at any point after admission. The admission packet required the resident or responsible party to complete this inventory, and the facility's policy stated that it was responsible for accounting for all resident belongings. Interviews with the DON and Administrator confirmed that the inventory process was not followed for this resident. The DON acknowledged that the inventory sheet was missing and that nurses were responsible for its completion, while the Administrator stated that the process was shared among nursing and other staff. Both confirmed that there was no documentation of the resident's belongings, and the DON had not previously noticed the omission. The facility's policy and documentation guidelines required a personal inventory list to be completed on admission and included in the medical record, but this was not done for the resident in question.
Failure to Provide Scheduled Wound Care for Resident
Penalty
Summary
The facility failed to provide treatment and care based on the comprehensive plan of care for a resident with an arterial ulcer on her right big toe. The resident, who was admitted to the facility with a diagnosis of Peripheral Artery Disease and other conditions, had orders for wound care to be performed three times a week. However, on one occasion, the wound care was not performed as scheduled. The resident's care plan required assessment of the wound bed and surrounding skin for signs of infection or complications, but the wound care was not documented on the specified date. Interviews with facility staff revealed a lack of clarity and communication regarding who was responsible for performing the wound care on the missed date. The assigned nurse for the shift did not perform the wound care, assuming it was the responsibility of the Wound Care Nurse, who was not present. The Director of Nursing confirmed that the resident had complained about the missed wound care, and although the wound did not worsen, the failure to provide care as ordered was acknowledged. The facility's policy required dressing changes to follow specific guidelines, which were not adhered to in this instance.
Torn Fall Mat Poses Risk for Resident at LTC Facility
Penalty
Summary
The facility failed to ensure that the environment for a resident, who was at risk for falls, was free from accident hazards. Specifically, the fall mat intended to prevent injuries for a resident diagnosed with dementia and bipolar disorder was found to be torn, exposing the internal foam and materials. This condition was observed during an inspection, and it was noted that the torn mat could pose a risk of falling if stepped on. The resident's care plan indicated that she was at risk for falls and required extensive assistance with activities of daily living, including transfers and walking. Interviews with facility staff revealed a lack of awareness and responsibility regarding the condition of the fall mat. The Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) acknowledged the mat's poor condition and the associated risks but had not taken action to replace it. The Director of Nursing (DON) and the Director of Rehabilitation (DOR) also recognized the hazard but indicated that there was no clear policy or procedure for addressing such issues. The maintenance and rehabilitation departments had differing views on who was responsible for replacing or repairing the mat, leading to further inaction.
Resident Received Oxygen Without Physician Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who was receiving oxygen therapy without a physician's order. The resident, a female with severely impaired cognition, was admitted to the facility without any diagnosis that warranted oxygen use. Despite this, she was observed receiving oxygen via a nasal cannula from 10/20/24 to 10/25/24 without any documented physician orders. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that the resident had acquired COVID-19 and was receiving breathing treatments, but there were no orders for oxygen therapy documented in the resident's records. The facility's policy requires that all medications, including oxygen, must have a physician's order, and the nurses are responsible for ensuring these orders are in the system. However, the DON acknowledged that the resident was on oxygen at 4 liters per minute without the necessary orders. The lack of proper documentation and physician orders for oxygen therapy could potentially place residents at risk of receiving incorrect or inadequate oxygen support. Interviews with other staff members, including a Licensed Vocational Nurse (LVN), highlighted the importance of maintaining oxygen saturation above 90 percent and the potential negative outcomes of not having proper orders in place.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents and their families had access to 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 and interview, it was noted that a clear storage bin, intended to hold the survey results, was empty. The receptionist confirmed that a binder containing the last survey inspection results should have been in the bin but was unable to locate it. The receptionist mentioned that the administrator had the survey binder in his office, indicating a lack of proper accessibility for residents and their families. In a group interview, eleven residents were unaware of their right to review past survey reports or where to find them. Additionally, the Unit Manager was also unaware of the location of the survey binder. The surveyor requested the facility's policy and procedure on posting previous surveys, but it was not provided before the surveyor's exit. This lack of accessibility and awareness among staff and residents led to the deficiency, as it hindered the residents' ability to exercise their rights to be informed about the facility's survey citation history.
Failure to Adhere to Nebulizer Treatment Protocols
Penalty
Summary
The facility failed to ensure that services provided to Resident #6 met professional standards of quality, specifically in the administration of nebulizer treatments. Licensed staff did not assess the resident's respiratory status before and after administering the nebulizer treatment, as required by the facility's policy and procedure. This included failing to document the resident's respiratory rate, lung sounds, and oxygen saturation pre- and post-treatment. The lack of assessment and documentation was observed during a medication pass, where the LVN did not perform the necessary checks or use gloves and proper hand hygiene. Resident #6, a 94-year-old female, was on oxygen therapy for shortness of breath, as outlined in her care plan. Despite having no documented pulmonary diagnosis or symptoms such as shortness of breath, the resident was receiving Pulmicort inhalation suspension via nebulizer for low oxygen saturations. The physician's orders required specific observations and documentation before and after nebulizer treatments, which were not adhered to by the staff. Interviews with the LVN, DON, and ADON revealed a lack of training and awareness regarding the proper administration of nebulizer treatments. The LVN admitted to not knowing the necessity of assessing the resident's respiratory status and had not been trained on nebulizer administration at the facility. The DON and ADON were unaware of the lack of documentation and training, indicating a gap in oversight and adherence to the facility's policies and procedures for nebulizer therapy.
Deficiencies in Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, specifically in the management of oxygen therapy and nebulizer treatments. For one resident, the oxygen machine's filter was observed to be dirty with multiple layers of dirt, indicating it had not been cleaned for months. This was confirmed by interviews with staff, who were unclear about the responsibility for maintaining the oxygen equipment. The Director of Nursing (DON) acknowledged the issue but downplayed the risk, stating that the machine would alert staff if it malfunctioned. However, the facility's policy required weekly cleaning of the oxygen equipment, which was not adhered to. Additionally, the same resident receiving nebulizer treatments did not have their respiratory status assessed before and after treatment, as required by the facility's policy. The Licensed Vocational Nurse (LVN) administering the treatment was unaware of the need for such assessments and did not follow proper infection control practices, such as using gloves and washing hands. The DON and Assistant Director of Nursing (ADON) admitted that there was no documentation of respiratory assessments in the Medication Administration Record, and they were unsure when the last training on nebulizer administration had occurred. For another resident, the facility failed to post an oxygen sign on the door, which is a safety measure to alert staff and visitors of the presence of oxygen in the room. The absence of this sign could lead to staff overlooking the need to check oxygen levels or tanks, and it poses a fire hazard if flammable items are brought into the room. Interviews with the Unit Manager and ADON confirmed the expectation for signs to be posted and the potential risks associated with their absence. The facility's policy required such signage, but it was not implemented in this case.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and secure storage of medications. Specifically, for one resident, the facility did not administer Gabapentin according to the physician's order. The resident, a 90-year-old female with diabetes mellitus and diabetic polyneuropathy, was prescribed Gabapentin 100 mg, two capsules, three times a day. However, during a medication pass, the LVN only poured one capsule instead of the required two. This discrepancy was noticed by the surveyor, and the LVN had to retrieve another blister packet to administer the correct dosage. Another deficiency was observed with a 67-year-old male resident with end-stage renal disease. The LVN prepared medications, including Docusate Sodium and Gabapentin, but the resident was not present to receive them as he was at a dialysis center. Instead of disposing of the medications as per facility policy, the LVN stored them in the medication cart, intending to administer them later. This action was against the facility's policy, which requires medications to be wasted if not administered as ordered. Additionally, the facility failed to ensure proper documentation of controlled substances. An LVN did not sign off on the Controlled Drugs-Count Record after verifying the controlled substances with the oncoming nurse at the change of shift. This oversight was acknowledged by the LVN, who later signed the record after being reminded by the surveyor. The facility's policy mandates that both the nurse coming on duty and the nurse going off duty verify and sign the controlled substance count to ensure accuracy and prevent drug diversion.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 14% due to four errors out of 27 opportunities. These errors involved three residents and were observed during medication administration by two licensed vocational nurses (LVNs). The errors included incorrect dosage and failure to administer medication with food as per physician's orders. One resident, a 90-year-old female with diabetes mellitus and diabetic polyneuropathy, was prescribed Gabapentin 100 mg, two capsules to be taken three times a day. During an observation, LVN A was found to have poured only one capsule instead of the prescribed two. The LVN acknowledged the mistake, citing a lack of medication in the blister packet, and corrected the error by obtaining another capsule from the medication room. Another resident, a 47-year-old female with cerebral arteritis, was prescribed Pentoxifylline ER 400 mg to be taken with food. LVN A administered the medication while the resident was participating in a group activity without food. The LVN justified the timing by stating the medication could be given within an hour of the scheduled time, assuming the resident would eat soon. Additionally, a 67-year-old male with end-stage renal disease was prescribed medications to be taken with meals, but the administration did not align with the meal schedule. The facility's policies require medications to be administered as per physician's orders, including with meals or food when specified.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications, as observed in two of three medication carts and one medication room. Medications were stored inappropriately after being poured, and controlled substances were not properly accounted for at shift changes. Specifically, an LVN poured medications for a resident who was not present and stored them in the medication cart, contrary to training protocols. Additionally, an LVN failed to sign the Controlled Medication Count Records Sheet after verifying the counts with the oncoming nurse, which is a required procedure. The facility also did not adhere to manufacturer specifications for glucose control solutions and test strips. Observations revealed that the glucometer control solutions were opened and not dated, and the staff was unaware of the manufacturer's guidelines for discarding these solutions after a specified period. This oversight was confirmed by the DON and ADON, who acknowledged the lack of awareness regarding the proper management of glucose control solutions. Furthermore, the medication room was found to be in disarray, with dust, stains, and particles on the floor, and IV bags stored improperly on the floor. Over-the-counter drugs were not stored according to their routes of administration, with various medications mixed together on the shelves. These storage issues were contrary to the facility's policies and procedures, which require medications to be stored safely and according to manufacturer recommendations.
Failure to Maintain Food Temperature and Quality
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for three diet test trays reviewed for food temperatures. Observations revealed that CNAs were leaving the doors open to the insulated meal cart while distributing trays, causing the food to become cold. This issue was observed on multiple occasions, and residents reported that meals were consistently delivered cold to those eating in their rooms. The Dietary Manager confirmed that the CNAs had been trained to keep the cart doors closed, but this practice was not being followed, resulting in food temperatures below the required levels. During a group interview, residents expressed ongoing dissatisfaction with the temperature of their meals, indicating that this was a persistent problem. The Dietary Manager acknowledged that the insulated meal cart was left open during tray distribution, which contributed to the cold food issue. Test tray sampling confirmed that food temperatures were below the required standards, with items like Tamale Pie recorded at 125 degrees Fahrenheit. The Dietary Manager stated that food should be reheated to 165 degrees Fahrenheit, but this was not consistently happening. The facility's Administrator, ADON, Dietary Manager, and Maintenance Director discussed resident concerns about cold food in department head meetings, but no written records were kept to document actions taken. The Administrator was unaware of the ongoing issue with the insulated meal cart and the cold food temperatures. The Dietary Manager also noted that there was no system in place to ensure the cart doors remained closed during meal service. Additionally, a review of the facility's Quality Assurance Monitor revealed that residents had voiced concerns about food temperature and quality, but these issues were not adequately addressed in the facility's QAPI minutes.
Deficiencies in Kitchen Sanitation and Food Safety
Penalty
Summary
The facility was found to have multiple deficiencies in its food storage, preparation, and service areas, as observed by surveyors. The kitchen was not maintained in accordance with professional standards, with dust, grease, and food particles found on floors, equipment, and storage areas. The refrigerator contained dried food particles, and perishable foods such as jalapeno peppers and cabbage were not discarded despite showing signs of spoilage. Additionally, opened food containers were not stored in sealed containers, and food preparation tables and equipment were not kept free of dust. The facility also failed to maintain kitchen equipment in proper working order, with missing and cracked control knobs on stoves, missing oven door handles, and a broken blade on the Robot Coupe food processor. The kitchen environment was further compromised by ongoing construction, which contributed to the accumulation of dust and debris. The plastic barriers intended to contain construction dust were not completely sealed, allowing dust to infiltrate food preparation areas. Furthermore, essential equipment such as the deep fryer and vents were not kept free of dust and grease build-up. Staff practices also contributed to the deficiencies, with kitchen staff failing to use hair nets and beard guards consistently, and not adhering to proper food handling procedures. For instance, a staff member was observed checking food temperatures without using gloves or a thermometer holder, and another staff member did not wash hands after picking up a pan from the floor. The facility also failed to post current menus in the dining room, and the food on the steam table was not maintained at the appropriate temperature, posing a risk of foodborne illnesses to residents.
Inadequate Documentation of Restorative Therapy for Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, specifically regarding their restorative therapy care. For one resident, the care plan lacked documentation for restorative therapy, which was intended to help maintain range of motion and facilitate activities of daily living (ADLs). Despite being approved for therapy, there was no documentation of completion dates or progress notes, and the resident was reportedly in pain and unable to tolerate certain interventions. The Director of Therapy acknowledged that there should have been a documented care plan, but it was not filled out. For the second resident, the family expressed concerns about the lack of progress in the resident's condition and questioned whether therapy was being provided, as the resident's condition appeared to be worsening. The Assistant Director of Nursing (ADON) was unaware of the resident's therapy approval status, and the Director of Therapy confirmed that the resident had been on restorative therapy but lacked proper documentation. The Director of Nursing (DON) was unable to find the necessary care plan documentation, and it was noted that progress notes should be completed daily and accurately, a responsibility that fell to the ADON.
Failure to Maintain Meal Temperatures
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to take necessary actions to improve performance and did not measure or track the success of any implemented actions. This deficiency was highlighted by the facility's failure to address ongoing concerns about meals being served cold to residents. Observations revealed that Certified Nursing Assistants (CNAs) were leaving the doors of the insulated meal cart open while distributing trays, which resulted in meals being delivered cold to residents who ate in their rooms. This issue was confirmed through interviews with residents who reported that cold meals were a persistent problem. Further observations and interviews with the Dietary Manager confirmed that the insulated meal cart was left open during meal distribution, which contributed to the food cooling down. The Dietary Manager acknowledged that CNAs had been trained to keep the cart doors closed to maintain meal temperatures, but this practice was not being followed. Test trays sampled during the survey showed that food temperatures were below the required levels, indicating that the meals were not being kept hot enough. The Dietary Manager admitted that there was no system in place to ensure the cart doors remained closed during meal service. Interviews with the facility's Administrator, Assistant Director of Nursing (ADON), Dietary Manager, and Maintenance Director revealed that while concerns about cold food had been discussed in morning meetings, no written records or QAPI minutes documented these discussions or any actions taken. The Administrator was unaware of the ongoing issue with the meal cart doors being left open and the resulting cold food temperatures. Additionally, the facility lacked documentation of the dietitian's recommendations for conducting monthly test tray audits to monitor food temperatures, further indicating a gap in the facility's quality assurance processes.
Failure to Address Dietary Concerns and Cold Food Service
Penalty
Summary
The facility failed to ensure that the Quality Assurance (QA) committee developed and implemented appropriate plans of action to address dietary concerns identified in group interviews and a Satisfaction Survey conducted by the consultant dietitian. Specifically, the facility did not address complaints regarding cold food being served to residents who ate in their rooms. Observations revealed that Certified Nursing Assistants (CNAs) left the doors of the insulated meal cart open while distributing trays, causing the food to become cold. This issue was reported by residents as an ongoing problem, with no effective measures taken to resolve it. During an interview with the Dietary Manager, it was confirmed that CNAs had been trained to keep the insulated meal cart doors closed to maintain food temperature, but this practice was not consistently followed. Test trays sampled during the survey showed that food temperatures were below the required levels, indicating that the meals were not being kept warm as needed. The Dietary Manager acknowledged the lack of a system to ensure the insulated cart doors remained closed during meal service, contributing to the problem of cold food being served. The facility's Administrator and Dietary Manager admitted that there was no documentation in the Quality Assurance and Performance Improvement (QAPI) minutes regarding the complaints about cold food and menu issues. Despite discussions in morning department head meetings, no written records were kept to demonstrate actions taken to address these concerns. Additionally, the facility did not have a system in place to monitor food temperatures and meal service effectively, as recommended by the dietitian. The lack of a corrective action plan and monitoring system contributed to the ongoing issue of cold food being served to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several observed deficiencies. A CNA did not perform hand hygiene between assisting residents with meals, despite acknowledging the need to do so. The CNA admitted to forgetting to sanitize hands and mentioned a lack of sanitizer, although sanitizer was available. Additionally, the facility's Director of Nursing (DON) confirmed that staff were trained to sanitize hands between residents to prevent cross-contamination. Another deficiency was observed during a medication pass, where an LVN did not use gloves or perform hand hygiene when administering a nebulizer treatment. The LVN failed to assess the resident's respiratory status before and after the treatment and did not wash hands after removing the nebulizer mask. The DON acknowledged that gloves should have been used to prevent cross-contamination. Furthermore, another LVN was observed not changing gloves between residents during medication administration, citing a shortage of gloves, although the DON stated there was no shortage. Additional issues included improper storage of medical supplies and equipment. A plastic container used for storing IV bags was found on the floor, and opened packages of gauze were not stored in sealed bags. The facility also failed to keep crash carts and linen cart covers free of dust and tears, respectively. These practices could contribute to cross-contamination and the spread of infection, as noted in the facility's policies and procedures on infection control.
Deficiencies in Kitchen and Laundry Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen and laundry equipment in safe operating condition. In the kitchen, the stove was found to be missing three control knobs, which were kept on a shelf above the stove due to their tendency to fall off. Additionally, the oven doors were missing handles, and multiple control knobs on the stove were cracked, greasy, and dusty. The Dietary Manager, who had been working at the facility for a few months, confirmed these observations and noted the issues had been present since her employment began. Furthermore, the Robot Coupe's blade was broken, contributing to the equipment deficiencies in the kitchen. In the laundry room, Dryer #1 was missing the metal cover on the top and the cover to the control panel, while Dryer #2 was also missing the control panel cover. Two washers were reported to be leaking water, with a white substance build-up and rust on their bases. The floor in front of the washers had rust and a black substance, and there was water on the floor and wall next to the washers. The Maintenance Director, who started working at the facility in April 2024, acknowledged these issues and stated he was unaware of any maintenance policies or procedures. He expressed that he was addressing the equipment problems as quickly as possible.
Environmental Deficiencies in Kitchen and Medication Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in several areas, including three of five halls, the kitchen, and a medication room. Observations and interviews revealed that the kitchen equipment vents in the food preparation area were full of dust, and there was a large hole in the ceiling with a missing electrical cover on a kitchen light. Water pipes had ruptured, causing water to drip from the ceiling to the kitchen floor, and part of the ceiling had been removed for repairs. Metal pots containing food were uncovered on the stove, and doors had chipped paint and were dusty. The Dietary Manager acknowledged the presence of dust due to ongoing construction and a lack of lids to cover pans on the stove. Despite training, dietary staff struggled to maintain cleanliness due to the construction dust. Interviews with CNAs revealed that the dust problem began on a recent Saturday and affected the tile floors, dining room tables, chairs, and nurse's stations. Plastic barriers intended to contain the dust were ineffective, as they were not completely sealed, and one barrier had been removed and was on the floor. Additionally, in the medication room, there were no paper towels in the dispenser by the hand sink, which was confirmed by the DON, who stated that the medication room should be cleaned daily and housekeeping should ensure paper towels are available.
Failure to Administer Medications with Meals as Ordered
Penalty
Summary
The facility failed to implement a comprehensive person-centered plan of care for two residents regarding their medication administration. Resident #41, a 47-year-old female with cerebral arteritis, was prescribed Pentoxifylline ER 400 mg to be taken with food. However, during a medication pass, the medication was administered by LVN A without food while the resident was engaged in a group activity. The LVN justified the timing by stating that medications could be given one hour before or after the scheduled time, assuming the resident would be eating something. Resident #48, a 67-year-old male with end-stage renal disease, was prescribed Calcium Acetate and Sevelamer Carbonate to be taken with meals. Observations revealed that the facility's meal schedule was not adhered to, as the medications were not administered during meal times as ordered. The DON confirmed that medications ordered to be given with meals must be administered accordingly, and staff had been trained to follow these orders. The attending physician emphasized the importance of administering medications with food or meals to prevent adverse drug effects. The facility's policy on medication administration requires adherence to the physician's orders and the 8 Rights of medication administration. Despite these policies, the facility's failure to administer medications as ordered placed the residents at risk of adverse drug effects and a decline in their health status.
Inadequate Catheter Care for Resident with Urinary Incontinence
Penalty
Summary
The facility failed to provide appropriate care for a resident with urinary incontinence, specifically in managing the resident's indwelling catheter. Observations revealed that the catheter tubing was improperly placed, with the tubing rolled up next to the resident's leg and the catheter bag hanging on the wheelchair's side, touching the wheel. Additionally, the resident's subpubic catheter was not secured with a leg strap, which is necessary to prevent potential injury and ensure proper urine flow. Interviews with staff, including a CNA, LVN, and the DON, confirmed that the catheter care was not in compliance with the facility's standards, as the resident did not have a leg strap, and the catheter bag was not placed in a privacy bag. The resident, who has a history of type 2 diabetes mellitus and benign prostatic hyperplasia, expressed discomfort and concern about the catheter tugging, which led him to place the tubing under his leg to avoid pulling. The facility's catheter care policy did not mention the use of leg straps, and staff interviews indicated a lack of training and awareness regarding proper catheter care. The administrator was unaware of the frequency of catheter care training, and an RN stated that she had not received any training from the facility, relying on her education from school. This lack of proper catheter management and training could place residents at risk of urinary tract infections and injury.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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