Northgate Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 5757 N Knoll, San Antonio, Texas 78240
- CMS Provider Number
- 455804
- Inspections on file
- 48
- Latest survey
- March 7, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Northgate Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the exit door alarm at the end of hall 100 was turned off, even though multiple non-ambulatory residents lived on that hall. During door checks with the Maintenance Director, the door failed to alarm when opened until he used a key to re-activate the mounted alarm box. The Maintenance Director reported that CNAs had keys and sometimes used the door to take residents outside, and he stated he normally checked exit doors weekly. The DON and ADMIN both stated their expectation that exit door alarms remain active and be re-armed after use, and acknowledged that a disabled alarm could allow a resident to exit without staff awareness, contrary to the facility’s wandering and elopement policy.
A resident with multiple comorbidities, including a chronic wound, colostomy, indwelling catheter, and ostomy, had active orders and posted signage for Enhanced Barrier Precautions (EBP), requiring staff to use gown and gloves during high-contact care such as wound care. During an observation, an LPN performed right upper arm wound care on the resident without wearing a gown, despite the EBP sign and the facility’s written policy specifying gown and glove use for wound care. In interviews, the DON and Administrator confirmed that staff were expected to wear gowns and gloves for residents on EBP and acknowledged that not doing so placed the resident and staff at risk for infection.
Surveyors found that required daily nurse staffing and census information was not posted at the beginning of, or within two hours of, a day shift. A document for the prior day’s staffing remained posted in the lobby until midday, when the correct day’s staffing sheet was finally posted. The DON reported that a weekend supervisor is normally responsible for posting this information, but the supervisor was absent and the task was completed late by the ADMIN, with no clear backup process identified. The ADMIN confirmed the posting is intended to inform the public of RN, LPN, CNA, and other direct care staffing per shift, consistent with facility policy requiring timely computation and posting of these data.
A resident with severe cognitive impairment and incontinence was left unattended for several hours, resulting in exposure, soiled clothing, and unsanitary room conditions. Staff failed to perform required rounds or follow the care plan, leading to the resident remaining in an undignified state with urine and feces present in the room. Interviews confirmed that staff were aware of the need for frequent checks but did not carry them out.
A resident with severe cognitive impairment and total incontinence was found in an unsanitary room with urine and feces on the floor, sticky tiles, and a strong odor. Staff interviews revealed that required rounds and cleaning were not performed as needed, and the resident was left without proper assistance or hygiene. Facility leadership acknowledged the failure to provide a safe and clean environment as required by policy.
Two residents experienced failures in timely reporting of suspected neglect and possible misappropriation of narcotic medications. In one case, a resident returned from leave with missing narcotic medication records, and staff did not follow required procedures for counting and documenting controlled substances or report the incident as possible misappropriation. In another case, a resident reported feeling neglected during her first week, but the allegation was not promptly reported to the administrator or authorities as required by policy.
A resident with multiple complex medical conditions, including a colostomy, was admitted without a completed baseline care plan reflecting her need for colostomy monitoring and care. Although nursing staff provided colostomy care as needed, the required instructions were not documented in the baseline or comprehensive care plans within the required timeframe, as confirmed by the DON and facility records.
A resident with cognitive impairment and a history of smoking-related safety issues was allowed to smoke under staff supervision without the required protective smoking apron, despite documented care plan interventions and facility policy. Staff interviews confirmed knowledge of the resident's need for the apron, but it was not enforced during the observed incident.
A resident prescribed opioid medications was allowed to leave the facility on pass without proper accounting or documentation of his controlled substances. An agency nurse provided the resident with his medications without conducting a two-nurse count or ensuring the required narcotic sheets were completed. Upon the resident's return, staff discovered the narcotic sheets were missing and had to create new documentation to account for the remaining medications. Facility leadership acknowledged that established protocols for handling controlled substances were not followed.
A resident admitted with a stage 4 sacral wound did not have Enhanced Barrier Precautions (EBP) implemented as required. Staff provided wound care using gloves but not gowns, and there was no PPE bin or signage outside the room. Despite documented training on infection control and EBP, staff were unaware of the need for EBP, and the care plan did not include appropriate interventions.
A resident with severe obesity and mobility limitations did not receive appropriate assessment or timely maintenance of their motorized wheelchair, resulting in prolonged use of equipment that may not have met their weight requirements. Facility staff failed to verify the wheelchair's specifications, coordinate necessary repairs, or refer the resident for a therapy evaluation, despite ongoing mechanical issues and clear indications that the facility was responsible for providing suitable DME. This led to the resident experiencing unsafe mobility and reduced independence.
A resident with severe cognitive impairment and a history of falls was left unsupervised in bed, which was not lowered to the required position, despite care plan directives and facility policy. A CNA admitted to forgetting to lower the bed after transferring the resident, and the DON confirmed the resident's high fall risk and need for the bed to be in the lowest position. No staff were present to supervise the resident, who was observed moving and reaching for items on the floor.
Surveyors found that the facility did not maintain a sanitary shower environment, with soiled linens and towels left in the shower room after use, and failed to ensure that two residents received required tuberculosis (TB) screenings at admission and annually. These deficiencies were confirmed through observations, interviews, and record reviews, and involved residents with complex medical conditions and varying cognitive status.
A resident with morbid obesity and multiple medical conditions did not receive a recommended bariatric bed and overhead trapeze, despite therapy and physician orders. The resident continued to use an inadequate bed, and staff interviews revealed delays and lack of documentation regarding the equipment order, resulting in unmet accommodation needs.
A resident with severe cognitive impairment and multiple medical conditions was unable to receive visitors after 8:00PM due to the facility's locked front door and lack of staff response to the doorbell. Despite repeated requests from the resident's POA and discussions among leadership about possible solutions, no effective measures were implemented, resulting in the resident's visitation rights not being honored according to facility policy.
Two residents were unable to access or use telephones for private communication due to a combination of visual impairment, lack of personal devices, and a non-functioning facility cordless phone. One resident's emergency contact reported calls to the facility were rarely answered, while another resident was repeatedly told the hallway phone was not working. Facility leadership and maintenance confirmed the phone was inoperable and no alternative was provided for those unable to use personal phones, resulting in a failure to ensure reasonable access and privacy for resident communication.
A resident who was assessed as a safe smoker was found to have cigarettes and a lighter in her room, in violation of facility policy requiring all smoking materials to be stored securely and smoking to be supervised. Staff interviews revealed inconsistent enforcement of the policy, and required documentation for tracking smoking materials was not maintained, resulting in a deficiency related to accident hazard prevention and supervision.
A resident with complex medical needs did not consistently receive the physician-ordered therapeutic diet, including double portions of protein and vegetables, due to food budget restrictions, lack of clear guidance on vegetable servings, and insufficient food supplies. Staff interviews and kitchen observations confirmed that prescribed dietary needs and resident preferences were not met, and facility policy requirements for therapeutic diets were not followed.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
A resident with severe cognitive impairment and multiple diagnoses was administered Olanzapine, an antipsychotic medication, without documented informed consent in the medical record. Staff interviews revealed unclear responsibility for obtaining psychotropic medication consents, and the required consent form was not present, despite facility policy requiring residents to be informed and to provide consent for such medications.
A resident with severe cognitive impairment and high assistance needs was observed in bed with her call light on the floor, out of reach and not visible. Staff confirmed the call light was not accessible, despite facility policy requiring it to be within reach for all residents.
A resident with a feeding tube did not have their enteral feeding formula and water containers properly labeled or discarded after use. Observations showed that the containers remained hanging and unlabeled after feedings, and staff were unsure about the timing and reuse of the formula. Facility policy required labeling and timely disposal, but these steps were not followed, as confirmed by both nursing staff and the DON.
A resident with complex medical needs was discharged to the hospital and not readmitted, but the facility failed to provide required discharge documentation, including a 30-day notice, physician orders, and a discharge summary in the EMR. Staff interviews indicated the decision was based on concerns about non-compliance and suspected drug use, but the facility did not follow its own policy for discharge notification and documentation.
Two residents made separate allegations of abuse, including inappropriate touching and being hit by another resident, but these incidents were not reported to the state agency or investigated as required. Staff interviews revealed that decisions not to report were based on factors such as cognitive scores and lack of witnesses, despite facility policy mandating immediate reporting of all abuse allegations.
Two residents made separate allegations of abuse and mistreatment, including inappropriate touching and being hit by another resident. Despite documentation by an LPN and awareness by the DON and administrator, neither incident was thoroughly investigated or reported as required by facility policy. Staff interviews revealed inconsistent application of reporting protocols, with decisions influenced by residents' cognitive status and lack of witnesses.
A facility failed to maintain a safe and clean environment for a resident, as a pile of yellow liquid, identified as urine, was found on the restroom floor. The resident, with multiple health issues including incontinence and unsteady gait, was at risk of falls due to this oversight. The care plan included measures to prevent such incidents, but they were not effectively implemented.
A medication cart in the facility was found unattended and unlocked, containing medication blister packs. LVN A, not assigned to the cart, acknowledged it should have been locked. The DON confirmed the cart was used for storage and was unaware of its last access. Facility policy requires secure storage of medications.
The facility failed to employ a certified dietary manager, placing residents at risk of foodborne illness and inadequate nutrition. The dietary manager, hired without the necessary certification, was unaware of the requirement. Interviews with the HR Director and Administrator revealed they were also unaware of the certification requirement, despite the facility's handbook mandating current licensure and certification for staff.
The facility failed to properly label and date food items in the refrigerator, and the dish machine's temperature gauge was non-functional, posing a risk of foodborne illness. Snacks in the Nourishment Rooms were also not consistently labeled or dated, and there was a lack of cleaning in the refrigerators. Interviews revealed that these issues were known but not adequately addressed, with no work order found for the dish machine repair.
The facility failed to provide a safe and sanitary environment, with issues such as a disconnected bathroom ceiling fan, broken light fixtures, and missing ceiling panels. The Maintenance Director had recently left, and there was no preventative maintenance policy in place, leading to unaddressed deficiencies.
The facility failed to maintain an effective pest control program, with numerous gnats and flies observed on the 200 hall and a cockroach in the conference room. The maintenance person responsible for pest control had quit, leaving the facility without proper oversight. The facility had a contract with a pest control company, but the issue persisted.
A facility failed to include a resident's use of the anticoagulant medication Eliquis in their care plan, despite its importance for treatment monitoring. Interviews with the DON and MDS LVN-A confirmed the omission, which was contrary to the facility's policy requiring comprehensive care plans with measurable goals.
A resident with severe impairments and a mechanically altered diet was left unsupervised during meals, contrary to care plan requirements. Observations showed the resident eating alone without necessary adaptive equipment, increasing the risk of choking. Staff interviews revealed communication gaps and failure to implement recommended supervision, leading to a deficiency in care.
The facility failed to maintain a clean and safe environment for residents, with issues such as a black substance in a toilet, peeling drywall, and unclean floors. Housekeeping and maintenance staff were aware of these problems but did not adequately address them, leading to discomfort and dissatisfaction among residents.
The facility failed to develop comprehensive care plans for two residents, leading to unmet needs and potential risks. One resident, with severe impairments and a history of dysphagia, was not properly supervised during meals despite recommendations for dining room supervision. Another resident, with a history of falls, had improper use of fall mats not addressed in her care plan. The lack of coordination and communication among staff resulted in these deficiencies.
A resident's medication was improperly stored when a nurse left a furosemide pill unattended on the bedside table, contrary to facility policy. The resident, who was cognitively intact but visually impaired, took the pill without supervision. The DON confirmed that medications should not be left unattended to prevent misuse or health risks.
A resident with severe impairments and on a mechanically altered diet was served a hard piece of toast, inappropriate for his dietary needs, and lacked necessary meal items. The dietary manager admitted the bread was overcooked and the gelatin snack was improperly prepared, highlighting the facility's failure to provide meals in the correct consistency.
A resident with a documented allergy to mushrooms did not have this allergy listed on their dietary form, leading to a failure in communication between nursing and dietary staff. The Dietary Manager was unaware of the allergy, and the Director of Nursing acknowledged the potential for a severe allergic reaction. The facility's policy on nutritional recommendations was not adhered to, resulting in this deficiency.
A resident with significant health issues, including dysphagia, was not provided with drinks consistent with their needs during meal service, lacking water and appropriate drinking aids like lids and straws. The resident's care plan required specific meal setup assistance, which was not fully implemented, leading to a deficiency in hydration support.
A resident with a history of stroke and multiple diagnoses requiring assistance with eating was not provided with the necessary special eating equipment, specifically a divided plate, as per their care plan and physician orders. Observations showed the resident struggling to eat with a regular plate, leading to food spillage and the resident eating with his hands. Interviews confirmed the oversight, despite the facility's policy outlining the need for adaptive equipment.
Exit Door Alarm on Hall 100 Found Disabled, Creating Elopement Hazard
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when the exit door alarm on hall 100 was found turned off. Record review showed there were 14 residents on hall 100 out of a total facility census of 47 residents. During an observation around midday, staff were present in the hallway and four resident room doors were open, with two residents in bed and two in wheelchairs; these residents were observed to be non-ambulatory and unable to move their wheelchairs independently. Later that afternoon, during a joint observation and interview with the Maintenance Director, seven exit doors were checked, and the exit door at the end of hall 100 did not alarm when the release bar was pushed and the door opened. The Maintenance Director used a key to turn on the mounted red exit door alarm, after which the alarm functioned properly. He stated he did not know why the alarm had been off and reported that CNAs had copies of the key and would occasionally use that door to let residents out for smoking breaks or to take residents out because it was closer to the ramps. He also stated he checked the doors every Monday and that this was the first time he had found an unsecured door. The DON stated her expectation was that staff would turn door alarms back on after disabling them with a key and acknowledged that if an alarm was disabled, residents could get out the door without staff knowing. The Administrator stated she expected fire exit doors to alarm when the handle was pushed and indicated staff would not have a reason to disable an alarm unless taking something out the back of the facility. Facility policy on wandering and elopements indicated the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.
Failure to Use Required PPE Under Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring appropriate use of personal protective equipment (PPE) under Enhanced Barrier Precautions (EBP) during wound care. A cognitively intact resident with diagnoses including cerebral infarction, colostomy status, malignant melanoma of the right upper limb, an indwelling catheter, an ostomy, and open skin lesions had active physician orders for daily right upper arm wound care and for EBP. The EBP orders specified that staff must use gown and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs), and that EBP is indicated for residents with wounds and indwelling medical devices regardless of MDRO colonization. The facility’s EBP policy, revised in March 2024 and February 2025, required targeted gown and glove use for high-contact care activities, including wound care for any skin opening requiring a dressing. On the survey date, an LPN was observed performing right upper arm wound care on this resident without donning a gown, despite an EBP sign posted next to the resident’s door and the active EBP orders. The LPN conducted the wound care while only partially complying with the required PPE, as she did not wear a gown for this high-contact activity. In interviews, the DON stated her expectation that staff wear gloves and gowns when entering and performing care on residents under EBP, and the Administrator stated that door precaution signs inform staff of required PPE, including gowns and gloves, and that she expected staff to wear them. Both the DON and Administrator acknowledged that failure to wear the appropriate PPE, including a gown, placed the resident and staff at risk for infection, demonstrating that the observed practice did not conform to facility policy or provider orders for EBP.
Failure to Timely Post Daily Nurse Staffing and Census Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing and census information at the beginning of, or within two hours of, the 6:00 a.m. to 6:00 p.m. shift on 03/07/2026. At 12:00 p.m. on that date, surveyors observed that the document posted in the front lobby was labeled as the daily staffing for Friday, March 6th, and contained the census and scheduled number and hours worked for CNAs, LVNs, RNs, hospitality aides, and total hours worked for the two 12-hour shifts. A subsequent observation at 12:49 p.m. showed that the correct document labeled as the daily staffing for Saturday, March 7th, was then posted in the same location, indicating that the required information had not been posted timely for that day’s day shift. During interviews, the DON stated that the weekend supervisor was responsible for posting the daily census and nurse staffing document on weekends, but the weekend supervisor did not work on 03/07/2026. She reported that the administrator posted the document but acknowledged it was posted late and was unsure who served as the weekend supervisor’s backup for this task, adding that she did not know the impact of the late posting because it had never happened before. The administrator stated her expectation was that the weekend supervisor post the daily census and nurse staffing document in the front area, and when there was no weekend supervisor, the manager on duty would usually complete the task. She could not explain why the document was not posted on time and confirmed that the document serves as a notification to the general public about staffing per shift, with the same information also available in a staffing book in the lobby. Policy review showed that the facility’s “Posting Direct Care Daily Staffing Numbers” policy, revised August 2022, requires that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care be computed by the charge nurse or designee and posted in a prominent, accessible location using the Nurse Staffing Information form.
Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident's right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. The resident, an older male with multiple diagnoses including chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, vascular dementia, type II diabetes mellitus, and paranoid schizophrenia, was noted to have severe cognitive impairment and was always incontinent of bowel and bladder. His care plan required frequent checks for incontinence and regular cleaning of his room due to his risk for unsanitary behaviors and falls. On the day of the survey, the resident was found sitting in his wheelchair, naked from the waist down, with wet pants on the floor and dried feces smeared from the toilet to the sink. The room had a strong odor of urine and feces, sticky floors, and a pool of liquid identified by the resident as urine. The resident reported that no one had checked on him since breakfast, and he felt bad about the soiled conditions. Staff interviews revealed that the assigned CNA did not perform required rounds or check the care plan, assuming the resident could toilet himself. The CNA acknowledged that the resident was left in an undignified state and that frequent checks were necessary due to his incontinence and behavioral issues. Further interviews with the LVN and DON confirmed that the resident required frequent monitoring and that the room should have been cleaned at least twice daily. The LVN admitted not checking on the resident during the morning hours due to being busy with medications, and the DON stated that the resident's condition and room were unacceptable. Facility records showed that staff had received training on resident rights and dignity, and the facility's policy required all residents to be treated with kindness, respect, and dignity.
Failure to Maintain Safe and Clean Environment for Resident with Incontinence
Penalty
Summary
A deficiency was identified when a resident's right to a safe, clean, comfortable, and homelike environment was not honored. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, vascular dementia, type II diabetes mellitus, and paranoid schizophrenia, was observed in a room with significant sanitation issues. The resident was always incontinent of bowel and bladder, required maximum assistance with activities of daily living except eating, and needed frequent checks and assistance with toileting. Despite these needs, the resident was found sitting in his wheelchair, naked from the waist down, with wet pants on the floor, and a pool of urine on the floor. The bathroom had smeared dried feces extending from the toilet to the sink, and the room had a strong odor of urine and feces with sticky floor tiles. Interviews revealed that the housekeeper assigned to the resident's hall did not start work until later in the morning, and although the floor was mopped twice daily, the sticky substance and feces persisted. The CNA assigned to the resident admitted to not performing rounds or entering the room as required, mistakenly believing the resident could toilet independently. The CNA also acknowledged the resident deserved a clean room and recognized the embarrassment caused by the unsanitary conditions. The LVN assigned to the resident was unaware if rounds had been completed and did not check on the resident during the morning medication pass, stating the resident would not use the call light to request assistance. Facility leadership, including the DON and Administrator, confirmed that the resident required frequent checks and that the room's condition was unacceptable. The DON acknowledged the risk of infection and health issues due to the presence of urine and feces on the floor and accepted accountability for the nursing care provided. Facility policies and job descriptions reviewed indicated a requirement for maintaining cleanliness and a safe environment, but these standards were not met in this instance.
Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, or misappropriation of resident property were reported immediately, as required by federal and state regulations. Specifically, two incidents involving two residents were not reported to the administrator and appropriate authorities within the mandated timeframes. The first incident involved a male resident who went out on leave during Thanksgiving and returned with missing narcotic medication cards for Tramadol and Tylenol #3. The agency nurse who signed him out did not follow the required procedure of counting and documenting the medications with the resident, nor did she provide the necessary narcotic sheets. Upon the resident's return, staff discovered the narcotic sheets were missing, and there was uncertainty about the quantity of narcotics the resident should have had. Although the incident was reported to the DON, it was not reported as a possible misappropriation or drug diversion to the administrator or state authorities as required. The second incident involved a female resident who reported feeling neglected during her first week of admission. She stated that her colostomy bag broke and she was unable to get assistance despite calling for help, and she believed her call light was intentionally misplaced. The resident reported this to the social worker (SW), who then informed the DON but failed to report the allegation to the administrator, who was also the abuse and neglect prevention coordinator. The DON did not recall being informed about the incident, and the administrator confirmed that the incident should have been reported immediately. The facility's own policies and staff training materials required immediate reporting of such allegations, but these procedures were not followed in either case. Record reviews confirmed that neither incident had been reported in the state's TULIP system, and interviews with staff revealed gaps in following established protocols for reporting and investigating allegations of abuse, neglect, or misappropriation. Both residents had significant medical needs, including pain management with controlled substances and complex wound and ostomy care, which heightened the importance of timely and accurate reporting. The facility's failure to report these incidents as required constituted a deficiency in protecting residents' rights and ensuring their safety.
Failure to Complete Baseline Care Plan for Colostomy Care
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who required specialized care, specifically for a colostomy. The resident, a female with multiple complex diagnoses including type 2 diabetes, bilateral above-knee amputations, stage III pressure ulcer, and peripheral vascular disease, was admitted with orders for colostomy care. Despite these needs, the baseline care plan was not completed to reflect her colostomy and the required monitoring and care instructions. The resident's electronic medical record and active orders indicated the necessity for colostomy bag checks and changes, but this was not incorporated into her baseline or comprehensive care plans. Observations and interviews revealed that the resident was experiencing pain and had a colostomy bag in place, with care being provided by nursing staff as needed. However, the Director of Nursing acknowledged that the baseline care plan was opened but not completed, and that the omission of colostomy care instructions could result in missed care. Nursing staff were aware of the resident's colostomy and provided care, but were not informed that the baseline care plan was incomplete. Facility policy required a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, but this was not followed in this case.
Failure to Provide Required Smoking Safety Equipment and Supervision
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, mild intellectual disabilities, and a history of smoking-related safety issues was allowed to smoke without the required protective smoking apron. The resident's care plan and smoking assessment both specified the need for supervision and the use of a smoking apron due to previous incidents of cigarette burns on his clothing and the tendency to rest a lit cigarette near his pants. Despite these documented requirements, the resident was observed smoking under the supervision of a housekeeper without wearing the apron. Interviews with staff confirmed awareness of the resident's need for the apron, with the housekeeper stating the resident refused to wear it and the DON reiterating that smoking should not occur without the apron. The social worker also confirmed the resident was not safe to smoke without the apron, even with supervision, due to his habit of letting the cigarette touch his pants. Facility policies required individualized safety interventions and adherence to smoking safety protocols, but these were not followed during the observed incident.
Failure to Account for Controlled Substances During Resident Pass
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the accurate accounting and documentation of controlled substances for a resident who went out on pass. The resident, who had intact cognitive status and was prescribed opioid medications for pain management, reported that when he left the facility for a pass, an agency nurse gave him a bag with his medications but did not count the narcotics with him or provide the required narcotic sheets. Upon his return, the resident informed facility staff that the medications were not counted at the time of his departure, and staff subsequently discovered that the narcotic sheets were missing. Facility staff, including two LVNs, counted the medications upon the resident's return and created new narcotic sheets to account for what was brought back. The DON later confirmed that the process for signing out controlled substances was not followed, as there was no two-nurse count, no resident signature for the medications provided, and the narcotic sheets were not given to the resident as per protocol. The DON also acknowledged that the incident was not reported as a potential drug diversion or misappropriation at the time, despite the lack of accountability for the narcotics. Interviews with facility leadership and staff revealed that the agency nurse responsible for the resident's medications was not properly oriented to the facility's procedures for handling controlled substances during resident passes. Facility policies required written prescriber authorization, two-nurse count verification, and documentation in the controlled substance disposition log, none of which were followed in this instance. The failure to adhere to these procedures resulted in a lack of accountability for the resident's narcotic medications during his absence from the facility.
Failure to Implement Enhanced Barrier Precautions for Resident with Stage 4 Wound
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident admitted with a stage 4 pressure wound to the sacrum. Upon admission, the resident had multiple diagnoses including type 2 diabetes mellitus, acute pain due to trauma, bilateral above-knee amputations, adult failure to thrive, stage III pressure ulcer of the sacral region, and peripheral vascular disease. Despite having an active order for wound treatment and dressing, there was no order or implementation of Enhanced Barrier Precautions (EBP) as required for residents with such wounds. The resident's baseline care plan was not completed, and the comprehensive care plan did not include EBP interventions. Observations revealed the absence of a PPE bin and signage outside the resident's room, and staff, including the ADON, provided wound care using gloves but not gowns. Interviews with staff indicated a lack of awareness and adherence to EBP protocols, despite documented training on infection control and EBP. The ADON, who performed wound care, acknowledged not using proper PPE and stated that the absence of signage contributed to this oversight. The infection control preventionist confirmed that EBP was necessary for the resident and that staff had been trained on the requirements. Facility policy required EBP for residents with wounds to reduce the transmission of multi-drug-resistant organisms, but this was not followed in the resident's care.
Failure to Ensure Appropriate Wheelchair Assessment and Maintenance for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and equipment to maintain or improve mobility with maximum practicable independence, unless a reduction in mobility was unavoidable. The resident in question had significant medical conditions, including morbid obesity, muscle weakness, and difficulty walking, and relied on a motorized wheelchair (MWC) for mobility. Despite documented weights consistently above 550 pounds, there was confusion and lack of verification regarding the wheelchair's weight capacity, with conflicting information from various sources and no clear documentation or assessment by facility staff to confirm the suitability of the equipment. Multiple interviews revealed that the resident experienced repeated mechanical issues with the MWC, including broken and bent casters, which led to reduced use of the wheelchair due to safety concerns. The facility staff, including the Director of Rehabilitation (DOR), Director of Nursing (DON), and Administrator (ADM), were aware of the equipment issues but did not take timely or coordinated action to assess the wheelchair's appropriateness or arrange for necessary repairs. The facility's therapy and nursing staff did not refer the resident for a wheelchair evaluation, and there was a lack of communication and follow-through regarding responsibility for repairs and equipment replacement, despite clear indications from the resident's insurance that the facility was responsible for durable medical equipment (DME) while the resident remained in the facility. Documentation and interviews further indicated that the facility did not obtain or review the wheelchair's specifications or owner's manual to verify its weight capacity, nor did they maintain records of repairs or ensure that the resident's needs were being met. The resident, feeling unsafe and unsupported, attempted to resolve the issues independently and through external vendors, but encountered barriers due to outstanding balances and vendor policies. The facility's failure to assess, document, and provide appropriate equipment and services resulted in the resident being at risk of unsafe mobility and not receiving care to maintain or improve range of motion and independence.
Failure to Maintain Bed in Lowest Position and Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
Nursing staff failed to ensure that a resident with severe cognitive impairment and a history of falls received adequate supervision and assistive devices to prevent accidents. The resident, diagnosed with neurocognitive disorder with Lewy bodies, psychotic disorder, generalized anxiety disorder, and severe dementia with behavioral disturbances, was observed lying in bed with the head elevated and the bed positioned approximately 3.5 feet off the floor. The care plan for this resident required the bed to be kept in the lowest position with brakes locked and frequent observation, as well as placement in a supervised area when out of bed. However, during observation, the resident was left unsupervised, moving and reaching for blankets on the floor, with no staff in the immediate vicinity. A CNA later confirmed that she had transferred the resident to bed 15-20 minutes prior and admitted to forgetting to lower the bed to its lowest position, despite knowing the resident was a fall risk and had a history of attempting to get out of bed without assistance. The DON also acknowledged that the resident was impulsive, unsteady, and required the bed to be in the lowest position to prevent falls. Facility policy on fall risk management specifically identified incorrect bed height as an environmental risk factor for falls. No falls were recorded for the resident during the review period, but the failure to follow care plan interventions and provide adequate supervision constituted a deficiency.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Specifically, residents on the 300/400 hallway were provided showers in a room that was not free of potentially infectious debris. Observations and interviews revealed that soiled briefs, linens, and dirty towels were left on the floor and shower chair in the shower room after use. One resident reported encountering these items upon entering the shower room, and another resident confirmed seeing dirty towels on the floor on different occasions. Photographic evidence of the soiled items was presented to facility leadership, who initially expressed disbelief but later acknowledged the issue. Housekeeping staff stated that they were responsible for cleaning the shower after each use and recognized the risk of infection transmission if soiled items were handled without gloves. Additionally, the facility failed to ensure that two residents were properly screened for tuberculosis (TB) prior to or upon admission and annually, as required by facility policy. Record reviews showed that one resident had no documentation of TB screening at admission or within the past year, and another resident, while screened at admission, had not received annual TB screening. The facility's policy mandates TB screening for all admissions and annual follow-up, but this was not consistently implemented. The residents involved had complex medical histories, including diagnoses such as Alzheimer's disease, pressure ulcers, osteomyelitis, respiratory failure, and other chronic conditions. Some residents were cognitively impaired, while others were cognitively intact. The failure to maintain a sanitary shower environment and to conduct required TB screenings directly contravened the facility's own infection control and TB screening policies, as confirmed by record reviews and staff interviews.
Failure to Provide Bariatric Bed and Trapeze for Resident Needing Accommodation
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident with significant medical needs, specifically by not ensuring the resident had the appropriate bariatric bed and overhead trapeze as recommended by the therapy department and ordered by the physician. The resident, who had a BMI over 70, morbid obesity, muscle weakness, and other complex medical conditions, required a 60-inch-wide bariatric bed and an overhead trapeze to facilitate self-positioning, self-transfer, and bed safety. Despite therapy and physician orders dating back to August, the resident continued to use a 48-inch-wide bed without a trapeze as of November, making it difficult for him to reposition and transfer independently. Interviews and record reviews revealed that the therapy department and physician had communicated the need for the equipment to the Administrator, DON, and Corporate RVP, but there was no evidence that the equipment was ordered or purchased in a timely manner. The Administrator stated she had placed the order as soon as she became aware, but could not provide a purchase order or delivery timeline. The DON was unable to explain the delay or provide documentation confirming the purchase, and conflicting statements were made regarding when staff were notified of the need. Facility policy confirmed the resident's right to reasonable accommodation, but the necessary adaptive equipment was not provided as required.
Failure to Ensure 24-Hour Visitation Access
Penalty
Summary
The facility failed to ensure that residents had unrestricted access to visitors of their choosing at any time, as required by federal and state regulations and the facility's own policies. Specifically, one resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's Disease, vascular dementia, and major depressive disorder, was unable to receive visitors after 8:00PM because the front door was locked and staff did not respond to the doorbell. The resident's POA reported having to arrive before 8:00PM to visit and stated that repeated requests to facility leadership to address the issue were unsuccessful. The POA also attempted to alert staff through an electronic surveillance device in the resident's room, but staff did not respond to the front door. Interviews with the DON and Administrator revealed confusion and lack of implementation regarding after-hours visitor access. Although discussions had occurred about possible solutions, such as posting an on-call phone number or assigning a charge nurse to answer the door, no measures had been put into practice. Facility policies reviewed confirmed that residents are entitled to 24-hour visitation access, but these policies were not followed in practice, resulting in the resident's inability to receive visitors after regular hours.
Failure to Provide Reasonable Telephone Access and Privacy
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of telephones, as required by resident rights policies. Two residents were specifically affected: one resident, who was cognitively intact but had significant visual impairment, possessed a personal cell phone but was unable to use it effectively due to her declining vision. Her emergency contact reported frequent difficulties reaching her through the facility, as calls to the facility phone were rarely answered. The activities director indicated that a cordless phone was available for residents on her hallway, but this was not accessible to her. Another cognitively intact resident did not have a personal cell phone and relied on the facility-provided cordless phone, which was found to be non-operational. She reported repeated requests to nursing staff about the phone, being told it needed charging or was not working. Observation confirmed the phone was unplugged and the wiring was pushed into a hole in the wall. The DON initially claimed the phone was functional but, upon inspection, acknowledged the issue and deferred to maintenance, who confirmed the phone had not worked for an undetermined period. There was no alternative provided for bedbound residents to access a phone if they did not have a personal device. Interviews with facility leadership revealed a lack of clear procedures for family access to the building and for ensuring residents could communicate with individuals outside the facility, especially after business hours. The facility's own policy required access to a telephone and privacy for communication, but these requirements were not met for the affected residents, as evidenced by the inoperable phone and lack of alternative arrangements.
Failure to Enforce Smoking Safety Policy and Supervision
Penalty
Summary
A deficiency occurred when a resident, who was assessed as a safe smoker and was cognitively intact, was found to have cigarettes and a lighter in her personal possession in her room, contrary to facility policy. The resident, who had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, and neuropathies, was fully ambulatory and required supervision to no assistance with activities of daily living. Her care plan specified that she should not keep cigarettes or a lighter in her room and that these items should be stored safely, with smoking to be supervised as needed. Despite these care plan interventions and the facility's smoking policy, which prohibits residents from keeping smoking articles in their rooms and requires all smoking to be supervised with items stored in a lock box, the resident stated she was allowed to keep her cigarettes and lighter because she was a safe smoker. She also reported that she did not have to follow the policy due to her status. Staff interviews revealed confusion and inconsistency regarding the enforcement of the smoking policy, with the DON stating the resident was allowed to smoke unsupervised, while the Corporate RVP confirmed that all residents should be supervised and not keep smoking articles in their rooms. Further review of facility documentation showed that the required documentation sheet for tracking cigarettes and lighters had not been filled out for the past 30 days, and some staff were unaware of the documentation process. The facility's smoking policy and in-service records clearly outlined the procedures for supervised smoking and the handling of smoking materials, but these were not consistently followed, leading to the deficiency.
Failure to Provide Prescribed Therapeutic Diet and Adequate Portions
Penalty
Summary
The facility failed to provide a resident with a nourishing, palatable, well-balanced diet that met the resident's daily nutritional and special dietary needs, as prescribed by the physician. The resident, a male with multiple diagnoses including morbid obesity, acute respiratory failure, and various mental health conditions, was cognitively intact and had specific dietary orders for a regular diet with double portions of protein at all meals and double portions of vegetables at lunch and dinner. Despite these orders, multiple instances were documented where the resident did not receive the prescribed portions or appropriate food substitutions, as evidenced by photos of meal trays and tray tickets provided by the resident and reviewed by the Ombudsman and surveyors. Interviews with facility staff, including the Dietary Manager, Administrator, and DON, revealed a lack of clarity regarding what constituted a vegetable, with staff acknowledging that items like French fries and mashed potatoes were not considered vegetables. The Dietary Manager reported that recent budget cuts by the new management company limited the ability to purchase fresh food and provide alternative meal choices, resulting in insufficient food to meet double portion requirements. The kitchen inventory confirmed a limited supply of fresh and frozen vegetables, and the Dietary Manager stated she was only allowed to prepare food for the exact number of residents, not accounting for second helpings or special dietary orders. Facility policy required that all therapeutic diets be served according to physician orders, with substitutions made for allergies and preferences as reviewed by the registered dietician. However, the facility's food master list did not specify which foods were considered vegetables, and the registered dietician was unavailable for comment. The resident expressed concerns about not receiving full meals and attributed the issue to budget constraints and management decisions, which was corroborated by staff interviews and observations.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent prior to the administration of a psychotropic medication. Specifically, for a female resident with diagnoses including Type 2 Diabetes Mellitus, Paranoid Schizophrenia, and Celiac Disease, there was no documented informed consent for the use of Olanzapine, an antipsychotic medication, in the resident's medical record. The resident had severe cognitive impairment as indicated by a BIMS score of 6, and her care plan included the use of antipsychotic medication with related interventions. Despite an order for Olanzapine and ongoing care, the required consent form was not present in the electronic medical record, and staff were noted to be awaiting the consent form from the contracted psychiatry agency. Interviews with facility staff revealed a lack of clear responsibility for obtaining psychotropic medication consents, with both nursing staff and the social worker sometimes involved. The DON and Administrator both acknowledged the importance of obtaining consent quickly, but there was no specific staff member assigned to this task. The facility's policy states that residents have the right to receive information about psychoactive medications and to refuse consent, but this process was not followed for the resident in question, as evidenced by the missing consent documentation for Olanzapine.
Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical assistance needs was found lying in bed with her call light on the floor, out of her view and reach. The resident's medical history included catatonic disorder, a parathyroid gland neoplasm, and sick sinus syndrome. Her care plan specifically identified her as being at risk for falls due to impaired cognition, mobility, and lack of safety awareness, and directed that the call light be kept within reach. Observation confirmed the call light was not accessible to the resident, and staff interviews acknowledged the issue, with an LVN noting the resident was unable to call for help. The facility's policy required call lights to be positioned conveniently for residents, but this was not followed in this instance.
Failure to Label and Discard Enteral Feeding Containers
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a feeding tube received appropriate treatment and services to prevent complications. Specifically, the feeding formula and water containers used for a resident with a gastrostomy tube were not labeled with the required identifiers, such as the resident's name, date, and time of infusion. Observations showed that the containers remained hanging from the feeding pole after the feeding was completed, and the feeding pump was turned off. Staff interviews confirmed that the containers were supposed to be labeled to ensure correct administration and to track how long the formula had been in use, but this was not done. Additionally, staff indicated uncertainty about the time frame for the resident's nocturnal feedings and whether the remaining formula and water could be reused. The resident involved was a female with a history of cerebral infarct, aphasia, dysphagia, gastro-esophageal reflux, and gastrostomy status, and was assessed as severely cognitively impaired. Physician orders specified the administration of enteral feedings and water flushes at set times and rates. Facility policy required that all feeding equipment be labeled and changed according to specific guidelines, but these procedures were not followed. The Director of Nursing acknowledged that the formula should be labeled and discarded after 24 hours, and failure to do so could result in the use of outdated formula.
Failure to Document and Notify Resident of Discharge and Appeal Rights
Penalty
Summary
The facility failed to ensure proper documentation and notification during the discharge process of a resident who was sent to the hospital for a change in condition and subsequently not readmitted. The resident, who was cognitively intact and had complex medical needs including a stage 4 pressure ulcer, neurogenic bladder and bowel, and quadriplegia, was discharged without a 30-day discharge notice, discharge orders, or a discharge summary present in the electronic medical record (EMR) at the time of review. The facility only provided a discharge order and summary after the surveyor requested it, and these documents were dated several weeks after the actual discharge event. Interviews with facility staff revealed that the decision not to readmit the resident was based on concerns about non-compliance with care, suspected drug use, and perceived safety risks to other residents. The administrator, DON, and social worker all supported the decision not to allow the resident to return, citing issues such as missed wound care appointments, non-compliance with repositioning, and reports of drug use and paraphernalia. However, the physician was not aware of the discharge at the time it occurred, and the DON admitted to not realizing that proper discharge documentation had not been completed. The facility's own policy required that residents and/or responsible parties be notified prior to transfer or discharge, and that discharge documentation, including physician orders and a discharge summary, be present in the clinical software. These requirements were not met in this case, as there was no evidence of a 30-day discharge notice or timely discharge documentation in the resident's EMR. The lack of proper documentation and notification could affect residents who are sent to the hospital for a change in condition and are not readmitted.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator and to the State Survey Agency, as required by regulation and facility policy. Specifically, two residents made allegations of abuse on the same day, but these were not reported to the appropriate authorities. The first resident, who had a history of paranoid schizophrenia and a BIMS score indicating intact cognition, reported being fondled by a male resident. The incident was documented in the LVN's progress notes, and the DON was informed and spoke with the resident, but the allegation was not reported to the state or further investigated as required. The second resident, who had severe cognitive impairment due to vascular dementia, reported being hit by a female resident. This allegation was also documented in the progress notes, and the resident was subsequently moved to another unit. However, the DON stated she was not aware of this allegation until the survey, and the administrator acknowledged seeing the nursing note but did not receive a direct report. Neither of these incidents was reported to the state agency, as confirmed by a review of the TULIP reporting system. Interviews with facility staff revealed confusion and inconsistency regarding the criteria for reporting abuse allegations. The DON indicated that the resident's BIMS score influenced her decision not to report, and the administrator cited a lack of eyewitnesses and the residents' histories of making unsubstantiated claims as reasons for not reporting. The facility's own policy requires immediate reporting of all allegations or suspicions of abuse, regardless of perceived credibility or witness presence, but this protocol was not followed in these cases.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse and mistreatment involving two residents. In the first incident, a resident with a history of psychiatric diagnoses and a BIMS score indicating intact cognition reported being fondled by a male resident. The LVN documented the resident's distress and her statement about being touched, and the DON was notified. However, the DON did not believe the allegation was reportable, citing the resident's cognitive status and the lack of direct disclosure during her own interaction with the resident. The administrator was aware of the allegation but did not interview the resident or initiate a formal investigation, referencing the resident's history of making unsubstantiated claims and the absence of witnesses. In the second incident, another resident with severe cognitive impairment and behavioral disturbances reported being hit by a female resident. The LVN documented the statement and observed the resident's agitation, but the DON was not made aware of the allegation and only learned of it during the survey. The administrator acknowledged seeing the nursing note but did not receive a formal report or initiate an investigation, as the resident could not recall the event and there were no witnesses. The LVN noted that the resident was moved to another unit following the incident, but no further documentation or investigation was completed. Interviews with facility staff revealed inconsistent responses to the allegations, with reliance on residents' cognitive status and the presence of witnesses as determining factors for reporting and investigating abuse. The facility's policy requires all allegations of abuse, neglect, or mistreatment to be promptly reported and thoroughly investigated, regardless of the circumstances. The failure to follow these protocols resulted in a lack of comprehensive investigation and documentation for both incidents, as required by facility policy and state regulations.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as observed during a survey. A pile of yellow liquid, identified as urine, was found on the restroom floor of the resident's room. This observation was made during a visit, and the floor was noted to be sticky with a foul odor present in the room. The presence of urine on the floor poses a risk of falls, as confirmed by an interview with an LVN who acknowledged that a resident could slip, fall, and potentially sustain a fracture. The resident involved had multiple diagnoses, including depression, anxiety, tremor, lack of coordination, type 2 diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease, cognitive communication deficit, unsteadiness on feet, paranoid schizophrenia, seizures, and abnormalities of gait and mobility. The resident's care plan indicated functional bowel/bladder incontinence and a risk for falling due to an unsteady gait. The care plan included approaches such as frequent checks and assistance with toileting, ensuring the floor is free of liquids, and performing frequent housekeeping rounds. Despite these measures, the facility did not maintain the environment as required, leading to the deficiency.
Unattended and Unlocked Medication Cart Found in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During an observation, a medication cart located near the nurses' station was found unattended and unlocked, with medication blister packs inside. The lock button on the cart was unengaged, leaving the medications unsecured. This incident involved Medication Cart 2, which was not assigned to any staff member at the time of the observation. Interviews with staff revealed a lack of awareness and responsibility regarding the unlocked medication cart. LVN A, who was not assigned to the cart, acknowledged that it should have been locked and was unaware of its contents. The Director of Nursing (DON) confirmed that the cart was being used for medication storage and was not aware of when it was last accessed by staff. The facility's policy mandates that medications be stored securely to prevent tampering or misuse, which was not adhered to in this instance.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a certified dietary manager as required, which could place residents at increased risk of foodborne illness and inadequate nutrition. The deficiency was identified during an interview and record review, revealing that the facility's dietary manager had not completed the necessary certification course. The dietary manager, hired on 06/17/21, was unaware of the requirement to complete a certified dietary manager course. This was her first position as a dietary manager, and her previous experience was limited to working as a cook. Interviews with the Human Resources Director and the Administrator further highlighted the oversight. The Human Resources Director admitted she was unaware of the certification requirement and acknowledged that she and the Administrator were responsible for ensuring department heads met their certification requirements. The Administrator also stated he was not aware of the certification requirement and agreed that completing the course would help the dietary manager run the kitchen more effectively. The facility's employee handbook, dated 81/21, mandates that all professionally registered, licensed, and certified staff maintain current licensure, registration, and/or certification.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Several items in the refrigerator, including a plastic bag of cheese, a plastic bag of beets, and a one-gallon plastic container of pudding, were not labeled or dated. This lack of labeling and dating could lead to the inability to determine the expiration dates of these food items, posing a risk of foodborne illness to residents. Additionally, the temperature gauge on the dish machine in the dish room was not functioning, which is crucial for ensuring proper sanitation. Interviews with the Dietary Manager revealed that the temperature gauge had been non-functional for about a month, and although the issue had been reported to the Maintenance Director and the dish machine service representative, no work order was found in the facility's Maintenance Log Book for the repair. The Dietary Manager also confirmed that food in the refrigerators must be dated and labeled, and acknowledged the importance of a working temperature gauge for sanitation purposes. Further observations and interviews highlighted issues with the distribution and labeling of snacks in the Nourishment Rooms. Snacks were not consistently labeled or dated, and there was a lack of cleaning in the refrigerators, with a build-up of ice and spilled liquids observed. The DON and Dietary Manager acknowledged these issues, noting that snacks should be labeled with the date and time they were brought out to ensure they are safe to eat. The facility's policies on food storage and kitchen safety were not being followed, contributing to these deficiencies.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation, several deficiencies were noted, including a disconnected bathroom ceiling fan, a broken bedroom light fixture, broken window shade vents, a wall penetration, a missing ceiling panel, water discoloration marks around a ceiling vent, missing floor molding, and non-working light bulbs in a hallway ceiling light unit. These issues were identified in various resident rooms and corridors, indicating a lack of proper maintenance and oversight. Interviews with the Administrator revealed that the Maintenance Director had recently self-terminated, and there was no facility policy on preventative maintenance. The Maintenance Director had maintained a work order communication log, but a review of the facility's Maintenance Log Book showed no recorded work orders for the identified issues over the previous months. The Administrator acknowledged that these deficiencies could negatively impact resident safety and satisfaction.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats in a resident room and numerous flies on the 200 hall. Additionally, a cockroach was observed in the conference room. These observations were made during a survey conducted on June 4 and June 5, 2024. The facility had a contract with a pest control company, which had serviced the facility twice in May 2024 to treat for ants and insects. However, the maintenance person responsible for overseeing the pest control program had quit on June 4, 2024, leaving the facility without proper oversight for pest management. The administrator acknowledged the issue and stated that the maintenance supervisor from a sister facility was temporarily handling pest control duties.
Failure to Document Anticoagulant Use in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's use of anti-coagulant medication, Eliquis, which was prescribed to the resident starting on February 6, 2024. This omission was identified during a review of the resident's care plan, which was initiated on the same date as the medication start date, but failed to document the anti-coagulant medication use. Interviews with the Director of Nurses and the MDS LVN-A confirmed that the resident's anti-coagulant medication use was not documented in the current care plan. Both staff members acknowledged the importance of including medication usage in the care plan for treatment monitoring purposes. The facility's policy, dated December 2017, requires staff to develop a comprehensive care plan with measurable and time-limited goals to meet the needs of the resident, which was not adhered to in this case.
Inadequate Supervision During Mealtimes
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during mealtimes, which led to a deficiency in care. The resident, a male with a history of seizures, cerebrovascular disease, and severe impairments in daily decision-making, was on a mechanically altered diet and required supervision during meals to prevent choking or aspiration. Despite these needs, the resident was observed eating alone in his room without the necessary adaptive equipment, such as a divided plate, and was not provided with the required supervision. This lack of supervision and appropriate equipment increased the risk of choking and aspiration for the resident. The resident's care plan and physician orders indicated the need for specific dietary modifications and supervision during meals. However, observations revealed that the resident was served meals that did not comply with these orders, including hard toast and a regular plate instead of a divided one. Additionally, the resident was left unsupervised, which contradicted the recommendations from the speech therapist, who had advised that the resident should eat in the dining room with staff supervision due to his inability to communicate effectively and the risk of emergency events if he were to choke or aspirate. Interviews with facility staff, including the Dietary Manager, Speech Therapist, and Director of Nursing, highlighted communication gaps and a lack of adherence to the resident's care plan. The Dietary Manager was unaware of the resident's food allergies, and the Speech Therapist's recommendations for supervision were not consistently implemented. The Director of Nursing acknowledged that the resident was supposed to be supervised during meals but did not document or care plan the resident's refusals to eat in the dining room. These oversights contributed to the deficiency in providing adequate supervision and care for the resident during mealtimes.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for several residents, as evidenced by multiple observations and interviews. Resident #2's bathroom had a black substance caked over the interior of the toilet bowl, and the air conditioning unit was covered in dust. Despite daily cleaning by housekeeping staff, the issue persisted, and the housekeeper acknowledged the need for additional materials to clean the toilet. The Maintenance Director was aware of the problem but had not provided the necessary resources to address it. Resident #3's room had peeling drywall on the wall behind the bed, which the Maintenance Director was aware of but had not yet addressed. This lack of maintenance contributed to an environment that was not homelike or comfortable for the resident. The Maintenance Director admitted that such conditions would be upsetting if his family were living in a similar facility. Resident #6 reported that her room had not been cleaned properly, with dirty mop water used and areas like the closet floor and behind a storage container left uncleaned. Resident #7's room was observed to have various debris and substances on the floor, and the resident expressed discomfort with the uncleanliness. The Maintenance Supervisor and Housekeeper B acknowledged the need for better cleaning practices but had not yet implemented them effectively.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in meeting their needs. For one resident, who had a history of seizures, cerebrovascular disease, and severe impairments in daily decision-making, the facility did not adequately address his refusal to eat in the dining room. Despite recommendations from the Speech Therapist for the resident to eat in the dining room for supervision due to his dysphagia and risk of choking, the resident was observed eating alone in his room with inappropriate meal setups, such as a regular plate instead of a divided plate, and without necessary adaptive equipment like lids and straws. The resident's care plan did not document his refusals to eat in the dining room, and staff did not consistently supervise him during meals, contrary to the Speech Therapist's recommendations. Another resident, who had a history of cerebral infarction, Alzheimer's disease, and falls, was not properly care planned for the use or refusal of fall mats. The resident was observed with a fall mat folded and not covering the side of the bed, which was not addressed in her care plan. The Director of Nursing acknowledged that the resident had memory issues and would often kick the fall mats out of the way, but this was not documented or care planned. The lack of a comprehensive care plan for the resident's fall risk and the improper use of fall mats could potentially place the resident at risk of injury. The facility's failure to develop and implement comprehensive care plans for these residents highlights a lack of coordination and communication among staff regarding the residents' needs and interventions. The Speech Therapist's recommendations were not effectively communicated or incorporated into the care plans, and the Director of Nursing was not fully aware of the residents' needs and the necessary interventions. This lack of comprehensive care planning could lead to unmet needs and potential risks for the residents.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, specifically in the case of a resident's medication storage. During an observation, it was noted that a resident had a furosemide pill left unattended on their bedside table. The resident, who was cognitively intact but had severely impaired vision, identified the pill and took it without supervision. The medication was left by a male nurse who had given it to the resident earlier but did not ensure it was taken or properly stored. The nurse admitted to leaving the medication at the bedside, acknowledging that it was against protocol as it could lead to medication misuse or loss. The Director of Nursing confirmed that medications should not be left unattended to prevent unauthorized access or potential health risks. The facility's policy stated that only authorized personnel should have access to medications, highlighting a breach in procedure that could affect the resident's health and safety.
Failure to Provide Properly Prepared Meals for Resident on Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident who was on a mechanically altered diet. The resident, who had a history of seizures, cerebrovascular disease, and severe impairment in daily decision-making, was observed being served a hard piece of toast, which was inappropriate for his mechanical soft diet. The resident attempted to eat the toast, resulting in a crunch noise, indicating the bread was too hard for him to consume safely. Additionally, the resident was seen eating spaghetti with his hands due to difficulty using a fork, and his meal tray lacked necessary items such as straws, condiments, and cheesecake. The dietary manager acknowledged that the bread was overcooked and unsuitable for residents on a mechanical soft diet. The manager also noted that the gelatin snack provided was not prepared correctly, being too watery. These observations and interviews highlight the facility's failure to ensure that the resident received meals in the proper consistency, which could lead to dissatisfaction, poor intake, choking, and weight loss.
Failure to Document and Communicate Resident's Food Allergy
Penalty
Summary
The facility failed to accommodate a resident's food allergy to mushrooms, as observed during a survey. The resident, a male with multiple medical conditions including seizures, cerebrovascular disease, and hemiplegia, was noted to have an allergy to mushrooms documented on his face sheet. However, during an observation, the resident's dietary form accompanying his meal tray did not list any allergies, indicating a failure to communicate this critical information to the dietary staff. Interviews with the Dietary Manager (DM) revealed that there was no record of the resident's mushroom allergy in the dietary binder, and the DM was unaware of the allergy. The DM stated that the kitchen did not have mushrooms at the time, but the lack of documentation posed a risk of exposure. The Director of Nursing (DON) acknowledged uncertainty about the severity of the allergy but emphasized the potential for a severe allergic reaction. The facility's policy on nutritional recommendations outlined procedures for addressing dietary needs, but these were not followed in this instance, leading to the deficiency.
Failure to Provide Adequate Hydration Support
Penalty
Summary
The facility failed to provide drinks consistent with the needs and preferences of a resident during meal service, specifically failing to provide water during lunch on a specified date. The resident, a male with a history of seizures, cerebrovascular disease, and other significant health issues, was observed with a coffee cup and a clear cup with a purple liquid, both without lids, and no straws were provided. The tray had liquid spilled all over it, and the resident's hand was shaking, indicating difficulty in managing the drinks provided. The resident's care plan required set-up assistance for eating and drinking, and he was on a mechanically altered diet with thin fluids. The speech therapist had evaluated the resident in March and noted that due to his history of stroke and dysphagia, he should have a divided plate with meals and cups with plastic lids and straws. However, during the observation, these recommendations were not fully implemented, as evidenced by the lack of lids and straws. The facility's policy on nutritional recommendations outlines a process for addressing dietitian recommendations, but it appears that the necessary adjustments for this resident's meal service were not adequately followed, leading to the deficiency.
Failure to Provide Special Eating Equipment for Resident
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them, specifically a divided plate, which was necessary for the resident's assistance with eating. This deficiency was observed during meal times when the resident was served meals on a regular plate instead of the prescribed divided plate. The resident, who had a history of stroke and was diagnosed with conditions such as seizures, cerebrovascular disease, and hemiplegia, was dependent on assistance for activities of daily living, including eating and drinking. The resident's care plan and physician orders clearly indicated the need for a divided plate and other adaptive equipment to aid in meal consumption. During observations, it was noted that the resident struggled to eat using a regular plate, resulting in food spillage and the resident resorting to eating with his hands. The dietary staff failed to adhere to the diet sheet instructions, which specified the use of a divided plate for the resident. Interviews with the Dietary Manager and Speech Therapist confirmed the oversight, with the Dietary Manager acknowledging the availability of divided plates and the need for staff to follow the diet sheet instructions. The Speech Therapist also emphasized the importance of the divided plate and additional adaptive equipment, such as cups with lids and straws, to assist the resident due to his dysphagia and preference for eating with his hands. The facility's policy on nutritional recommendations outlined the process for addressing dietary needs and recommendations, including the use of adaptive equipment. However, the failure to provide the necessary equipment as per the resident's care plan and physician orders indicates a lapse in following these procedures. This oversight could potentially impact the resident's ability to consume meals effectively, leading to issues such as weight loss and diminished independence.
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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