Northgate Plaza
Inspection history, citations, penalties and survey trends for this long-term care facility in Irving, Texas.
- Location
- 2101 Northgate Dr, Irving, Texas 75062
- CMS Provider Number
- 675967
- Inspections on file
- 58
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Northgate Plaza during CMS and state inspections, most recent first.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
A resident with dementia and severe cognitive impairment was observed sitting in a wheelchair with a can of disinfectant spray and a bottle of hand sanitizer spray on the chest of drawers in the room. Staff, including a Med Tech, an LVN, and the DON, acknowledged that aerosol and disinfectant sprays are hazardous and should not be kept in resident rooms, especially for confused residents, and stated that all staff are responsible for checking rooms and removing such items. Despite this, the hazardous sprays remained accessible in the resident’s environment, resulting in a deficiency related to accident hazard prevention and supervision.
A resident with Type 1 DM and severe cognitive impairment, whose care plan and MD orders included routine blood sugar checks and insulin administration, had a blood glucose test performed by an LVN in the hallway outside the room rather than in a private setting with the door closed. The LVN acknowledged the test should have been done in the room for privacy. The DON, Clinical Resource Nurse, and Administrator confirmed that the test should have been conducted in the room with the door closed, consistent with facility policy requiring examinations and treatments to be performed in a manner that maintains bodily privacy and shields residents from passers-by.
Three residents with cognitive and physical impairments did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Observations found call lights placed on a side table, inside a drawer, and on the floor, making them inaccessible. Staff interviews confirmed that call lights should be within reach, but this was not consistently ensured.
A resident with severe cognitive impairment and an indwelling catheter was observed without a privacy bag covering the catheter bag, despite staff awareness and physician orders requiring its use to maintain dignity. Staff interviews confirmed the expectation for privacy bags, but the bag was not replaced after being removed, resulting in a failure to uphold the resident's right to a dignified existence.
A resident returned from the hospital with an indwelling catheter, but the admitting RN did not transcribe or obtain physician orders for catheter care, as required by facility policy. This omission resulted in a lack of documented instructions for catheter management, including care procedures and assessments, for a resident with urinary retention and severe cognitive impairment.
A deficiency was identified when a resident with COPD did not have her breathing mask stored in a protective bag after use, as required by facility policy. The mask was left on the overbed table by an LVN who failed to replace the storage bag, resulting in improper storage of respiratory equipment and deviation from professional standards.
A medicated skin protectant containing zinc oxide was found left unsecured on a resident's side table, despite the resident having severe cognitive impairment and a physician's order for its use after incontinence care. Staff interviews confirmed the product should have been stored in a locked cart, in accordance with facility policy and regulations requiring all drugs and biologicals to be kept in locked compartments accessible only to authorized personnel.
A CNA failed to wear a gown while providing incontinent care to a resident with an indwelling catheter and an order for enhanced barrier precautions (EBP), despite clear signage and facility policy requiring gown and gloves for high-contact care. The resident had severe cognitive impairment and a care plan specifying EBP, but the required infection control measures were not followed.
A resident with a history of traumatic brain injury, major depressive disorder, and repeated falls was observed in bed without a fall mat, despite being assessed as high fall risk and having a care plan specifying the need for a floor mat. Staff interviews revealed a lack of awareness and documentation regarding the fall mat requirement, and the intervention was not implemented as outlined in the care plan and facility policy.
Three residents with fall risks and varying cognitive impairments were found to have their call lights out of reach while in bed, despite care plans and staff training specifying the need for accessible call lights. Staff interviews confirmed the oversight, and facility records indicated the importance of call light accessibility for these residents.
Three residents with cognitive impairment and high fall risk were found using scoop mattresses as physical restraints without physician orders. Facility staff confirmed the absence of required orders, in violation of policy requiring medical justification for restraint use.
A resident with a history of falls and severe cognitive impairment was found lying in bed without the required fall mat placed alongside the bed, as specified in her care plan. The fall mat was instead located under the bed, and staff interviews confirmed this was not in accordance with fall prevention protocols. Facility policy and staff statements indicated that the fall mat should have been in place to reduce accident hazards.
A resident with multiple comorbidities, including dementia, diabetes, and a history of recurrent UTIs, exhibited signs of infection and clinical decline. Despite a recommendation from the Infectious Disease NP to transfer the resident to the hospital, the facility did not act on this advice, and there was no documentation explaining the decision. The resident's condition worsened, and he was only sent to the hospital after family intervention, where he was diagnosed with sepsis, UTI, aspiration pneumonia, and an infected pressure ulcer, ultimately resulting in death.
Two residents with specific dietary needs and preferences were not provided with appropriate meal alternatives, resulting in them frequently missing nutritious and palatable options. One resident with multiple medical conditions and food allergies was repeatedly served meals he could not eat, while another resident with dietary restrictions due to GERD and kidney disease had to purchase her own food due to lack of suitable options. Staff interviews revealed ongoing issues with budget constraints, lack of alternative menus, and poor communication between departments.
Two residents with pressure ulcers did not have their wound care treatments documented as ordered by physicians, with multiple missed entries in the TAR and no progress notes explaining the omissions. One resident's care plan lacked interventions for a documented wound, and both residents had complex medical histories requiring diligent wound management. Staff interviews revealed that wound care was sometimes provided but not always documented, especially during periods without a designated wound care nurse. The facility's policy required immediate documentation, but this was not consistently followed, leading to gaps in the medical record.
The facility's kitchen failed to meet food safety standards, with issues such as dusty ice machine vents, improperly labeled and stored food items, and pest presence. Dietary staff did not change gloves appropriately, and food was not thawed under cold running water. The Dietary Manager was unaware of proper labeling and storage procedures, and the facility's policy on food disposal was not followed.
The facility failed to maintain RN coverage for 8 consecutive hours daily, 7 days a week, across four quarters, with 42 days lacking coverage. Despite employing five RNs and using agency staff, the facility could not provide documentation for the required RN hours. Interviews revealed that the DON made himself available when needed, but weekends often lacked RN coverage, posing risks to resident care.
A resident with severe cognitive impairment and COPD was not regularly assisted out of bed, despite being dependent on staff for transfers. Interviews and observations revealed that the resident had not been out of bed for several months, and staff failed to document refusals or address the issue in the care plan. This deficiency placed the resident at risk for health complications.
A facility failed to maintain accurate medical records for a resident, particularly regarding transfer refusals. The resident, with severe cognitive impairment and dependent on staff for transfers, was not consistently assisted out of bed, despite expressing a desire to do so. Staff interviews revealed that refusals were not regularly documented, and the resident had not been out of bed since returning from the hospital months prior. This lack of documentation and assistance could risk the resident's health.
A facility failed to secure confidential information for four residents, leaving sensitive details visible on a nurse's cart. This included a resident's death details, medication schedules, and vital signs. The oversight was acknowledged by the involved LVN, and the facility's policy mandates the protection of such information.
The facility failed to provide a clean and safe environment for residents, with observations of unclean conditions in several rooms and throughout the facility. Air conditioning units were filled with dirt and dust, bathroom floors had dirt and stains, and handrails were stained. Interviews revealed understaffing in housekeeping, contributing to inadequate cleaning. The Administrator acknowledged the concerns as an infection control issue.
The facility failed to provide proper respiratory care for residents with COPD, as humidifiers were left empty and breathing apparatuses were improperly stored, risking contamination. A resident's humidifier was found empty, while two residents had unbagged nasal cannulas and breathing masks, exposing them to potential infection. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to proper storage procedures.
The facility's kitchen failed to meet food service safety standards, with an unclean ice machine and unlabeled food items in storage. Dietary staff acknowledged the importance of proper labeling and cleaning to prevent foodborne illnesses, yet observations revealed lapses in these practices.
The facility failed to ensure that call lights were within reach for two residents, both with unsteadiness and muscle weakness, placing them at risk of being unable to obtain assistance. Observations showed call lights on the floor, contrary to care plans and facility policy. Staff interviews confirmed the importance of accessible call lights for resident safety and communication, highlighting a lapse in adherence to the policy.
A resident requiring total assistance for ADLs did not receive scheduled showers, as confirmed by facility records and staff interviews. The resident, with muscle weakness and unsteadiness, was scheduled for three showers a week but reported receiving only one. The facility's documentation was incomplete, and staff failed to follow protocols for documenting and addressing shower refusals.
A resident with severe disabilities was found with a mattress improperly propped up on one side, posing a risk of injury or entrapment. The setup was not part of the care plan, and staff interviews revealed it was done by an unknown staff member, possibly during the night shift, to prevent the resident from rolling out of bed. The DON acknowledged the practice was unsafe and against the facility's policy.
A facility failed to secure medication properly, leaving a box of nebulizer medication unattended in a resident's room. The resident, with severe cognitive impairment and multiple health issues, was unsure when the medication was brought in. Staff interviews confirmed the medication was not the current prescription and should not have been left unsecured. The facility's policy requires medications to be locked or attended by authorized personnel.
A CNA in a LTC facility failed to follow proper infection control procedures while providing incontinent care to a resident with gastroenteritis and colitis. The CNA did not change gloves or sanitize hands after touching contaminated surfaces and cleaning the resident, despite having received training. This failure to adhere to facility policies on perineal care and hand washing could lead to cross-contamination and infection spread.
A resident with a history of bipolar disorder and other conditions accused a PTA of physical abuse, but the allegation was not reported to the State Survey Agency as required. The incident was documented by the ADON, and the resident was later transferred to a hospital for evaluation. The Interim DON learned of the allegation the next day, leading to an investigation and suspension of the PTA. The Administrator, who was aware of the allegations, failed to report them due to confusion over the resident's behavior.
The facility failed to document the administration of medications for two residents, leading to potential risks. One resident, with severe cognitive impairment, had undocumented doses of albuterol sulfate and buspirone HCL. Another resident, moderately cognitively impaired, had multiple medications undocumented, including atorvastatin calcium and duloxetine. Staff interviews revealed uncertainty and lack of recollection regarding these omissions, and the facility's policy on medication documentation was not followed.
A facility failed to update a resident's care plan after multiple elopement attempts, despite the resident's severe cognitive impairment and history of dementia. The MDS Nurse cited a communication error for the oversight, and the facility's care planning policy did not address updating care plans with individualized interventions.
A resident with severe cognitive impairment and a history of wandering eloped from the facility multiple times due to inadequate supervision. Despite having a care plan and a wander guard, the resident managed to leave the building on several occasions, including one incident where she became aggressive and required medication to calm down. Staff interviews revealed a lack of communication and coordination in managing the resident's elopement risk.
The facility failed to immediately inform a resident's representative of a significant change in the resident's physical status when a screw was observed protruding from the resident's left lower extremity wound. The delay in communication was confirmed through interviews with the DON and WCN, who acknowledged that the family should have been notified immediately upon discovering the exposed hardware.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Hazardous Aerosol Products Left in Cognitively Impaired Resident’s Room
Penalty
Summary
Surveyors identified a deficiency in maintaining a resident environment free from accident hazards when a cognitively impaired resident had access to hazardous aerosol products in his room. Record review showed that the resident was an [AGE]-year-old male with a diagnosis of dementia, confirmed on the MDS assessment dated 03/10/26, which documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. During an observation on 03/31/26 at 10:45 a.m., the resident was seen sitting in his wheelchair with a can of disinfectant spray and a bottle of hand sanitizer spray on the chest of drawers in his room. In interviews conducted the same day, multiple staff members, including a Med Tech, an LVN, and the DON, stated that disinfectant and aerosol sprays should not be kept in residents' rooms. They acknowledged that such items are considered hazardous, particularly for confused or cognitively impaired residents, and that all staff are responsible for checking rooms and removing these items during rounds. Staff described that confused residents could spray or ingest the products, and that inhalation or exposure could cause choking, allergic reactions, or poisoning, especially in residents with respiratory issues. Despite this understanding and stated responsibility, the hazardous sprays remained in the resident’s room at the time of the surveyor’s observation.
Failure to Maintain Privacy During Blood Glucose Testing
Penalty
Summary
Surveyors identified a failure to maintain resident privacy during medical treatment for one resident. The resident was an elderly female with Type 1 Diabetes Mellitus, admitted in January 2026, with a severe cognitive impairment documented on a quarterly MDS assessment. Her comprehensive care plan included interventions for Diabetes Mellitus, including blood sugar checks per physician orders, and her physician orders directed administration of insulin glargine twice daily. Despite these orders and care plan interventions, her blood sugar testing was not conducted in a private setting. On the survey date at 12:15 p.m., LVN P was observed performing a blood sugar test by pricking the resident’s finger to draw blood while the resident was in the hallway outside her room, rather than inside the room with the door closed. During the observation and interview, LVN P acknowledged that the test should have been conducted in the resident’s room with the door closed for privacy. The DON, Clinical Resource Nurse, and Administrator, when informed of the observation, each stated that the blood sugar test should have been completed in the resident’s room with the door closed to maintain privacy and comply with the facility’s policy. The facility’s Resident Rights, Dignity and Respect policy stated that residents shall be examined and treated in a manner that maintains the privacy of their bodies, with a closed door or drawn curtain shielding them from passers-by, and that people not involved in the resident’s care shall not be present without the resident’s consent during examination or treatment.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to three residents who were reviewed for reasonable accommodation of needs. Observations on the specified date revealed that one resident's call light was placed on top of a side table and not within reach while the resident was in bed with eyes closed. Another resident's call light was found inside a drawer, making it inaccessible while the resident was eating breakfast in bed and unable to locate it when asked. A third resident's call light was observed on the floor, and the resident reported not being able to find or see the call light cord, expressing concern about what would happen if he needed help and could not leave the room. Record reviews indicated that all three residents had care plans specifying that call lights should be within reach due to their risk for falls and varying levels of cognitive and physical impairment. The residents' medical histories included diagnoses such as muscle weakness, lack of coordination, and severe to moderate cognitive impairment, with some being dependent on staff for activities of daily living. Staff interviews confirmed that the expectation was for call lights to be within reach at all times, and that staff were responsible for ensuring this during rounds and after providing care. Despite these policies and care plan interventions, staff failed to consistently ensure call lights were accessible. Staff members interviewed acknowledged the importance of call lights for resident safety and communication, and admitted to not always checking their placement. The facility's written policy also required that call devices be left within the resident's reach before staff left the room, but this procedure was not followed for the residents involved in the deficiency.
Failure to Provide Privacy Bag for Catheter Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a male resident with severe cognitive impairment and an indwelling urinary catheter was not provided with a privacy bag for his catheter bag, as observed during a survey. The resident, who was admitted with urinary retention and required significant assistance, was found in his bed with the catheter bag hanging on the side frame of the bed without a privacy bag. The resident's care plan included catheter care, and a physician's order specified the positioning of the privacy bag and tubing below the bladder. Multiple staff interviews confirmed awareness that a privacy bag was required to maintain the resident's dignity, even when the resident was in his room, due to the potential for visitors to see the catheter bag and its contents. Staff interviews revealed that a CNA noticed the missing privacy bag but forgot to inform the nurse, and an LVN admitted to removing the privacy bag because it was ripped but did not immediately replace it due to unfamiliarity with the supply location. The DON, ADON, and Administrator all acknowledged the expectation that catheter bags should be covered with privacy bags to protect resident dignity, although there was no specific written policy for this practice. The lack of a privacy bag for the catheter was identified as a failure to treat the resident with dignity and to promote the enhancement of his quality of life.
Failure to Transcribe Catheter Care Orders Upon Resident Re-Admission
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder and returned from the hospital with an indwelling catheter had appropriate physician orders in place for catheter care upon re-admission. Record review showed that when the resident was re-admitted, there were no orders transcribed for the catheter, including instructions for catheter care, when to change or flush the catheter, or what to assess. The resident had a diagnosis of urinary retention and severe cognitive impairment, and was observed with a catheter in place, but the necessary orders to guide ongoing care were missing from the medical record. Interviews with the DON, ADON, and RN involved in the admission confirmed that the admitting nurse did not place the required catheter orders, despite the resident returning with a catheter from the hospital. The facility's policy requires that all treatments, including catheter care, be administered only upon a physician's order, and that such orders be recorded immediately in the resident's chart. The lack of orders for the catheter upon re-admission resulted in a failure to ensure continuity of care for the resident.
Improper Storage of Respiratory Equipment
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), who required respiratory care including oxygen therapy and aerosolized medications, did not have her breathing mask stored properly after use. The resident, who had severe cognitive impairment, was observed with her breathing mask placed on top of her overbed table rather than being stored in a protective bag as required. The mask had been removed from its plastic bag by an LVN, who then placed it on the table and did not immediately replace the bag, citing being busy and forgetting to do so. The facility's policy required that oxygen therapy equipment, such as masks and cannulas, be kept clean and covered when not in use to prevent contamination. Interviews with facility staff, including the LVN, DON, ADON, and Administrator, confirmed that the responsibility for cleaning and properly storing the breathing mask after use fell to the staff member administering the treatment. The staff acknowledged that the mask should have been bagged to prevent cross contamination and respiratory infection, and that the failure to do so was not in line with facility policy or professional standards of practice. The incident was identified through observation, interview, and record review.
Failure to Secure Medicated Cream in Locked Storage
Penalty
Summary
Facility staff failed to store a medicated skin protectant in accordance with state and federal regulations requiring all drugs and biologicals to be kept in locked compartments accessible only to authorized personnel. During an observation, a tube of skin protectant containing zinc oxide was found on top of a resident's side table, accessible to the resident, who had severe cognitive impairment as indicated by a BIMS score of 00 and was incontinent for bowel and bladder. The resident's care plan included the use of barrier cream after each incontinent episode, and a physician's order authorized its application as needed. Interviews with staff, including a CNA, ADON, DON, and the Administrator, confirmed that the skin protectant should not have been left in the resident's room and should have been secured in a locked cart after use. The facility's policy required all drugs and biologicals to be stored in locked compartments, accessible only to licensed nursing personnel. The failure to secure the medicated cream was directly observed and acknowledged by multiple staff members as not meeting facility policy or regulatory requirements.
Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the case of one resident with an indwelling urinary catheter and an order for enhanced barrier precautions (EBP). On the date of observation, a CNA provided incontinent care to this resident without wearing a gown, despite clear signage outside the resident's room indicating the need for EBP and a physician's order specifying the use of gown and gloves for high-contact care activities. There was no evidence of a used gown in the trash, and the CNA confirmed during interview that she had forgotten to wear the required gown while providing care. The resident involved had severe cognitive impairment and was dependent on staff for care, with medical records reflecting the presence of an indwelling catheter and a care plan intervention for EBP. Facility policy required the use of gown and gloves for residents with indwelling medical devices during high-contact care. Interviews with the DON, ADON, and Administrator confirmed that staff were expected to follow EBP protocols, and that the CNA's failure to wear a gown during care was not in compliance with facility policy and physician orders.
Failure to Provide Fall Mat for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident assessed as high fall risk. The resident, who had a history of traumatic brain injury, major depressive disorder, and repeated falls, was observed in bed on two occasions without a fall mat in place, despite care plan interventions specifying the need for a floor mat while in bed. Record reviews showed the resident had multiple unwitnessed falls in the preceding months and was assessed as high fall risk. The care plan included several fall prevention interventions, including the use of a floor mat, but there was no physician order for a fall mat, and staff were unaware of the requirement. Interviews with facility staff, including a CNA, the resident's nurse practitioner, the DON, and the administrator, confirmed that a fall mat was expected and appropriate for the resident's safety. The CNA was unaware of the need for a fall mat and did not see any instructions in the charting system. The nurse practitioner and DON both stated that a fall mat should have been in place due to the resident's frequent falls and high risk status. Facility policy required individualized care plans for high-risk residents, including interventions to address identified risk factors, but the intervention was not implemented as required.
Failure to Ensure Call Light Accessibility for Residents at Risk of Falls
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents who were identified as being at risk for falls and requiring assistance with activities of daily living. Observations revealed that the call light buttons for these residents were either on the floor or otherwise out of reach while the residents were in bed. Staff interviews confirmed that the call lights were not placed within reach after care was provided, despite care plans specifying that call lights should be accessible to the residents at all times. The residents involved had varying levels of cognitive impairment and physical assistance needs, with documented histories of falls and unsteadiness. Record reviews showed that each resident's care plan included interventions to keep the call light within reach due to their fall risk and need for assistance. Staff acknowledged during interviews that the call lights were not accessible and recognized the importance of having them within reach. The facility's in-service training materials also specified proper placement of call lights, but there was no formal policy on call light accessibility. The deficiency was identified through direct observation, staff interviews, and review of resident records.
Failure to Obtain Physician Orders for Scoop Mattresses Used as Restraints
Penalty
Summary
The facility failed to ensure that three residents were free from the use of physical restraints, specifically scoop mattresses, which were implemented without physician orders. Observations confirmed that these residents, all of whom had significant cognitive impairments and required substantial or extensive assistance with activities of daily living, were using scoop mattresses. Record reviews for each resident showed no corresponding physician orders authorizing the use of these mattresses. Interviews with the ADON and DON confirmed that the scoop mattresses were in use for residents identified as fall risks, but neither staff member could locate physician orders for these devices. The facility's own policy requires that physical restraints not be used for discipline or convenience and mandates physician orders to ensure that such devices are not being used as restraints. The absence of physician orders for the scoop mattresses constituted a failure to comply with this policy.
Failure to Ensure Fall Mat Placement for Resident at Risk of Falls
Penalty
Summary
A deficiency was identified when a resident with a history of falls, unsteadiness on her feet, and severe cognitive impairment was observed lying in bed without a fall mat placed alongside her bed, as required by her care plan. The resident's care plan, updated after a hip fracture from a previous fall, specifically included the intervention of having a floor mat alongside the bed to prevent further accidents. During the observation, the fall mat was found under the bed rather than in the correct position next to it. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that the resident was considered a fall risk and that both the low bed position and the placement of the fall mat alongside the bed were necessary interventions. Staff acknowledged that the fall mat should have been in place and that its absence was likely due to it not being repositioned after care activities. The facility's policy on fall management also requires maintaining an environment as free of accident hazards as possible and implementing appropriate interventions to prevent falls.
Failure to Follow Infectious Disease NP Recommendation and Delayed Hospital Transfer
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences and goals. Specifically, a male resident with a history of type II diabetes, hypotension, dementia, pressure ulcers, recurrent urinary tract infections (UTIs), and acute kidney failure exhibited signs and symptoms of infection, including increased confusion, lethargy, hypotension, and laboratory evidence of leukocytosis. Despite a recommendation from the Infectious Disease Nurse Practitioner (NP) to transfer the resident to the hospital for further evaluation and treatment, the facility did not follow this recommendation. The resident continued to display symptoms of infection and clinical decline, including confusion, drowsiness, and unresponsiveness. Progress notes indicated ongoing abnormal vital signs and changes in mental status, yet there was no documentation explaining why the resident was not sent to the hospital as recommended. Communication breakdowns occurred between nursing staff, the former Director of Nursing (DON), and the attending physician, with conflicting accounts regarding whether the physician objected to the transfer. The resident was eventually sent to the hospital only after family intervention, at which point he was diagnosed with acute metabolic encephalopathy due to sepsis, UTI, aspiration pneumonia, and an infected pressure ulcer. Interviews with staff and family revealed delays in obtaining necessary laboratory tests and initiating appropriate interventions. The family reported concerns about the resident's care and noted that their requests for a urine test were not promptly addressed. The Infectious Disease NP confirmed that his recommendation for hospital transfer was not communicated back to him if it was not followed, and the attending physician stated he did not object to the transfer. The lack of timely response and failure to follow clinical recommendations contributed to the resident's deterioration and subsequent death.
Failure to Provide Dietary Accommodations for Resident Preferences and Allergies
Penalty
Summary
The facility failed to provide food that accommodated the allergies, intolerances, and preferences of two residents, resulting in these residents not receiving nutritious and palatable meal substitutes. One resident, a male with diagnoses including hemiplegia, depression, epilepsy, protein-calorie malnutrition, and GERD, was on a mechanical soft diet and reported being allergic to eggs and not eating pork. He stated that he was not satisfied with the food, found it unappetizing, and was not offered alternative meals, often resorting to eating cold cereal for multiple meals. During observation, he was served a dry chicken breast as the only alternative to pulled pork, which he could not eat, and declined the offer of gravy as a solution. Another resident, a female with bipolar disorder, morbid obesity, hypertension, acute kidney failure, and heart failure, was on a special diet for GERD and kidney disease. She reported that the kitchen did not always serve meals she could eat, was not offered substitutes, and had to purchase her own food, such as salads, to meet her dietary needs. She also stated that breakfast options always included pork with no alternatives, and her requests for no pork and no gravy with additional vegetables were not accommodated. Her concerns had been expressed to previous management without resolution. Interviews with staff revealed that the Dietary Supervisor was aware of the lack of alternative options due to budget constraints and had communicated these concerns to management without receiving support. The Dietary Supervisor also noted poor communication between nursing and kitchen staff, leading to residents directly requesting changes. The Operations Manager was unaware of these issues, and there was no facility policy on alternative meals. CNAs confirmed that there was no All Day Menu and that alternatives were not consistently available, sometimes requiring staff to purchase food for residents themselves.
Failure to Document and Provide Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice, specifically by not documenting wound care treatments as ordered by physicians for two residents. For one resident, there were multiple instances in which wound care treatments to the right heel and coccyx were not documented in the Treatment Administration Record (TAR), and there were no progress notes explaining the lack of documentation. The resident's care plan also lacked interventions for the right heel wound, despite physician orders and ongoing wound care needs. The resident had a history of significant medical conditions, including diabetes, dementia, and pressure ulcers, and was at risk for further skin breakdown. For the second resident, the facility similarly failed to document wound care treatments as ordered for multiple wounds, including the right heel, sacrum/coccyx, left heel, and right ankle. The TAR showed missing signoffs for several wound care treatments, and there were no notes indicating whether the treatments were completed or refused. The resident's care plan acknowledged the risk of pressure ulcer development and included interventions such as monitoring nutritional status and using pressure-relieving devices, but the lack of documentation persisted. Interviews with nursing staff revealed that wound care was sometimes provided by floor nurses when the wound care nurse was unavailable, and some staff admitted to forgetting to sign the TAR due to busy shifts, even though they stated that care was provided. The facility's own policy required immediate documentation of wound care after treatment, but this was not consistently followed. The absence of documentation could not be explained by staff or supported by progress notes, and the facility experienced a period without a designated wound care nurse, during which floor nurses were responsible for wound care. Family members of one resident expressed concerns about the care provided, and the resident was ultimately hospitalized with severe sepsis from a UTI and wound infection, later expiring in hospice. Observations and interviews confirmed that wounds were present and being treated, but the lack of documentation created uncertainty about the consistency and timeliness of care provided.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The ice machine's vents were found to be dusty, and the eyewash station had dust and debris. Food items in the refrigerator and dry storage were not properly labeled or stored according to professional standards. Specifically, chicken was left to thaw in a sink without cold running water, and various food items lacked labels indicating their description, preparation, or discard dates. Additionally, some items were past their expiration dates, and there were dented cans in the storage area. The facility's dietary staff did not change gloves after touching other surfaces or upon re-entering the kitchen, which could lead to cross-contamination. Observations revealed that a cook handled food and kitchen equipment without changing gloves or washing hands, which is against food safety protocols. Furthermore, the kitchen was not free of pests, as ants were observed on food items and shelving in the dry storage room. The Dietary Manager (DM) was unaware of the proper procedures for labeling and storing opened food items and did not know how to report pest issues effectively. The facility's policy required all perishable foods, including leftovers, to be dated, labeled, and disposed of after 72 hours or by the package expiration date. However, the DM could not articulate the potential harm to residents from dust on vents or food from dented cans. The DM acknowledged the need for more caution in sealing food packaging. The facility's failure to comply with these standards could place residents at risk for food-borne illness and cross-contamination.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, as required. This deficiency was observed across all four quarters reviewed, with a total of 42 days lacking the necessary RN coverage. The facility's Payroll-Based Journal (PBJ) reports indicated specific dates where there was no consecutive 8-hour RN coverage. Interviews with the staffing coordinator and the Director of Nursing (DON) revealed that the facility had been using agency staff to assist with RN coverage, but there were still instances where no RN was available for the required hours. The staffing coordinator acknowledged the risk to residents when RN coverage was not met, and the DON confirmed that he would make himself available if needed, although there were still weekends without RN coverage. The facility's staffing policy, dated February 2024, outlined the requirement for RN hours, including a minimum of 0.55 hours of RN care per resident day and an RN on-site 24/7. Despite having five RNs employed, the facility was unable to provide punch card hours for the dates in question, indicating a lack of documentation and oversight. The operations manager, filling in for the administrator, was unable to provide the requested punch cards, further highlighting the deficiency in maintaining adequate RN coverage. This lack of RN presence could potentially lead to inadequate supervision and missed treatments for residents.
Failure to Assist Resident with Mobility Needs
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services for mobility. The resident, an elderly male with severe cognitive impairment and a diagnosis of Chronic Obstructive Pulmonary Disease, was dependent on staff for transfers from bed to wheelchair. Despite the care plan indicating the need for assistance with transfers, the resident was not regularly assisted out of bed, as confirmed by multiple interviews and observations. The resident's family member reported that he had not been out of bed since returning from the hospital several months prior, and the resident himself expressed a desire to get out of bed but stated that no one was available to help him. Interviews with facility staff, including RNs, CNAs, and hospice nurses, revealed a lack of consistent assistance provided to the resident for getting out of bed. Several staff members, including a hospice nurse and the Director of Nursing, acknowledged the issue but did not take effective action to address it. The hospice nurse reported notifying facility management multiple times about the resident's lack of mobility assistance, but no significant changes were made. The Director of Nursing admitted to not being aware of the resident's situation and stated that refusals to get out of bed were not consistently charted or addressed in the care plan. Observations and interviews indicated that the resident was at risk for developing wounds and infections due to prolonged bed rest, although no active wounds or infections were noted in the records. The facility's failure to provide adequate mobility assistance to the resident was a significant deficiency, as it did not align with the care plan's requirements and placed the resident at risk for health complications. The lack of documentation and communication among staff further contributed to the deficiency, as there was no clear record of the resident's refusals or any contraindications to transfers.
Failure to Document and Assist Resident Transfers
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of refusals of transfers. The resident, an elderly male with severe cognitive impairment and dependent on staff for transfers, was admitted to the facility with a care plan indicating the need for assistance with transfers and a potential risk for pressure ulcers. Despite this, the facility did not accurately document the resident's refusals to be transferred from bed to wheelchair, nor did they provide consistent assistance as required by the care plan. Interviews with staff and family members revealed that the resident had not been regularly assisted out of bed since returning from the hospital several months prior. The resident expressed a desire to be assisted out of bed, but staff did not consistently offer or document these offers and refusals. The resident's family member reported that the resident had not been out of bed since May, and staff interviews confirmed that the resident was rarely seen out of bed, with some staff noting that refusals were not typically charted. The lack of documentation and inconsistent assistance with transfers could place the resident at risk for health complications such as pressure ulcers and pneumonia. The facility's Director of Nursing acknowledged the responsibility to ensure appropriate care, including transfers, regardless of hospice status, and noted that refusals should be documented and addressed in the care plan. However, the facility's policies regarding documentation of refusals were not obtained, indicating a gap in the facility's adherence to professional standards and practices.
Failure to Secure Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for four residents, as observed during a survey. LVN B left sensitive information unattended and visible on top of a nurse's cart in the 200 Hall. This included details about a resident's death, medication schedules for two residents, and vital signs and code status for another resident. These actions were observed by a staff member who attempted to conceal the information by flipping the papers over. Resident #6's information included her name, time of death, and details about her funeral arrangements, which were left exposed. Resident #7's medication schedule for Norco, an opioid, was also visible, as was Resident #8's schedule for Baclofen, a muscle relaxant. Additionally, Resident #9's vital signs and DNR status were left on display. These lapses in securing confidential information were acknowledged by LVN B, who admitted to the oversight and recognized the importance of maintaining privacy. Interviews with the Interim DON and the Administrator confirmed that the facility's policy mandates the protection of residents' personal and medical information. Both acknowledged the breach of privacy and confidentiality, emphasizing that such information should not be exposed to unauthorized individuals. The facility's HIPAA policy, revised in September 2022, underscores the importance of safeguarding health information, which was not adhered to in these instances.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by observations of unclean conditions in five resident rooms and throughout the facility. Specifically, the air conditioning units in these rooms were found to have vents filled with black dirt debris and thick dust, and the bathroom floors had thick black dirt along the corners and brownish stains around the toilets. Additionally, the handrails throughout the facility were observed to have dark and light stains, indicating a lack of proper cleaning and sanitization. Interviews with facility staff revealed that the housekeeping department was understaffed, which contributed to the inadequate cleaning. The Housekeeping Supervisor acknowledged the issues and mentioned that they had recently hired additional staff to address the backlog of cleaning tasks. However, the current housekeeping staff member stated that due to being the primary person responsible for cleaning, she did not have sufficient time to clean the rooms thoroughly. The Administrator also recognized the concerns as an infection control issue and a matter of resident dignity.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, leading to deficiencies in their treatment. Resident #3, diagnosed with chronic obstructive pulmonary disease (COPD), was found with an empty humidifier connected to her oxygen therapy, contrary to the physician's order to check and refill the humidifier every shift. This oversight was noted during an observation and interview, where the resident was unaware of the issue, and the nurse had not checked the humidifier during her rounds. Resident #4, also diagnosed with COPD, had her breathing mask and nasal cannula improperly stored when not in use. The breathing mask was left unbagged on a table, and the nasal cannula connected to a portable oxygen tank was not bagged, exposing them to potential contamination. Interviews with the Director of Therapy (DOT) and a Licensed Vocational Nurse (LVN) confirmed the improper storage and the risk of cross-contamination and respiratory infection. Resident #5, another COPD patient, had a nasal cannula connected to a portable oxygen tank coiled on her wheelchair handle without being bagged. This improper storage was observed during an interview, where the resident expressed unawareness of the need to bag the nasal cannula. Similarly, Resident #10's nebulizer mask was found propped on an open drawer without a bag, risking contamination. Interviews with nursing staff and the Director of Nursing (DON) highlighted the failure to adhere to proper storage procedures, which could compromise respiratory care and increase the risk of infection.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. The ice machine in the kitchen had black stains near the inside door hinges, and the ice scoop holder contained dirt debris. Additionally, several food items stored in the refrigerator and freezer, including a large container of reddish sauce, bread sticks, tater tots, frozen fish fillets, red potatoes, and breaded chicken tenders, were not labeled with a stored date. These lapses in food storage and sanitation practices were identified during observations and interviews with the dietary staff and management. Dietary Manager A, who had been in the role for a month, acknowledged the importance of labeling and dating food to prevent serving expired items, which could lead to food poisoning. Despite the facility's policy to prevent foodborne illness, the ice machine was reportedly cleaned daily, yet visible stains were present. Dietary Manager C, assisting in training, emphasized the need for proper labeling and cleaning to ensure resident safety. The facility's administrator also recognized the risks of serving expired food and the necessity of maintaining cleanliness in the kitchen, particularly with the ice machine, to prevent infections among residents.
Failure to Ensure Call Lights Are Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach and accessible for two residents, which could place them at risk of being unable to obtain assistance when needed. Resident #1, a female with diagnoses of unsteadiness on feet and muscle weakness, was observed in her bed without access to her call light, which was found on the floor. Her care plan indicated she was at risk for falls and required the call light to be within reach. Similarly, Resident #2, also with unsteadiness and muscle weakness, was observed without her call light, which was also on the floor. Her care plan noted she required moderate assistance and needed a reachable call light due to balance problems. Interviews with staff, including a CNA, an LVN, the Interim DON, and the Administrator, revealed a consensus that call lights should always be accessible to residents. The CNA admitted not noticing the call lights were out of reach during her morning rounds. The LVN emphasized the importance of call lights for resident communication and safety, noting that without them, residents might attempt tasks independently, risking falls. The Interim DON and Administrator both acknowledged the necessity of ensuring call lights are within reach and stated that all staff are responsible for this. The facility's policy on call lights mandates that they be placed within the resident's reach before staff leave the room. Despite this policy, the observations and interviews indicated a lapse in adherence, leading to the deficiency. The Interim DON mentioned initiating an in-service training to address the issue, and the Administrator planned to coordinate with the DON to ensure compliance with the call light policy.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident, who required total assistance for activities of daily living (ADLs), received the necessary services to maintain personal hygiene. The resident, who had diagnoses of muscle weakness and unsteadiness on feet, was scheduled to receive three showers a week but reported only receiving one. The facility's records corroborated this, showing only four shower sheets completed for the entire month of October, with one instance of refusal noted. The Acting Director of Nursing (DON) confirmed the lack of documentation and was unsure if the resident had received the scheduled showers. Interviews with staff revealed that the Certified Nursing Assistants (CNAs) were responsible for completing shower sheets, even if a shower was refused, and notifying the nurse to persuade the resident. However, this protocol was not consistently followed. The Licensed Vocational Nurse (LVN) on the floor stated that she believed the CNA was providing showers, but the documentation did not support this. The facility's policy required that residents receive appropriate treatment and services to maintain their well-being, which was not adhered to in this case.
Improper Mattress Setup Poses Risk to Resident
Penalty
Summary
The facility failed to implement appropriate interventions for a resident with multiple complex medical conditions, including severe intellectual disabilities and spastic hemiplegic cerebral palsy, who was at risk of rolling out of bed. The resident's mattress was improperly propped up on one side using wedges and a pillow, which was not part of the care plan and posed a risk of injury or entrapment. This setup was observed during a survey, and staff interviews revealed that the mattress had been arranged this way by an unknown staff member, possibly during the night shift, in an attempt to prevent the resident from rolling out of bed. The facility's Director of Nursing (DON) and other staff members acknowledged that the mattress should not have been propped up and that this practice was not safe. The DON noted that the use of the mattress in this manner could be considered a restraint, which was against the facility's policy of providing a least restrictive environment. The care plan for the resident included the use of a fall mat next to the bed to cushion any falls, but the improper use of the mattress was not documented as an intervention. Staff members were unaware of who was responsible for the setup, and the facility planned to conduct in-service training to address the issue.
Unsecured Medication Found in Resident's Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medication for one resident. During an observation, a box containing vials of nebulizer medication was found unattended and unsecured on the nightstand at the bedside of a resident diagnosed with COPD, dementia, chronic kidney disease, and a femur fracture. The resident, who had severe cognitive impairment, was unsure when the medication was brought to him, and it was labeled with his name from a pharmacy. Interviews with staff revealed that the medication should not have been in the resident's room unattended, and it was not the current prescription ordered by the doctor. The RN acknowledged the risk of the resident taking medication at the wrong time and removed the medication from the room. The DON confirmed that the resident did not self-administer medication and that an assessment was required to determine if a resident could safely do so. The facility's policy stated that only authorized personnel should have access to medications, which should be locked or attended.
Infection Control Lapse During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of a CNA during the provision of incontinent care to a resident. The resident, a cognitively intact female diagnosed with gastroenteritis and colitis, was observed to be always incontinent for bladder and bowel. During the care process, the CNA did not change gloves or perform hand hygiene after touching potentially contaminated surfaces, such as a trash can, and after cleaning the resident's soiled areas. This lapse in protocol occurred despite the CNA having received training in hand hygiene and incontinent care. The CNA's failure to change gloves and sanitize hands between tasks could lead to cross-contamination and the spread of infections. The facility's policies on perineal care and hand washing, which emphasize the prevention of irritation or infection and the cleansing of hands to prevent transmission of infectious material, were not adhered to during this incident. Interviews with the Interim DON and the Administrator confirmed that the expected procedures were not followed, which could contribute to the development of infections among residents.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged incident of abuse involving a resident and a Physical Therapy Assistant (PTA) within the required timeframe. The incident occurred when the resident, who has a history of bipolar disorder, diabetes, depression, and is legally blind, became agitated and accused the PTA of physical abuse. Despite the resident's cognitive intactness as indicated by a BIMS score of 14, the allegation was not reported to the State Survey Agency by the Administrator as required. The incident was documented in a progress note by the Assistant Director of Nursing (ADON), who witnessed the resident's agitated behavior and attempts to deescalate the situation. The resident was later transferred to a hospital for a psychological evaluation, where he reiterated the abuse allegation. However, the Interim Director of Nursing (DON) only became aware of the allegation the following day when reviewing hospital records, prompting an investigation and suspension of the PTA. Interviews with facility staff revealed that the Administrator was aware of the resident's allegations during the incident but did not report them, citing confusion due to the resident's erratic behavior. The facility's policies require immediate reporting of such allegations, but this protocol was not followed, potentially placing residents at risk of undetected abuse.
Failure to Document Medication Administration for Two Residents
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, specifically for two residents reviewed for pharmacy services. For the first resident, there was a lack of documentation indicating that albuterol sulfate and buspirone HCL were administered on specified dates. This resident, who was severely cognitively impaired and had a history of dementia with mood disorder, anxiety disorder, and insomnia, was at risk due to the facility's failure to document medication administration. Interviews with staff revealed uncertainty and lack of recollection regarding the administration and documentation of these medications. For the second resident, the facility also failed to document the administration of several medications, including atorvastatin calcium, duloxetine, melatonin, sennosides-docusate sodium, and carboxymethyl cellulose on various dates. This resident, who was moderately cognitively impaired and had diagnoses including acute kidney issues, atrial fibrillation, and dry eye syndrome, was similarly affected by the lack of documentation. Attempts to interview staff responsible for medication administration were largely unsuccessful, and one staff member admitted to possibly forgetting to document due to being new to the facility's system. The facility's policy on medication administration requires that any deviation from the scheduled medication administration be documented, but this was not adhered to in these cases. The Clinical Resources staff member, who was new to the building, acknowledged the issue but was unsure why the Medication Administration Record (MAR) was incomplete. The report highlights the facility's failure to ensure proper documentation of medication administration, which could lead to medical complications and a decrease in therapeutic dosages for the residents involved.
Failure to Update Care Plan After Elopement Attempts
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team following each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for a resident who had multiple elopement attempts on specific dates. Despite the resident's care plan being revised earlier in the year to address elopement risks, the plan was not updated after each elopement incident, which could lead to the resident's individual needs not being met. The resident involved was an elderly female with a history of dementia with mood disorder, dementia with psychotic disturbance, anxiety disorder, and insomnia. She was severely cognitively impaired, as indicated by a BIMS score of 01. The MDS Nurse acknowledged that the care plans should be updated annually, quarterly, and as needed, but cited a communication error as the reason for the oversight. The facility's policy on care planning, dated August 2015, did not address the need for updating care plans with individualized interventions.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for a resident with severe cognitive impairment, who was at risk for elopement. The resident, diagnosed with dementia, anxiety disorder, and insomnia, had a history of wandering and was identified as an elopement risk. Despite having a care plan that included interventions such as offering diversions and monitoring a wander guard, the resident managed to leave the building on multiple occasions. On three separate dates, the resident attempted to elope from the facility. On one occasion, the resident slipped through a door, and on another, exited through a door left open by a visitor. The most concerning incident involved the resident being outside the building, walking towards the street, and becoming aggressive when staff attempted to redirect her. The staff struggled to manage the situation, and the resident required medication to calm down. Interviews with staff revealed a lack of communication and coordination in handling the resident's elopement risk. The staff was not adequately informed about the resident's movements, and there was confusion about who was responsible for supervising her. The facility's policy on elopement and unsafe wandering was not effectively implemented, leading to repeated incidents of the resident leaving the building without proper supervision.
Failure to Notify Resident's Representative of Significant Change
Penalty
Summary
The facility failed to immediately inform the resident's representative of a significant change in the resident's physical status. Specifically, the facility did not notify the resident's family member when a screw was observed protruding from the resident's left lower extremity wound. The wound care nurse (WCN) identified the exposed hardware on 01/03/24 and noted it in the resident's records, but did not inform the resident's representative at that time. The resident's representative only became aware of the issue during a follow-up appointment with the orthopedic surgeon on 01/05/24, when the screw was visibly protruding from the wound and was subsequently removed by the surgeon. The delay in communication was confirmed through interviews with the Director of Nursing (DON) and the WCN, who acknowledged that the family should have been notified immediately upon discovering the exposed hardware. The resident, a [AGE] year-old female, had multiple diagnoses including a fracture of the left tibia shaft, type 2 diabetes mellitus, Parkinson's disease, COPD, non-Alzheimer's dementia, and a burn of unspecified body region. The resident was admitted to the facility following a surgical procedure and required daily wound care. The resident's comprehensive care plan included goals for healing the impaired skin and preventing serious injury from falls. Despite these plans, the facility did not follow its own policy for notifying the resident's representative of significant changes in condition, as evidenced by the lack of timely communication regarding the exposed screw. Interviews with the resident's representative and facility staff revealed that the family member was generally satisfied with the facility's communication but was taken aback by the discovery of the exposed screw during the orthopedic appointment. The facility's policy on change of condition requires immediate notification of the physician and responsible party when significant changes occur. However, this policy was not followed in this instance, leading to a delay in addressing the resident's condition and potentially compromising the resident's care and safety.
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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