Paradigm At Katy
Inspection history, citations, penalties and survey trends for this long-term care facility in Katy, Texas.
- Location
- 1480 Katy Flewellen, Katy, Texas 77494
- CMS Provider Number
- 676064
- Inspections on file
- 29
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Paradigm At Katy during CMS and state inspections, most recent first.
A resident with COPD and heart failure experienced shortness of breath and activated the call light for help, but staff did not respond due to an ineffective nurse call system that lacked audible alerts. The resident called 911 for assistance, and EMTs confirmed the system only provided a visual alert not visible from the nurse station. Staff and residents had previously reported issues with the call system, but these concerns were not communicated to facility leadership, resulting in delayed response to care needs.
A resident with respiratory needs was unable to receive timely staff assistance due to a malfunctioning nurse call system that only activated a visual hallway light, which was not visible from the nurse station and did not provide an audible alert. Staff relied on visually monitoring hallway lights, and concerns about the system's effectiveness were not communicated to facility leadership. The resident ultimately called 911 for help when staff did not respond to the activated call light.
A resident with dementia and multiple comorbidities experienced an unwitnessed fall resulting in a hip fracture. Although the incident was documented and the resident was sent to the hospital, the facility did not submit the required 5-day investigation report to the state survey agency as mandated by policy and law. Interviews indicated confusion during an administrative transition contributed to the reporting failure.
A CNA placed her personal jacket and eyeglass case on a clean linen cart containing folded linens after her sleeves became wet while assisting a resident with a bed bath. This action was observed and confirmed by staff, including an RN, ADON, Administrator, and DON, as a violation of infection control policy, which requires personal items to be kept separate from clean resident supplies.
Three residents did not receive timely assistance with ADLs, including incontinent care and personal grooming. Two residents were left in soiled briefs and bedding for extended periods, and another had long, untrimmed toenails despite staff awareness of the issue. Staff interviews revealed missed care rounds, high workloads, and confusion over responsibilities, resulting in unmet hygiene and grooming needs.
The facility did not provide meaningful, person-centered activities as required, particularly on weekends, with observations and resident interviews confirming that scheduled activities were not conducted and residents were left without engagement. Staff interviews and review of the activities calendar further supported that activities were either not offered or did not meet residents' interests, resulting in a lack of support for residents' physical, mental, and psychosocial well-being.
A resident with significant medical needs, including an indwelling catheter, was found with an exposed foley catheter bag and visible urine, contrary to facility policy requiring privacy covers. Nursing staff and the DON confirmed that privacy bags are mandated and that staff are regularly trained on this requirement, but the privacy bag was not replaced after catheter care, resulting in a lapse in maintaining the resident's dignity.
A resident with sepsis and heart failure, who required oxygen therapy, did not have oxygen use addressed in her comprehensive care plan. The omission was confirmed by staff review of records and interviews, revealing that the care plan lacked measurable objectives and interventions for oxygen until after the issue was identified.
Two bottles of hair products belonging to former residents were found unsecured on a dresser in a resident's room. The resident was totally dependent on staff for care and unable to communicate. Staff interviews confirmed that such items should be labeled and stored in drawers to prevent cross-contamination and access by wandering residents, but this protocol was not followed.
A CNA did not follow proper perineal care procedures for a female resident who was incontinent, failing to separate the labia and adequately clean the area during incontinent care. The issue was identified during an observation, and additional cleaning was required to remove fecal matter. The resident had multiple medical conditions and required assistance with daily living activities. Facility policy and staff interviews confirmed that the correct procedure was not followed, increasing the risk of infection.
A resident with a gastrostomy tube was administered high-protein tube-feeding formula at a rate of 56ml/hr instead of the physician-ordered 55ml/hr. This discrepancy was identified through observation, record review, and staff interviews, which revealed that the feeding machine settings were not properly verified and adjusted according to the order. Staff acknowledged the error and noted that CNAs may have inadvertently changed the settings during care, and the responsible RN did not confirm the correct rate as required by facility policy.
A resident's medications, including Ipratropium and Budesonide, were found on a medication cart after the resident had been discharged. An LVN confirmed these medications should have been removed to prevent administration to other residents, and the DON stated that facility policy requires immediate removal and secure storage of discontinued medications.
A medication cart was found to contain a Lidocaine vial with injection marks and no date of opening, contrary to facility policy requiring multi-dose vials to be dated. The LVN assigned to the cart stated she was not the one who opened the vial, and the DON confirmed the vial should have been dated.
A deficiency was cited when the side door of a dumpster was found open and half-full of trash, contrary to facility policy requiring dumpsters to remain closed. Staff interviews confirmed that all departments use the dumpster and acknowledged it should be kept closed to prevent pest entry and infection control issues.
Surveyors identified infection control deficiencies involving two residents: one had Foley catheter tubing resting on a fall mat and at times on the floor, despite staff training and facility policy requiring proper placement to prevent infection; another resident's room contained hair products labeled for other residents, contrary to protocols for labeling and storing personal hygiene items to prevent cross-contamination.
A deficiency was identified when a CNA improperly repositioned a fully dependent male resident with complex medical needs by pulling his arm to move him in bed, rather than following proper procedures. The incident was witnessed on video, and both involved CNAs acknowledged the technique was inappropriate. The facility's policy required individualized and documented repositioning, which was not followed in this case.
The facility failed to maintain an effective infection control program, leading to the spread of Candida auris among residents. Staff were observed not using PPE or performing hand hygiene when interacting with residents on contact precautions. Interviews revealed gaps in infection control practices, with the new Infection Preventionist unaware of the number of affected residents and lacking a clear mitigation plan. The administration also showed a lack of oversight, contributing to the ongoing outbreak.
A facility's call light system was non-functional for five months, leaving residents without a reliable way to call for help. One resident, who was quadriplegic and on mechanical ventilation, experienced a delay in care, leading to a 911 call. Other residents faced similar challenges due to inadequate alternative devices.
A resident with complex medical needs experienced a significant change in condition, including shortness of breath and high fever, during the night shift. Despite family members calling the facility multiple times, staff did not respond or provide necessary interventions. The resident's condition was not addressed until EMS arrived, highlighting a failure in monitoring and communication.
A facility failed to create a comprehensive baseline care plan for a newly admitted resident with complex medical needs, including quadriplegia and a tracheostomy. The care plan did not address essential areas such as communication methods, tracheostomy care, and nighttime anxiety management, despite these being critical to the resident's care. Interviews with staff revealed that the baseline care plan was not adequately updated to reflect the resident's needs, contrary to facility policy.
The facility failed to ensure staff had gloves readily available, leading to care delays and increased infection risks. Despite claims of sufficient supplies, interviews revealed frequent struggles to access gloves, exacerbated by a storm and unpaid invoices. Residents reported delays in care due to supply issues, highlighting a disconnect between ordering, payment, and availability.
The facility failed to provide timely emergency medical treatment to two residents with end-stage renal disease. One resident missed dialysis due to a problematic catheter and was not promptly transferred to the hospital, resulting in his death. The second resident required a blood transfusion but faced delays in transportation, with no specific dialysis interventions in his care plan. Staff interviews revealed communication issues and a lack of urgency in addressing the residents' medical needs.
A resident with end-stage renal disease did not receive timely dialysis due to a malfunctioning catheter and poor communication between the facility and dialysis center. The resident missed several treatments, leading to fluid overload and eventual death. Staff failed to act urgently, scheduling non-emergency transport instead of immediate medical intervention.
The facility failed to investigate and report alleged violations involving infection control, physical environment, and abuse for several residents. The Administrator misunderstood the reporting requirements, believing that an email to TULIP sufficed instead of completing the required 3613-A PIR form. The Regional Nurse was unaware of any self-reports other than a recent abuse allegation, indicating a lapse in communication and adherence to the facility's policy.
A resident with a tracheostomy independently changed her inner cannula without sterile technique, and the facility failed to notify her physician or document the incident as required by policy. The resident, who had complex medical conditions, reported changing her cannula multiple times a week without staff assistance. Interviews revealed inadequate training and communication among staff regarding tracheostomy care responsibilities.
The facility failed to maintain the call light system in shower room [ROOM NUMBER] in safe operating condition, with exposed wires and no emergency call light cord in shower stall #2. Staff were unaware of the issue, and no repair requests were documented. A resident confirmed noticing the exposed wires for several months and avoided using the stall out of fear of electrocution.
The facility failed to ensure a working call system in shower stall #2 in shower room [ROOM NUMBER], leading to exposed wiring and an inoperable call bell. Staff were unaware of the issue, and no maintenance requests were logged despite the problem being present for several months. A resident with a history of falls and ventilator dependence had noticed the issue, highlighting a significant lapse in maintenance and reporting procedures.
The facility's 200-Hall restrooms lacked a functioning call system, with observations showing that call light cords did not activate exterior lights and emergency bells were faint. Staff interviews confirmed the bells were not loud enough, and records indicated the call system had been problematic since before January 2023. The current system was deemed beyond repair, necessitating replacement.
A resident with multiple health issues, including diabetes and kidney failure, experienced a significant change in condition, including vomiting and high blood sugar levels. The facility failed to notify the physician and the resident's representative, and insulin was discontinued without proper oversight. The resident was eventually sent to the hospital and died. Interviews revealed a lack of communication and documentation among staff.
A resident with multiple health issues, including diabetes, experienced a change in condition that was not adequately addressed by the facility. The resident had high blood glucose levels and began vomiting, but the facility failed to monitor and manage these symptoms according to the care plan. Insulin was erroneously discontinued, and there was a delay in sending the resident to the hospital, leading to hospitalization and eventual death.
A resident with diabetes and multiple health conditions was left without insulin due to a nurse's error in discontinuing both insulin NPH and Lispro, despite only Lispro being ordered to stop. The resident experienced high blood sugar levels for several days, and the facility failed to notify the physician or take corrective action. This oversight led to the resident's hospitalization and subsequent death.
Failure to Provide Timely Assistance Due to Ineffective Nurse Call System
Penalty
Summary
The facility failed to provide timely assistance to a resident with a history of COPD, congestive heart failure, and anxiety when she experienced shortness of breath and required staff assistance. The resident activated her call light for help but did not receive a response from staff, leading her to call 911 for emergency assistance. Upon arrival, EMTs found that the nurse call system only activated a visual light above the resident's door, with no audible alert in the hallway or at the nurse station, making it difficult for staff to be aware of calls for help. Interviews with staff revealed that the nurse call system had been previously repaired, but the audible alerts were still not functioning, and staff relied solely on visual cues, which were not always visible from the nurse station or other areas. Staff and residents had previously complained about the call light system, but these concerns were not communicated to the administrator, DON, or maintenance staff. The lack of an effective alert system limited staff's ability to monitor and respond promptly to resident needs, particularly for those with respiratory conditions. The resident's care plan included interventions for monitoring respiratory status and responding to signs of distress, but these were not effectively implemented due to the call system's deficiencies. The facility's policy required a functional and responsive call light system, but observations and interviews confirmed that the system did not meet these requirements at the time of the incident. There was no evidence of a specific policy for residents with respiratory needs, and maintenance logs did not reflect any repairs to the call light system during the relevant period.
Failure to Provide Functional Nurse Call System for Resident Assistance
Penalty
Summary
The facility failed to ensure that a reliable and effective nurse call system was available and functional for residents, specifically impacting a resident with significant respiratory needs. The call system in the resident's room and bathroom only activated a visual hallway light, with no audible alert to the nurse station or hallway, and the hallway lights were not visible from the nurse station. Staff interviews confirmed that the system did not provide audible alerts and that staff relied on visually monitoring hallway lights, which could not always be seen if staff were in other rooms or areas. Staff and residents had previously complained about the call system, but these concerns were not communicated to the administrator, DON, or maintenance staff. A resident with chronic respiratory conditions, including COPD and respiratory failure, experienced shortness of breath and attempted to call for assistance using the call light system. No staff responded, leading the resident to call 911 for help. Emergency medical personnel arrived and found that the nurse call system did not provide adequate notification to staff, as only a light above the door was activated without an audible alert. The EMTs had to contact the facility's front desk to alert staff to the resident's needs. The resident reported feeling that her oxygen supply was inadequate at the time and could not recall staff responding to her activated call light. Observations by the surveyor confirmed that the nurse call system in multiple rooms only activated a visual hallway light, with no audible alert in the hallway and only a low audible alert at the nurse station. Maintenance logs showed no repairs to the call light system in the 30 days prior to the incident, and the administrator and DON were unaware of any ongoing issues. Staff interviews indicated that the lack of an effective call system limited their ability to respond promptly to residents' needs, particularly for those with urgent medical conditions.
Failure to Report and Investigate Resident Fall with Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—were reported and investigated in accordance with state law and facility policy. Specifically, for one resident with multiple diagnoses including dementia, Alzheimer's disease, and muscle weakness, there was an unwitnessed fall resulting in a left hip fracture. The clinical record and progress notes indicated that the fall was documented, the resident was assessed, and sent to the hospital for further evaluation and treatment. However, there was no evidence that a provider investigation report or the required 5-day investigation report was submitted to the state survey agency as mandated. Interviews with the DON and the current Administrator revealed that the transition between administrators contributed to the lack of clarity regarding whether the required investigation report was submitted. The DON was unsure if the previous Administrator had completed the process, and the current Administrator could not locate the 5-day investigation report in the facility's records. The facility's own policy required reporting all such incidents to the administrator or designee and to the state agency, but this was not followed in this case.
Personal Items Placed on Clean Linen Cart Breaches Infection Control Protocol
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) placed her personal hooded jacket and eyeglass case on top of a clean linen cart in Hallway A, which contained folded linen sheets and briefs. The CNA reported that her jacket sleeves became wet while giving a resident a bed bath, so she removed the jacket and placed it, along with her eyeglass case, on the clean linen cart before returning to care for the resident. This action was observed by a registered nurse (RN), who confirmed that personal items should not be on the clean linen cart and identified it as an infection control issue. Other staff, including another CNA, the Assistant Director of Nursing (ADON), the Administrator, and the Director of Nursing (DON), all acknowledged during interviews that personal items should not be placed on the clean linen cart and that this practice could present an infection control concern. The facility's infection control policy, last revised in June 2024, emphasizes maintaining a safe and healthy environment through effective infection control practices, including proper handling of materials and environmental safety. The incident was identified during observation, interview, and record review, and it was noted that the facility had residents with major infections on the halls, increasing the importance of strict adherence to infection control protocols. The presence of personal items on the clean linen cart was recognized by multiple staff members as a breach of these protocols.
Failure to Provide Timely ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. For two residents, staff did not provide timely incontinent care. One resident, a male with a history of ventilator dependence, hypertension, and gastrostomy, was found with a saturated and soiled brief, a strong ammonia odor in the room, and a soaked draw sheet. Staff interviews revealed that required two-hour rounding and incontinent care were not performed as scheduled, with the CNA citing being overburdened with other residents and tasks. The nurse and unit manager confirmed that the resident was at risk for skin breakdown due to the lack of timely care. Another resident, a female with diagnoses including colon cancer, hypertension, atrial fibrillation, and cognitive communication deficit, also did not receive timely incontinent care. She reported feeling wet and neglected, and observation confirmed her brief was saturated with urine and bowel movement, with soiling extending to the draw sheet. Staff interviews indicated that the resident had not been changed for several hours, and the CNA responsible stated she was doing her best given her workload. The DON and medical director acknowledged that the lack of timely care placed the resident at risk for skin maceration and breakdown. A third resident, a female with ventilator dependence, tracheostomy, hypotension, and cognitive communication deficit, was observed to have long, classified toenails. Staff interviews revealed that aides had reported the issue to nursing staff weeks prior, but no action was taken to address the toenails. There was confusion among staff regarding responsibility for toenail care, especially after the resident was placed on hospice care. The DON, unit manager, and ADON all acknowledged the risk posed by the long toenails, but there was no documentation or follow-up to ensure the resident received appropriate grooming and personal hygiene.
Failure to Provide Meaningful Activities for All Residents
Penalty
Summary
The facility failed to provide activities that met the interests and supported the physical, mental, and psychosocial well-being of all residents reviewed for activities. Observations on both a Sunday and the following Monday revealed that no activities were visible in the activity area during the survey period. Interviews with residents indicated that there were no weekend activities, and the activities listed on the posted calendar were not actually provided. Residents reported that the Activity Director was present on Sundays but remained in her office, and that the activities listed on the calendar were not reflective of their actual experiences. Residents expressed feelings of boredom and frustration, noting that passive options like watching TV in their rooms were not meaningful activities, and some activities listed, such as bird watching, were not genuinely offered. Interviews with the Activity Director and other staff confirmed that many scheduled activities were not conducted, with the Activity Director attributing this to residents' refusals or lack of interest. However, residents disputed this, stating that activities were not offered as described. Review of the activities calendar showed limited and repetitive options on weekends, such as family visits, individual activity sheets, and watching TV, with minimal engagement opportunities. The facility's policy required meaningful, person-centered activities, but these were not observed or reported by residents during the survey period.
Failure to Maintain Resident Dignity by Not Covering Foley Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including functional quadriplegia, dementia, and an indwelling urinary catheter, was observed in bed with his foley catheter bag exposed and urine visible. The resident was unable to respond to verbal stimuli at the time of observation. Facility policy and staff interviews confirmed that catheter bags are required to be stored in privacy bags to maintain resident dignity, and this expectation was reinforced through regular in-service training for nursing staff. Despite these policies and trainings, the resident's catheter bag was not covered, and staff acknowledged that it was their responsibility to ensure privacy bags were used. The lack of a privacy bag was attributed to the previous cover being discarded and not replaced after catheter care. Multiple staff, including LVNs, RNs, and the DON, confirmed the requirement for privacy covers and their roles in ensuring compliance, but the deficiency occurred due to a lapse in following established procedures.
Failure to Include Oxygen Use in Resident's Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the resident's oxygen use as a focus area. Record review showed that the resident, a cognitively intact female with diagnoses including sepsis and heart failure, required substantial to maximal assistance with activities of daily living and used oxygen as a special treatment. Despite this, her comprehensive care plan did not include any interventions or objectives related to oxygen use. Interviews with facility staff confirmed that there was no care plan for oxygen use in either of the electronic medical record systems until it was added after the deficiency was identified. The MDS Coordinator acknowledged the omission, and the DON emphasized the importance of comprehensive care plans and MDS assessments in ensuring correct and safe care. Facility policy requires the interdisciplinary team to develop a comprehensive care plan within seven days of completing the assessment, but this was not followed in this case.
Unsecured Personal Care Products Found in Resident Room
Penalty
Summary
A deficiency was identified when two bottles of hair products, belonging to former residents, were found unsecured on top of a dresser in a resident's room. The resident in question was a female with significant medical conditions, including Type 2 Diabetes Mellitus, Dementia, Dysphagia, a traumatic subdural hemorrhage, and a tracheostomy. She was totally dependent on staff for all activities of daily living and was rarely or never understood, as indicated by her MDS assessment. The facility census also indicated that five residents were ambulatory, increasing the risk of access to unsecured items. During observation, the resident was unresponsive and resting in bed, with the hair product bottles clearly visible and accessible. Staff interviews revealed that personal hygiene products should be labeled, sealed, and stored in residents' drawers to prevent cross-contamination and reduce risk to wandering residents. However, the bottles were not stored according to these protocols, and the facility did not have a specific accident/hazards policy in place. The facility's Resident Rights policy emphasized the need for a safe environment, but this was not adhered to in this instance.
Failure to Provide Proper Perineal Care During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was incontinent of bowel and bladder. During an observation, the CNA did not separate the resident's labia while performing incontinent care, which was contrary to the facility's policy and standard infection control practices. The surveyor intervened before the CNA closed the clean brief, prompting the CNA to properly separate the labia and continue cleaning, at which point fecal matter was still present and required additional wiping to achieve cleanliness. The resident involved had a history of malignant neoplasm of the colon, hypertension, atrial fibrillation, and a cognitive communication deficit, but was assessed as cognitively intact and required assistance with activities of daily living. Interviews with the CNA, unit manager, and director of nursing confirmed that the expected procedure was not followed, as the CNA should have separated the labia and cleaned from front to back using a clean wipe for each stroke. The facility's policy on perineal care also specified these steps to reduce infection risk and promote skin integrity.
Failure to Follow Physician Orders for Enteral Feeding Administration
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a gastrostomy tube was administered the prescribed amount of high-protein tube-feeding formula as ordered by the physician. The physician's order specified that the resident should receive 55ml per hour of a 1.5 calorie formula continuously for 22 hours each day. However, observation and record review revealed that the feeding machine was set to deliver 56ml per hour instead of the ordered 55ml per hour. The resident in question had significant medical conditions, including acute and chronic respiratory failure, moderate protein-calorie malnutrition, and dehydration, and was dependent on tube feeding for more than half of his caloric intake. The care plan for the resident emphasized the importance of following physician orders for tube feedings to prevent complications such as aspiration, dehydration, and nutritional compromise. Despite this, the medication administration record and direct observation confirmed that the feeding was not administered as ordered. Interviews with facility staff, including the DON, Administrator, and the responsible RN, confirmed that the deviation from the physician's order was not intentional and may have resulted from CNAs stopping and starting the feeding machine during care, potentially altering the settings. The RN acknowledged responsibility for verifying the correct administration rate and was unaware of the discrepancy until it was brought to his attention. Facility policy required staff to review and implement physician orders accurately and document any clarifications, but this was not followed in this instance.
Failure to Remove Discharged Resident's Medications from Medication Cart
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not removing or disposing of medications belonging to a discharged resident. During an observation of a medication cart, it was found that medications labeled for a resident who had already been discharged remained on the cart, including Ipratropium .02% solution, Ipratropium .02% nebulizer solution, and Budesonide inhalation suspension. The nurse interviewed confirmed that these medications should have been removed from the cart upon the resident's discharge to prevent them from being administered to another resident. The Director of Nursing stated that medications may remain on the cart for up to 24 hours if a resident is expected to return, but should be disposed of if the resident does not come back. Facility policy requires that discontinued or discharged residents' medications be immediately removed from active supply and stored separately until destroyed. The failure to follow these procedures resulted in the continued presence of the discharged resident's medications on the active medication cart.
Undated Lidocaine Vial Found on Medication Cart
Penalty
Summary
A deficiency was identified when a medication cart (Cart B) was found to contain a vial of Lidocaine Hydrochloride injection with visible injection marks on the seal and no date indicating when it was opened. During observation, it was noted that the vial was not labeled with the date of opening, as required by facility policy and professional standards. The LVN responsible for the cart stated that she would have dated the vial if she had opened it, but she was not the person who did so. The DON and Corporate Nurse confirmed that the vial should have been dated to ensure proper tracking of the medication's shelf life. Review of the facility's policy confirmed that multi-dose vials must be labeled with the date opened.
Improper Disposal of Garbage Due to Open Dumpster Door
Penalty
Summary
A deficiency was identified when the facility failed to properly dispose of garbage and refuse by leaving the side door of Dumpster A open, as observed during a survey. The dumpster was found half-full of trash with the left-side sliding door open. Multiple staff members, including the dietary supervisor, dietary manager, housekeeping supervisor, and the administrator, acknowledged during interviews that the dumpster should remain closed to prevent access by animals, pests, and unauthorized individuals, as well as to avoid potential infection control issues. Review of the facility's waste disposal policy confirmed that dumpsters are required to be closed at all times to prevent disease transmission and pest attraction.
Infection Control Deficiencies Related to Foley Catheter Care and Personal Hygiene Product Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. For one resident with functional quadriplegia, a gastrostomy, and a tracheostomy, observations revealed that his Foley catheter tubing was resting on his fall mat and at times on the floor. Nursing staff, including LVNs and RNs, acknowledged that the tubing should not be on the floor or on the fall mat, as this does not follow infection control protocols. Staff interviews indicated that the resident's bed being in the lowest position made it difficult to keep the tubing off the floor, but it was still the staff's responsibility to ensure proper placement. Facility in-service records confirmed that staff had received training on Foley catheter care, including the importance of keeping tubing off the floor and allowing for gravity drainage. For another resident who was totally dependent on staff for activities of daily living and had diagnoses including diabetes, dementia, and a tracheostomy, two bottles of hair products labeled with other residents' names were found on her dresser. Staff interviews confirmed that personal hygiene products should be labeled and stored in a way that prevents cross-contamination, such as in sealed bags or drawers. The presence of these items in the resident's room was recognized by staff as a potential source of cross-contamination between residents' personal items. Facility policy reviews showed that there were established procedures for catheter care and infection control, including the prevention, identification, and control of infections. However, the observed practices did not align with these policies, as evidenced by the improper handling of catheter tubing and the storage of personal hygiene products belonging to other residents in a resident's room.
Improper Repositioning and Inadequate Supervision of Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) improperly repositioned a dependent male resident with multiple complex medical conditions, including acute and chronic respiratory failure, end stage renal disease, a tracheostomy, and a history of being fully dependent for activities of daily living. The resident was observed on video lying sideways in bed with his head hanging off the edge. CNA A entered the room and, without assistance, pulled the resident by his left arm to reposition him toward the center of the bed. Another CNA entered the room during the incident but did not intervene in the repositioning process. Interviews with staff and the resident's family member confirmed that the resident was unable to move himself and was at risk of falling from the bed. The family member reported witnessing the incident via a camera in the resident's room and described the repositioning as rough and inappropriate, though no bruising was observed. Both CNAs involved acknowledged that the repositioning technique used was not appropriate and did not follow proper procedures, with CNA A stating she acted out of fear that the resident would fall. CNA A also admitted she had not received recent training on proper repositioning techniques. A review of the facility's policy on turning and repositioning indicated that such care should be individualized, planned, and performed according to established procedures, with documentation required every shift. The incident demonstrated a failure to provide adequate supervision and to follow proper repositioning protocols, as the resident was handled in a manner inconsistent with facility policy and best practices for dependent residents.
Inadequate Infection Control Leads to Candida Auris Outbreak
Penalty
Summary
The facility failed to maintain an effective infection control program, resulting in the spread of Candida auris among residents. Observations revealed that staff did not consistently use personal protective equipment (PPE) or perform hand hygiene when entering and exiting rooms of residents on contact precautions. Specifically, CNA B and LVN M were observed not adhering to proper infection control protocols, such as failing to wash or sanitize hands and not changing PPE between resident interactions. This negligence contributed to the transmission of Candida auris within the facility. Interviews with staff, including the Infection Preventionist (IP B) and the Local Health Department Epidemiologist, highlighted significant gaps in the facility's infection control practices. IP B, who was newly hired, was unaware of the number of residents affected by Candida auris and lacked a clear plan to mitigate the infection's spread. The facility's previous Infection Preventionist and Director of Nursing (DON) had been working with the health department, but there was no evidence of a surveillance plan being implemented to track and monitor infections effectively. The facility's administration also demonstrated a lack of awareness and oversight regarding the infection control program. The Administrator could not articulate a structured system to mitigate the risk of Candida auris transmission and was unaware of the number of residents affected. The facility's failure to implement and monitor transmission-based precautions, as well as the lack of staff training on Candida auris, contributed to the ongoing outbreak and placed residents at risk of exposure to the infection.
Removal Plan
- Candida auris Education: The Regional Nurse Consultant initiated education provided to all staff on Candida auris (including background/definition, PPE & isolation protocols (including co-horting), disinfectant protocols, equipment/clothes/linen handling, meal service, and methods to prevent the spread of Candida auris). Staff will be educated prior to initiating their next shift. Staff will show competency and understanding of education through testing. Education on Candida auris, including testing will occur in Facility Orientation.
- Environmental Cleaning Education: The Regional Nurse Consultant initiated education provided to housekeeping staff on cleaning schedules for residents affected by Candida auris and the requirement to clean/disinfect twice a day and using EPA-approved disinfectants effective against Candida auris per the county health department recommendations. Housekeeping staff will be educated prior to initiating their next shift. The Administrator will ensure compliance.
- Infection Control Education: The Regional Nurse Consultant initiated education with all staff on Handwashing and Equipment Disinfection between resident rooms. Staff will be educated prior to initiating their next shift.
- 1:1 Education: The Regional Nurse Consultant provided 1:1 education with the Infection Preventionist, Weekend RN Supervisor, and Administrator on Candida auris, Infection Prevention Program Policy to include surveillance.
- Medical Director Notification: The Administrator notified the Medical Director of the IJ template and will be updated on the POR as indicated.
- Surveillance: The Regional Nurse Consultant audited 100% of resident's charts to identify residents with a presence of Candida auris and whether the infection was facility or community acquired. Outcome: (12) facility acquired & (16) Community acquired. Active surveillance listing will be maintained by the Facility Infection Preventionist to include Infection Type and acquired status (Facility vs Community).
- Sustainability: The Administrator is responsible for reviewing all compliance reports (including health department recommendations) and taking immediate corrective action where needed. The Infection Preventionist or Weekend RN Supervisor will conduct Daily audits for PPE compliance and environmental cleaning logs will continue for 30 days and then as needed. The Infection Preventionist will collaborate with the health department as directed and will ensure recommendations are carried out timely.
- Policy / Recommendation Review: The Administrator reviewed the Infection Control Program Policy and Procedure and the Candida auris policy and procedure and no updates were required. The Regional Nurse Consultant, IP, and Administrator reviewed the current Health Department recommendations and initiated Candida auris training and increased environmental cleaning.
Deficient Call Light System Leads to Delayed Care
Penalty
Summary
The facility failed to maintain a functioning call light system for five months, affecting all four halls. This deficiency left residents without a reliable means to call for staff assistance, particularly in emergencies. The call light system was damaged by inclement weather, and despite the facility's attempts to replace it, the system remained non-functional. Residents were provided with alternative devices like cowbells and buzzers, but these were not always effective or accessible, leading to delays in care. One resident, who was quadriplegic and required continuous mechanical ventilation, experienced a significant delay in receiving care due to the lack of a functioning call system. The resident's family attempted to contact the facility 45 times without success, ultimately calling 911 when the resident showed signs of respiratory distress. Upon EMS arrival, the resident was found to be febrile, tachycardic, and in need of suctioning, highlighting the critical nature of the deficiency. Other residents also faced challenges due to the broken call system. One resident had a buzzer provided by their family, but its sound was not always audible to staff. Another resident was unaware of the availability of a bell for assistance, and a third resident had no device to call for help. These observations underscore the facility's failure to ensure that all residents had adequate means to request assistance, posing a risk of delayed medical care and assistance with daily activities.
Failure to Address Resident's Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care to a resident who experienced a significant change in condition during the night shift. The resident, who had a complex medical history including quadriplegia, tracheostomy, and chronic respiratory failure, showed signs of distress such as shortness of breath, fever, tachycardia, and diaphoresis. Despite these symptoms, the night shift staff did not recognize or provide necessary clinical interventions, resulting in a delay in urgent medical treatment. The resident's family attempted to contact the facility approximately 45 times between 1:53 a.m. and 3:47 a.m. to report the resident's condition, but their calls went unanswered. The resident, who was able to communicate using an eye tracker system, indicated to family members that he was experiencing difficulty breathing and needed assistance. Eventually, the family called 911, and emergency medical services arrived to find the resident in moderate distress with a high fever and occluded tracheostomy tube. Interviews with facility staff revealed that the resident's condition was not adequately monitored, and vital signs were not consistently checked. The staff did not respond to the family's calls, and the resident's symptoms were not addressed until EMS arrived. The facility's Director of Nursing acknowledged the communication issues and the need for staff to anticipate the resident's needs due to his inability to use call bells or buzzers.
Failure to Develop Comprehensive Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident, identified as CR #1, which included necessary instructions to provide effective and person-centered care. This deficiency was observed in the case of CR #1, who was admitted with significant medical conditions including quadriplegia, a tracheostomy, and chronic respiratory failure requiring continuous mechanical ventilation. Despite these complex needs, the baseline care plan did not address critical areas such as communication methods, tracheostomy/ventilator care, and management of nighttime anxiety. CR #1's medical history included a gunshot wound leading to severe injuries and subsequent quadriplegia, necessitating a tracheostomy and mechanical ventilation. Upon admission, CR #1 was able to communicate using an eye tracker system on his tablet, which was not documented in the baseline care plan. Additionally, the care plan failed to include specific instructions for tracheostomy care and suctioning, despite physician orders indicating the need for regular suctioning every two hours or as needed. The resident's tendency to experience anxiety during the night was also not addressed, even though this information was communicated to the facility by the resident's representative. Interviews with facility staff, including the DON, ADON, and other nursing staff, revealed a lack of comprehensive assessment and documentation in the baseline care plan. The staff acknowledged that the baseline care plan should have included all identified needs upon admission, but these were not adequately captured or updated. The facility's policy required a baseline care plan to be developed within 48 hours of admission, yet CR #1's plan was incomplete, leaving critical care areas unaddressed during his stay.
Deficiency in Supply Management and Availability
Penalty
Summary
The facility failed to ensure that staff had gloves readily available to provide care for residents, which could lead to delays in care and increased risk of infections and hygiene concerns. Interviews with staff and residents revealed that gloves were not easily accessible, and staff often had to wait for central supply to deliver them. This issue was exacerbated by a recent storm, which delayed supply deliveries. Despite the Central Supply Supervisor's claim that the facility never ran out of gloves, multiple anonymous interviews indicated that staff frequently struggled to find gloves and had to rely on central supply or other departments to obtain them. The Central Supply Supervisor stated that she ordered supplies regularly and had no issues with contracts, but acknowledged a delay in receiving supplies due to the storm. However, interviews with company representatives revealed that the facility's supply orders were on hold due to unpaid invoices, which contradicted the Administrator's assertion that the facility had not run out of supplies. The Administrator mentioned using multiple supply companies and local stores to ensure supplies were available, but also noted that not everyone had access to supplies due to theft concerns. Residents reported that staff sometimes had to hunt for supplies, and there were instances where residents were not changed promptly due to a lack of appropriate supplies. The Director of Nursing, who had only been at the facility for a short time, was unaware of why bills were not being paid. The facility's policy on ordering supplies indicated that a purchasing agent was responsible for processing orders, but it appears there was a disconnect between ordering, payment, and supply availability, leading to the deficiency.
Failure to Provide Timely Emergency Medical Treatment
Penalty
Summary
The facility failed to provide timely emergency medical treatment to two residents, leading to significant deficiencies in their care. The first resident, a male with end-stage renal disease, missed several days of dialysis due to a problematic central venous catheter. Despite the dialysis nurse's concerns about fluid overload and a doctor's order for hospital evaluation, the resident was not promptly transferred to the hospital. Instead, non-emergency medical transportation was scheduled, resulting in a delay. The resident was later found unresponsive and pronounced deceased after unsuccessful resuscitation efforts. The second resident, also with end-stage renal disease, required a blood transfusion due to low hemoglobin levels. Although the dialysis nurse received a doctor's order for hospital transfer, the resident was transported via non-emergency services, which took several hours to arrive. During this time, the resident remained at the facility without receiving the necessary emergency treatment. The care plan for this resident did not include specific goals or interventions related to dialysis, indicating a lack of comprehensive planning for his condition. Interviews with facility staff revealed communication issues and a lack of urgency in responding to the residents' medical needs. The Director of Nursing and other staff members did not recognize the situations as emergencies, relying on non-emergency transportation despite the critical nature of the residents' conditions. The facility's policies on charting, documentation, and changes in residents' conditions were not adequately followed, contributing to the deficiencies in care.
Failure to Provide Timely Dialysis Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, leading to a critical situation. The resident, a male with end-stage renal disease and other significant health issues, did not receive hemodialysis treatments as ordered by his physician. This resulted in symptoms of fluid overload, requiring emergency medical care. The resident's dialysis access port malfunctioned, and he did not receive dialysis for four days, which contributed to his deteriorating condition. The report details multiple instances where the resident's dialysis treatment was either missed or incomplete due to issues with the dialysis catheter. Despite the resident's critical need for dialysis, there was a lack of communication and coordination between the facility and the dialysis center. The dialysis staff was not informed of the resident's return to the facility after a hospital visit, leading to further delays in treatment. Additionally, when the resident's catheter malfunctioned, there was a failure to promptly address the issue, resulting in the resident missing several dialysis sessions. The situation escalated when the resident was found unresponsive, and despite efforts to resuscitate him, he was pronounced deceased. Interviews with staff revealed a lack of urgency in addressing the resident's condition, with non-emergency transport being scheduled instead of immediate medical intervention. The facility's policies and procedures for handling such critical situations were not effectively implemented, contributing to the resident's untimely death.
Failure to Report and Investigate Alleged Violations
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and reported to the appropriate authorities within the required timeframe. Specifically, the facility did not complete a Provider Investigation Report (PIR) for three separate intakes involving allegations of infection control, physical environment issues, and abuse. These intakes involved six residents, and the facility did not submit the necessary reports through the Texas Unified License Information Portal (TULIP) as required by state law. Interviews with the facility's Administrator revealed a misunderstanding of the reporting requirements, as she believed that sending an email to TULIP was sufficient instead of completing the 3613-A PIR form. The Regional Nurse confirmed that the Administrator was trained by the corporate team and that the facility was supposed to notify the corporate team of self-reports before submission. However, the Regional Nurse was unaware of any self-reports other than a recent abuse allegation. The facility's policy required a follow-up investigation report within five business days, but this was not adhered to, leading to a failure in reporting and investigating alleged violations.
Failure to Provide Appropriate Tracheotomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring tracheotomy care, specifically in maintaining sterile technique and notifying the resident's physician when the resident changed her inner cannula. The resident, who was cognitively intact and had multiple complex medical conditions including acute and chronic respiratory failure, COPD, and a tracheostomy, independently changed her inner cannula without sterile technique, which was not documented or reported to the physician as per facility policy. The resident's care plan did not include interventions related to her ability or desire to change her inner cannula independently, and there was a lack of documentation and communication regarding her respiratory care needs. The resident reported that she had been changing her inner cannula two to three times a week without the knowledge of the respiratory therapy department or consistent assistance from nursing staff. The facility's respiratory care policy required sterile technique and documentation of the procedure, which was not followed in this case. Interviews with staff revealed a lack of clarity and training regarding the responsibilities of nurses in providing tracheostomy care. The LVN involved did not perform an assessment or notify the appropriate personnel after learning the resident had changed her inner cannula. The DON and other staff acknowledged gaps in training and communication, which contributed to the deficiency in care provided to the resident.
Failure to Maintain Safe Operating Condition of Call Light System
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically the call light system in shower room [ROOM NUMBER]. Observations revealed that call light #2 in shower stall #2 had exposed wires and no emergency call light cord, which could place residents at risk of not receiving emergency care in a timely manner. The Maintenance Director, who had only been in his role for two days, was unaware of the issue until it was brought to his attention during the survey. He stated that the wires were not live and posed no danger, but this was not verified by any testing or documentation. Interviews with various staff members, including Central Supply staff, CNAs, and the Utility Tech, indicated that none of them were aware of the exposed wires or missing call light cord in shower stall #2. The staff members stated that they would have reported such issues to the maintenance department if they had noticed them. However, no repair requests for the call light system in shower room [ROOM NUMBER] were found in the maintenance request logs for the months of January through April 2024. Resident #1, who regularly used the shower room, confirmed that she had noticed the exposed wires in shower stall #2 for several months and avoided using that stall out of fear of electrocution. The facility's Maintenance Service Policy requires the maintenance department to keep the building and equipment in safe and operable condition at all times, but this policy was not followed in this instance. The lack of awareness and reporting among staff, combined with the failure to document and address the issue, led to the deficiency in maintaining a safe environment for residents.
Failure to Maintain Working Call System in Shower Room
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically in shower stall #2 in shower room [ROOM NUMBER]. Observations revealed that the call bell system in this shower stall had an open electrical socket with no call bell cord and exposed wiring. Multiple staff members, including the Maintenance Director, CNAs, and the Utility Tech, were unaware of the issue, indicating a lack of proper maintenance and oversight. The Maintenance Director eventually acknowledged the problem and took steps to cover the exposed wires, but this was only after the surveyor's observations and interviews highlighted the deficiency. Resident #1, a cognitively intact individual with a history of falls and dependence on a ventilator, had noticed the exposed wires in shower stall #2 for several months. Despite this, there were no maintenance requests logged for the call light system in the shower room from January to April 2024. This indicates a significant lapse in the facility's maintenance and reporting procedures, as the issue had been present for an extended period without being addressed. Interviews with various staff members, including CNAs and the HRM, revealed that none of them had noticed the missing call bell plate or exposed wires during their shifts. This lack of awareness and reporting further underscores the facility's failure to maintain a safe environment for its residents. The facility's Maintenance Service Policy, which mandates maintaining the building and equipment in a safe and operable manner, was not adhered to, leading to this deficiency.
Deficient Call System in 200-Hall Restrooms
Penalty
Summary
The facility failed to provide a functioning call system in the restrooms of the 200-Hall, which is essential for residents to call for staff assistance. Observations revealed that when the call light cords were pulled in the restrooms, the exterior lights did not activate, and the sound of the emergency bells was faint. Staff members, including a Medical Assistant (MA), Licensed Vocational Nurse (LVN), and Certified Nursing Assistants (CNAs), confirmed that the bells were not loud enough to ensure they could hear them, especially if they were not specifically listening for them. Interviews with staff members indicated that the call lights in the restrooms had been non-functional for an extended period, with some staff unsure of the exact duration. The facility had resorted to using bells attached to the call light cords, but these were not effective in alerting staff to emergencies. The Director of Nursing (DON) and the Administrator acknowledged the issue, with the Administrator noting that the call light system had been problematic since before January 2023. A review of the facility's records showed a lack of consistent inspection logs for the 200-Hall call lights, with several months missing. An estimate dated March 2024 indicated that the current call light system was beyond repair and required replacement. This deficiency in the call system could potentially prevent residents from receiving timely assistance, as staff might not be aware of emergencies occurring in the restrooms.
Failure to Notify Physician and Family of Change in Condition
Penalty
Summary
The facility failed to consult with the resident's physician and notify the resident's representative for a resident who experienced a change in condition. The resident, who had a history of type 2 diabetes, kidney failure, cerebral infarction, malnutrition, hemiplegia, high blood pressure, sepsis, and heart disease, began vomiting a brown substance repeatedly. Despite this significant change in condition, the facility staff did not immediately notify the physician. Additionally, the resident's insulin NPH was discontinued without proper notification to the physician, even though the resident was experiencing high glucose readings for six days. The resident's blood sugar levels were consistently high, with readings reaching as high as 598 mg/dL. The facility's care plan required that any abnormal findings be reported to the physician and family members, but this was not done. Interviews with staff revealed confusion and lack of documentation regarding the resident's condition and the actions taken. The resident was eventually sent to the hospital, where she died. Interviews with various staff members, including CNAs, LVNs, and the DON, highlighted a lack of communication and documentation regarding the resident's condition. The facility's policy required notification of the physician and resident's representative in the event of a significant change in condition, but this was not adhered to. The failure to notify the physician and the discontinuation of insulin without proper oversight contributed to the resident's decline and eventual death.
Failure to Recognize and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to a significant deficiency in quality of care. The resident, who had a history of type 2 diabetes, kidney failure, cerebral infarction, malnutrition, hemiplegia, high blood pressure, sepsis, and heart disease, experienced a change in condition that was not adequately recognized or addressed by the facility staff. The resident began vomiting and had extremely high blood glucose levels for several days, which were not properly monitored or managed according to the care plan and physician's orders. The facility's staff did not follow the prescribed protocol for monitoring and responding to the resident's high blood glucose levels. Despite the resident's blood sugar readings consistently exceeding 300 mg/dL, and at times reaching above 600 mg/dL, there was a lack of timely intervention and communication with the physician. The insulin NPH, which was part of the resident's treatment plan, was erroneously discontinued, and the facility failed to administer insulin as required by the sliding scale orders. Additionally, the facility delayed in sending the resident to the hospital, opting to call a non-emergency line despite the resident's critical condition, which included non-responsiveness, a blood sugar level of 598 mg/dL, and an oxygen saturation of 88%. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition. Several staff members, including CNAs and nurses, noted the resident's vomiting and high blood sugar levels but did not take appropriate action or document the events accurately. The facility's policies on blood sugar checks, oxygen saturation, and change in condition were not adhered to, contributing to the resident's deterioration and eventual hospitalization, where the resident later died.
Failure to Administer Insulin Leads to Resident's Hospitalization and Death
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident with type 2 diabetes, kidney failure, cerebral infarction, malnutrition, hemiplegia, high blood pressure, sepsis, and heart disease. The resident was initially admitted to the facility with orders for insulin NPH and Lispro to manage her diabetes. However, a nurse erroneously discontinued both insulin medications following a verbal order to discontinue only the insulin Lispro due to low blood sugar levels. This error left the resident without necessary insulin coverage, leading to high blood sugar levels over several days. Despite the resident's blood sugar readings being significantly elevated, reaching levels as high as 491 mg/dL, the facility staff failed to notify the physician or take appropriate action to address the hyperglycemia. Interviews with various nursing staff revealed a lack of communication and documentation regarding the resident's insulin orders and blood sugar management. The Lead Nurse Practitioner confirmed that the discontinuation of insulin NPH was not authorized and emphasized the importance of maintaining NPH for basal coverage. The Director of Nursing and other staff members acknowledged that the nurses were responsible for ensuring the accuracy of medication orders and for contacting the physician if blood sugar levels exceeded 300 mg/dL. However, the facility's failure to adhere to these protocols resulted in the resident being sent to the hospital, where she subsequently died. The facility's policy on administering medications was not followed, contributing to the resident's deteriorating condition and eventual death.
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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