Paradigm At The Oak
Inspection history, citations, penalties and survey trends for this long-term care facility in Schulenburg, Texas.
- Location
- 507 West Ave, Schulenburg, Texas 78956
- CMS Provider Number
- 675971
- Inspections on file
- 35
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 12 (3 serious)
Citation history
Health deficiencies cited at Paradigm At The Oak during CMS and state inspections, most recent first.
The facility failed to ensure readily available hot water in upstairs restrooms and shower rooms, resulting in faucets with no flow and water temperatures in the 70s°F after running for several minutes. A resident reported that there had been no hot water upstairs for months and that residents were routinely taken downstairs for showers unless they accepted cold water. Multiple CNAs, housekeeping staff, maintenance, LVNs, and the DON acknowledged ongoing hot water problems on the upstairs wing, with staff describing that all residents were sharing a single downstairs shower and that housekeeping obtained hot water from a downstairs sink. Staff repeatedly stated that the lack of hot water had persisted for months to a year and expressed that this situation could be or felt like a resident rights concern, while the facility’s own Resident Rights policy requires a clean, safe, comfortable, and home-like environment.
A resident with bipolar disorder, thrombotic microangiopathy, and SLE, who had moderate cognitive impairment and depended on staff for multiple needs, was verbally threatened and had the back of his head pushed by an LVN in the dining room, an event witnessed by multiple staff. The resident reported feeling humiliated and later avoided the LVN and felt very uncomfortable requesting PRN and pain medications while she remained his nurse. A medication tech promptly informed the Administrator, but the Administrator did not immediately report the allegation to the state, did not notify nursing leadership, and did not remove the LVN from duty, allowing her to continue caring for the resident through the weekend. Staff interviews and the facility’s written abuse policy showed that allegations of abuse were required to be reported immediately and that staff alleged to have committed abuse were to be suspended pending investigation, but these procedures were not followed, resulting in an abuse-related deficiency at the Immediate Jeopardy level.
A resident with bipolar disorder, thrombotic microangiopathy, SLE, and moderate cognitive impairment alleged that an LVN argued with him in the dining room, made threatening and demeaning comments, and struck the back of his head, causing his head to move forward. Two CNAs witnessed the LVN push the resident’s head and confirmed with the resident that it occurred, and an MT reported the incident by text to the Administrator, who was identified by staff as the abuse/neglect coordinator. Despite this, the LVN remained on duty and continued caring for the resident for the rest of that day and the next, while the resident reported feeling scared or uncomfortable asking the LVN for PRN and pain medications and humiliated by the incident. The ADON, DON, RDO, and regional nurse consultant all stated that facility policy required immediate reporting of any abuse allegation to the state and immediate suspension of the accused staff member, and record review of the written policy confirmed that employees alleged to be involved in abuse or neglect must be suspended pending investigation; these procedures were not followed in this case.
A resident with bipolar disorder, thrombotic microangiopathy, SLE, and moderate cognitive impairment alleged that an LVN argued with him in the dining room, made threatening and demeaning remarks, and tapped or pushed the back of his head, an event witnessed and reported by multiple staff. A medication tech notified the Administrator, but the LVN continued working and remained assigned to the resident, and leadership staff were not promptly informed. The Administrator delayed reporting the allegation to the state and did not immediately remove the LVN from duty, and the facility lacked evidence of a timely, thorough investigation and complete documentation as required by its abuse/neglect policy.
A resident with bipolar disorder, thrombotic microangiopathy, lupus, and moderate cognitive impairment alleged that an LVN argued with him, made a threatening comment related to his parole status, and struck or pushed the back of his head in the dining room, which he and multiple CNAs described as humiliating and making him feel unsafe and uncomfortable requesting PRN pain meds. A medication tech promptly informed the Administrator by text, but the Administrator did not immediately report the allegation to the State Agency, did not immediately involve nursing leadership, and allowed the LVN to continue working and remain assigned to the resident for two more days. Staff interviews confirmed they had abuse/neglect training, knew allegations must be reported immediately, and recognized that the facility’s abuse reporting and protection policies were not followed, resulting in past noncompliance at the Immediate Jeopardy level.
A resident with paraplegia and psychiatric diagnoses, but no documented cognitive impairment, had a history of noncompliance with smoking rules and had signed a smoking behavior contract. Despite a facility safe smoking policy requiring staff to control smoking materials and limit smoking to designated times and areas, staff repeatedly documented and reported smelling smoke in the resident’s room, finding cigarettes there, and observing the resident smoking outside approved times and locations. CNAs and nurses observed the resident with lighters hidden on his person and under his wheelchair cushion, and multiple clinical staff, including the DON, ADON, NP, PMHNP, and RNC, expressed concern or belief that he was smoking in his room in violation of policy. The facility’s failure to prevent the resident’s ongoing access to cigarettes and lighters and to ensure adherence to the safe smoking policy resulted in inadequate supervision to prevent accidents.
A nurse failed to perform hand hygiene between glove changes while providing wound care to a resident with multiple wounds and complex medical conditions. Despite using gloves and gowns as required, the nurse did not sanitize or wash hands between treating different wound sites or after removing gloves, contrary to facility policy and infection control expectations. Interviews with leadership confirmed the requirement for hand hygiene between glove changes and after glove removal.
The facility did not maintain an effective pest control program, resulting in ongoing sightings of roaches, rodents, and other pests in resident rooms, common areas, and the kitchen. Multiple residents and staff reported seeing pests, and pest control service records documented repeated infestations and structural gaps allowing pest entry. Despite regular pest control visits, the measures taken were insufficient to prevent continued pest activity, and leadership was aware of the issue through direct reports and observations.
A resident with paraplegia and multiple fractures did not receive prescribed lidocaine pain patches on numerous occasions due to the facility's failure to ensure medication availability and proper documentation. Staff interviews revealed inconsistent communication and lack of notification to the NP about missed doses, resulting in the resident not receiving ordered pain management.
The facility did not consistently serve hot, palatable food to residents, as multiple residents with complex medical needs reported receiving cold meals on several occasions. Staff interviews and meal temperature checks confirmed that food was often below the required temperature at the point of service, and concerns about cold food were documented in resident council meetings. Lack of clear responsibility and communication among dietary and nursing staff, as well as the absence of a dietary manager, contributed to the ongoing issue.
A resident with severe cognitive impairment and psychiatric conditions was transferred to another facility without proper documentation, notification to the ombudsman, or a written discharge notice to the legal guardian. The transfer occurred to a location outside the guardian's jurisdiction, despite the guardian providing a list of acceptable areas. Facility staff did not follow established discharge procedures, and the psychiatric NP did not determine the resident was a danger to himself or others.
A resident with paraplegia and multiple fractures was admitted without a baseline care plan specifying transfer needs within the required 48-hour timeframe. Although therapy staff determined the need for a mechanical lift and maximum assistance, this was not documented in the care plan until several days later. Staff interviews revealed confusion about responsibility for care plan completion, and the facility's policy requiring timely care planning was not followed.
Multiple residents with cognitive impairments and behavioral histories were involved in two separate altercations, resulting in physical abuse between residents. Staff witnessed and reported the incidents but expressed uncertainty about how to prevent such events, and interventions in care plans focused mainly on redirection and medication review. Despite staff training and an abuse policy, the facility did not prevent these abusive interactions.
A resident with multiple chronic and psychiatric conditions did not receive numerous scheduled, time-sensitive medications over several weeks. Staff often did not administer medications when the resident was asleep and failed to consistently notify providers or document the reasons for missed doses. Key clinical staff were unaware of the extent of missed medication administration, and required documentation and communication protocols were not followed.
A resident with multiple complex medical and psychiatric conditions did not receive several scheduled, time-sensitive medications over an extended period. Medication administration records showed repeated missed doses, often attributed to the resident being asleep, with inconsistent documentation and lack of timely notification to clinical staff or providers. Staff interviews revealed a lack of awareness about the missed doses, and facility policy for medication management and documentation was not consistently followed.
The facility failed to provide a safe and homelike environment, affecting several residents. Issues included inadequate hot water supply for bathing, a resident's wheelchair with exposed screws, and a dining room with missing floor tiles and damaged walls. These deficiencies were confirmed through observations and staff interviews, revealing a lack of communication and prioritization in addressing maintenance needs.
The facility failed to update comprehensive care plans within seven days after MDS assessments for three residents, risking inadequate care. A resident with seizures and dementia, another with severe cognitive impairment and wound care needs, and a third with cognitive impairment and an eye infection did not have timely care plan updates. Staff interviews confirmed the expectation for timely updates, which were not met.
The facility failed to provide an ongoing activities program for residents on the secure unit, as the activity calendar was not tailored to their needs. Scheduled activities, such as church services, did not occur, and there was no documentation of in-room or group activities for January 2025. Staff confirmed the absence of activities, and the Activity Director admitted to not ensuring proper documentation and follow-up. The Administrator noted the lack of evidence for activities, which could negatively impact residents.
A facility's medication error rate exceeded the acceptable threshold, involving two residents and two medication aides. One resident did not receive blood pressure medications due to missing parameters, while another received an incorrect vitamin D dosage. The facility's policy requires adherence to the '8 Rights' of medication administration, which was not followed in these instances.
The facility failed to maintain food safety standards as Dietary Aides did not wear required hair restraints and did not follow proper hand sanitation procedures. This included not wearing hair nets or beard guards and failing to change gloves or wash hands between tasks, leading to potential contamination risks. The Dietary Manager and Administrator acknowledged these lapses, which could compromise resident safety.
A facility failed to maintain an effective infection prevention and control program, as evidenced by improper aseptic techniques during tracheotomy and wound care by an RN, and failure to sanitize a blood pressure cuff between residents by an MA. These actions were contrary to the facility's policies, risking cross-contamination and infection.
A facility failed to include a care plan for a resident's right-hand contracture, despite the resident's severe cognitive impairment and need for assistance with ADLs. Observations showed the resident's hand in a contracted position without splints or palm guards. Staff interviews revealed a lack of communication from therapy services, resulting in the omission of contracture interventions in the care plan.
A resident with multiple health conditions and moderate cognitive impairment did not receive necessary nail care from the facility staff, resulting in long and dirty fingernails over several days. Despite requests for assistance, staff either claimed to be too busy or did not have time to address the issue. Observations and interviews revealed that the facility failed to adhere to its policy of assisting residents with nail care as needed.
A facility failed to ensure proper pressure ulcer care for a resident with multiple Stage IV ulcers. During wound care, an RN did not perform hand hygiene between glove changes and used a cleaning technique that risked cross-contamination. The RN also placed a clean dressing on the bed, which became contaminated and was applied to the resident's wound. The facility's policies on dressing changes and hand hygiene were not followed, potentially placing the resident at risk for infection.
A resident with severe cognitive impairment and limited range of motion was not provided with appropriate interventions for a right-hand contracture. The care plan lacked strategies for managing the contracture, and no therapy services were ordered. Observations showed the resident's hand was contracted with long nails causing indentations. The DON and MDS coordinator acknowledged the oversight, and the facility lacked a contracture management policy.
A resident with a catheter was at risk for urinary tract infections due to improper care by a nurse who placed the catheter bag on the bed during wound care, preventing proper drainage. The resident, in a persistent vegetative state with multiple diagnoses, was observed with a full condom catheter not draining into the collection bag. Interviews confirmed the catheter bag should have been kept below bladder level to prevent backflow and ensure proper drainage, as per facility policy.
A resident requiring tracheostomy care did not receive proper aseptic technique during a procedure by an RN. The RN failed to perform hand hygiene, used contaminated gloves, and did not maintain a sterile field, contrary to facility policy. The DON confirmed the need for sterile techniques to prevent infections.
A facility failed to monitor a resident's prophylactic antibiotic use, leading to a deficiency in ensuring the drug regimen was free from unnecessary drugs. The resident, with a history of cerebral infarction and other conditions, was on Macrobid for UTI prophylaxis without proper monitoring for side effects. Facility staff, including the DON and ADON, were unaware of the resident's antibiotic use, and the Pharmacist Consultant was not informed. The facility's Antibiotic Stewardship Program was not effectively implemented, resulting in a lack of tracking and monitoring.
A resident in an LTC facility was on indefinite prophylactic antibiotic therapy without proper monitoring, contrary to the facility's infection control policy. The resident's prolonged use of Macrobid was not tracked in the facility's monthly infection surveillance, and staff were unaware of the situation until a state surveyor's inquiry. Interviews revealed a lack of oversight by the DON, ADON, and pharmacist consultant, highlighting a deficiency in the facility's antibiotic stewardship program.
A resident in the facility was unable to reach the call light, which was positioned behind the head of the bed, making it inaccessible. Despite the resident's need for assistance due to medical conditions, the call system was not within reach, as confirmed by staff and observations. The facility's policy requires call lights to be accessible, but this was not followed, leading to the deficiency.
The facility failed to provide adequate room sizes for residents, with 7 rooms not meeting the required square footage per resident. The Administrator acknowledged the deficiency and intended to provide a waiver to the state surveyor. A total of 10 residents were affected by this issue.
A resident with cognitive impairments and a history of elopement exited the facility undetected on two occasions due to inadequate supervision and unsecured exits. The resident left through a malfunctioning gate and an unlocked kitchen door, highlighting lapses in staff training and environmental security.
A resident with severe cognitive impairment was sexually assaulted by another resident, a registered sex offender, in a LTC facility. Despite staff witnessing the incident and reporting it, the administration failed to take immediate action, including notifying authorities or providing medical evaluation for the victim. The facility's policies on abuse and neglect were not followed, leading to an Immediate Jeopardy situation.
A facility failed to implement its abuse prevention policies when a resident with severe cognitive impairment was sexually assaulted by another resident with a history as a registered sex offender. Despite staff witnessing the incident, the Administrator did not take immediate action to protect the victim, investigate the incident, or report it to authorities. This failure resulted in an Immediate Jeopardy situation, highlighting significant deficiencies in the facility's handling of abuse allegations.
A facility failed to effectively manage an incident where a male resident, a registered sex offender, was observed sexually assaulting a female resident with severe cognitive impairment. The Administrator did not report the incident to authorities, instructed staff not to document or notify law enforcement, and altered a witness statement. This led to an Immediate Jeopardy situation, highlighting a serious deficiency in handling abuse and neglect cases.
A resident experienced a prolonged plumbing issue in their closet, leading to a musty/moldy odor affecting their clothing and causing embarrassment. Despite the resident's repeated requests for repairs, the issue persisted for six months. Maintenance staff managed the situation temporarily, but the problem was not resolved, compromising the resident's quality of life and dignity.
The facility failed to provide cigarettes for five days to three residents, impacting their quality of life and rights. The residents, who had cognitive impairments and mental health conditions, were visibly upset and expressed frustration over the lack of cigarettes, which were a source of enjoyment for them. The issue arose due to a failure in the process of obtaining funds for cigarette purchases, as the ADM or DON did not sign the necessary check. This was not the first time residents experienced such a delay, and the facility's Safe Smoking Policy was not adhered to.
The facility failed to provide palatable and aesthetically pleasing food for three residents, leading to dissatisfaction and potential nutritional issues. A resident with moderate cognitive impairment and another with severe cognitive impairment expressed dissatisfaction with the food, describing it as terrible and lacking flavor. An observation revealed that the food served was unappetizing and lacked taste. The facility's policy emphasized the need for nutrient-dense and flavorful food, but this was not met.
A facility failed to report a sexual abuse incident involving two residents to the appropriate authorities. A female resident with severe cognitive impairment was found disrobed and distressed in a male resident's room, who is a registered sex offender. Despite staff witnessing the incident, the Administrator instructed them not to document or report it, violating facility policies on abuse and neglect.
A resident with a history of epilepsy and anxiety was administered diphenhydramine HCl by an LVN without a physician's order after becoming agitated. The DON stated that a verbal order was likely obtained, but it was not documented. The facility's policy requires confirming medication orders before administration.
Prolonged Lack of Hot Water on Upstairs Wing Affecting Resident Showers and Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment on the upstairs wing by not ensuring that restrooms and shower rooms had readily available hot water. Surveyor observations over two days showed that multiple upstairs restrooms and shower rooms either had no hot water flow or water that did not reach a hot temperature after running for two minutes. In restroom D, the hot water faucet turned on but no water came out on two separate observations. In restrooms C and F, and in restroom/shower rooms A and B, the hot water at hand sinks and showers consistently measured in the 73–78 degrees Fahrenheit range after running for two minutes, with low water pressure also noted in one instance. Interviews with residents and staff confirmed that the lack of hot water upstairs had been an ongoing issue for months. One resident reported that there had not been any hot water upstairs for months and that residents were taken downstairs for showers unless they wanted a cold shower, stating that administration and all staff were aware of the problem and that no completion date for repairs was provided. Multiple CNAs stated that the upstairs restrooms and shower rooms did not really have access to hot water, that shower room A never really heated up and shower room B only heated after a long time, and that residents were routinely taken downstairs to receive showers. Several CNAs reported that this situation had been occurring for at least several months, with one CNA stating it had been an issue for the entire four months of her employment and another stating it had been at least six months. Additional staff interviews further described the impact of the lack of hot water upstairs. Housekeeping staff reported that there had been no hot water upstairs for the entire year of employment and that they obtained hot water for cleaning from a downstairs supply closet sink, while upstairs residents received their showers downstairs. Nursing staff, including LVNs, acknowledged awareness of hot water issues upstairs, with some unsure of the current status but confirming that residents were taken downstairs for showers if they wanted hot water. One CNA reported coming in early to complete resident showers because the entire facility was sharing one shower, making it difficult to complete showers on assigned days. Several staff members, including CNAs, housekeeping, maintenance, and nursing staff, stated that not having hot water upstairs could be or felt like a resident rights concern or violation. The DON acknowledged that ideally the upstairs shower rooms and restrooms should have hot water, that there was an ongoing issue, and that there had been a problem with the hot water upstairs since January 2026. Review of the grievance log showed no grievances related to hot water for the prior six months, and the facility’s Resident Rights policy stated that the facility provides a clean, safe, comfortable, and home-like environment.
Failure to Protect a Resident From Abuse and to Act on an Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to implement its abuse and neglect policies after an allegation was reported. A 51-year-old male resident with bipolar disorder (current hypomanic episode), thrombotic microangiopathy, and systemic lupus erythematosus had a quarterly MDS indicating moderate cognitive issues and a care plan stating he was dependent on staff for emotional, intellectual, physical, and social needs. On the morning in question, during breakfast in the dining room, an LVN interacted with the resident in a manner that multiple witnesses and the resident described as inappropriate and abusive. The LVN told the resident to sit right or he would fall back, get blood all over the floor, and the LVN would have to pick it up, and then pushed or “popped” the back of his head, causing his head to move forward. The resident reported that this did not physically hurt but made him feel humiliated, stupid, and as if the LVN could “take over him.” A medication technician (MT) present that morning reported by text to the Administrator that she would be writing a grievance about the LVN due to the incident at breakfast. In the text exchange, the MT stated that the LVN argued with the resident about going to his room and said she could not wait until he was off parole so she could show him what a nurse was about. The MT also relayed that the resident told her the LVN tapped him on the back of the head and that the LVN was angry because the resident had told her to quit talking to herself. The Administrator responded by text acknowledging the report and thanking the MT but did not come to the facility that day. The MT later stated she reported the incident between approximately 9:30 AM and 10:00 AM and that the LVN worked the remainder of her shift that day and her shift the following day. Two CNAs who were in the dining room corroborated seeing the LVN touch or push the back of the resident’s head, causing his head to move forward. One CNA stated she asked the resident if the LVN had pushed his head and he confirmed that she had; she described the action as intentional, without apology, and stated it was never acceptable to touch a resident in that manner. The other CNA similarly reported seeing the LVN behind the resident and pushing his head forward, noting that even if it was not a full-force push, staff should not “play” with residents by pushing their heads. Both CNAs indicated they had been trained multiple times on abuse and neglect, knew the Administrator was the abuse and neglect coordinator, and understood that abuse and neglect should be reported immediately. They did not independently report the incident because they believed the MT had already reported it. The resident later reported feeling uncomfortable and humiliated by the incident, stating that he avoided the LVN afterward and felt very uncomfortable asking her for his pain or PRN medications over the weekend because she remained his nurse. He reported feeling psychologically uncomfortable and isolating himself somewhat during that time. The ADON learned of the allegation on the following Monday, assessed the resident, and found no visible discoloration or skin injury. During that assessment, the resident confirmed that the LVN had pushed the back of his head, describing it as a “little pop,” and stated he had not felt safe asking the LVN for PRN medication over the weekend. The DON and ADON both indicated that prior staff reports described the LVN as easily agitated or argumentative. The Administrator acknowledged receiving the allegation on the day it occurred but did not report it to the state agency until the following Monday. She stated she did not immediately report or suspend the LVN because she believed it was a personal issue between the MT and the LVN and wanted to investigate first. The ADON, RDO, and RNC all stated that, under facility policy and state guidelines, any allegation of abuse or neglect should be reported immediately to the state, and any staff member alleged to have committed abuse should be immediately suspended pending investigation. They further stated that the Administrator did not follow the facility’s abuse and neglect policies, did not notify nursing leadership when she first learned of the allegation, and allowed the LVN to continue working and to remain assigned to the resident after the allegation was made. The facility’s written abuse, neglect, and exploitation policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required immediate reporting and protective actions when allegations arose. The surveyors identified this as past noncompliance at the level of Immediate Jeopardy, beginning on the date of the incident and ending several days later.
Failure to Remove Alleged Abusive Nurse and Timely Report Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse, neglect, and exploitation policies when an allegation of physical and verbal abuse was made against a nurse. A male resident in his early fifties with bipolar disorder (current hypomanic episode), thrombotic microangiopathy, and systemic lupus erythematosus, who had a care plan indicating dependence on staff for emotional, intellectual, physical, and social needs and an MDS showing moderate cognitive impairment, reported being struck on the back of the head by an LVN in the dining room. A medication technician (MT) texted the Administrator the same morning to report that the LVN had argued with the resident about going to his room, threatened that she could “show him what a nurse [is] about” once he was off parole, and that the resident said the LVN had tapped him on the back of the head. The Administrator responded that she would take care of it but did not come to the facility that day. Multiple staff and the resident provided consistent accounts of the incident and its immediate impact. The resident stated that the LVN told him to sit right or he would fall back, get blood on the floor, and she would have to pick it up, and then hit the back of his head; he said it did not hurt but made him feel like she could take over him and made him feel stupid, and that his head went forward. A CNA in the dining room reported seeing the LVN touch the back of the resident’s head, causing his head to move forward, and confirmed with the resident that the LVN had pushed his head; she stated it was never okay to touch a resident in that manner and that the LVN did not apologize or excuse herself. Another CNA also reported seeing the LVN push the resident’s head forward and stated that staff had been trained many times on abuse and neglect and that such conduct was not acceptable. Both CNAs indicated they understood the Administrator to be the abuse and neglect coordinator and that abuse and neglect should be reported immediately. Despite these reports, the LVN remained on duty and continued to care for the resident for the remainder of the day of the incident and the following day. The resident later told staff he was scared or uncomfortable asking the LVN for anything, including PRN and pain medications, during that weekend and that he isolated himself somewhat and felt humiliated by being hit in front of others. The ADON, who first learned of the allegation two days after the incident, assessed the resident and confirmed that he reported the LVN had pushed the back of his head and that he had felt unsafe and afraid to ask her for PRN medication over the weekend. The DON and ADON both stated that the LVN was known to be easily agitated and that, under facility policy, any staff member alleged to have committed abuse should be immediately suspended pending investigation. The Administrator acknowledged receiving the text report of the allegation on the day it occurred and admitted she did not report the allegation to the state agency until two days later. She stated she did not immediately report or suspend the LVN because she believed it was a personal issue between the MT and the LVN and wanted to investigate first. The ADON, RDO, and regional nurse consultant all stated that the facility’s abuse and neglect policies required immediate reporting of any allegation of abuse or neglect to the state and immediate suspension of any staff member alleged to be involved, and that these procedures were not followed. Review of the written facility policy on Abuse, Neglect and Exploitation confirmed that any employee alleged to be involved in abuse or neglect was to be interviewed and suspended pending investigation and not permitted to return to work unless allegations were unsubstantiated or residents were determined not to be in danger. The surveyors concluded that the facility failed to implement these policies for this resident when the Administrator did not promptly report the allegation or remove the LVN from duty after the alleged abuse was reported.
Failure to Thoroughly Investigate and Document Alleged Abuse by LVN
Penalty
Summary
The deficiency involves the facility’s failure to have evidence that an allegation of abuse involving one resident and an LVN was thoroughly investigated and documented. A male resident in his early fifties with bipolar disorder (current hypomanic episode), thrombotic microangiopathy, and systemic lupus erythematosus, and with moderate cognitive impairment per MDS, alleged that an LVN tapped or pushed the back of his head in the dining room after making comments about his behavior and posture. A medication technician reported by text to the Administrator that the LVN argued with the resident about going to his room, stated she could not wait until he was off parole so she could show him what a nurse was about, and that the resident told her the LVN tapped him in the back of the head. The Administrator acknowledged receiving this report on the date of the incident. Multiple staff and the resident provided accounts of the incident and its immediate impact. The medication technician stated she heard the LVN tell the resident she could not wait until his parole release so she could show him what a nurse was about, and that the resident reported the LVN had popped him in the back of the head. A CNA reported witnessing the LVN touch the back of the resident’s head, causing his head to move forward, and confirmed that the resident told her the LVN had pushed his head; she stated it was never acceptable to touch a resident in that manner and that the LVN did not apologize or excuse herself. Another CNA also reported seeing the LVN push the resident’s head forward and stated that staff had been repeatedly trained in abuse and neglect and that such behavior was not appropriate. The resident reported that the LVN was very outspoken, told him to sit right or he would fall back and get blood on the floor that she would have to clean, and then hit the back of his head, which did not cause pain but made him feel humiliated and as though she could take over him. The Administrator, ADON, DON, RDO, and RNC all provided information indicating that the facility’s abuse and neglect policies and procedures were not implemented as required in response to this allegation. The Administrator stated she received the report of alleged abuse on the day it occurred but did not immediately report it to the state agency, did not immediately suspend the LVN, and did not promptly involve the DON or ADON, explaining that she initially believed it was a personal issue between staff and misjudged the situation. The ADON reported she did not learn of the allegation until two days later, at which time she assessed the resident and confirmed that he reported the LVN had pushed the back of his head and that he felt uncomfortable and afraid to ask her for PRN medication over the weekend. The DON and ADON both stated that the LVN continued to work and remained the resident’s nurse after the allegation was reported to the Administrator, contrary to facility policy that staff alleged to have committed abuse should be suspended pending investigation. The RDO and RNC stated that any allegation of abuse should be reported immediately to the state agency, that staff involved should be removed from duty pending investigation, and that the Administrator did not follow facility and state guidelines. Facility policy required timely investigation of any alleged abuse, neglect, mistreatment, injuries of unknown origin, or exploitation, including gathering evidence, interviewing witnesses, reviewing records, and documenting all findings and actions, but the surveyors found the facility lacked evidence that such a thorough investigation and documentation were completed for this allegation.
Failure to Timely Report and Act on Allegation of Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse and to protect a resident from further potential abuse after the allegation was made. A male resident in his early fifties with bipolar disorder (current hypomanic episode), thrombotic microangiopathy, and systemic lupus erythematosus was care planned as dependent on staff to meet his emotional, intellectual, physical, and social needs and had a quarterly MDS indicating moderate cognitive issues. On the morning of 02/07/2026, a medication technician (MT) texted the Administrator stating she would be writing a grievance on an LVN due to an incident at breakfast. In the text, the MT reported that the LVN argued with the resident about going to his room, told him she could not wait until he was off parole so she could show him what a nurse was about, and that the resident reported the LVN had tapped him on the back of the head in the dining room. The Administrator acknowledged the text and told the MT she would take care of it but did not come to the facility that day. Interviews with staff and the resident confirmed the allegation and described the events in more detail. The MT stated she heard the LVN tell the resident she was tired of him going back and forth and heard the resident tell the LVN she had whole conversations by herself, after which the LVN responded that she could not wait until his parole release so she could show him what a nurse was about. The MT reported that the resident told her the LVN popped him in the back of the head and that he was scared to ask the LVN for anything for the rest of the day. A CNA reported seeing the LVN touch the back of the resident’s head, causing his head to go forward, and confirmed that the resident told her the LVN had pushed his head; she stated it was never okay to touch a resident in that manner and that the LVN did not apologize or excuse herself. Another CNA also reported seeing the LVN push the resident’s head forward and stated that, although it was not a full-force push, staff should not play with residents by pushing their heads. Both CNAs indicated they had been trained in abuse and neglect, knew the Administrator was the abuse and neglect coordinator, and understood that abuse and neglect should be reported immediately. The resident reported that the LVN was “very opened mouthed,” told him she was tired of giving him his 2:00 PM pill, and in the dining room told him to sit right or he would fall back, get blood all over the floor, and she would have to pick it up, then hit the back of his head. He stated the contact did not hurt but made him feel like she could take over him, made him feel stupid, and humiliated him in front of others. He reported that he avoided the LVN afterward, felt uncomfortable and worried she might be verbally inappropriate again, and did not feel comfortable asking her for his PRN pain medications even though he was in pain, describing that he felt he had to beg for his pills. The ADON, who learned of the incident on 02/09/2026, assessed the resident and found no visible discoloration or skin injury; during that assessment, the resident confirmed that the LVN had pushed the back of his head and reported that over the weekend he did not feel safe and was afraid to ask the LVN for PRN medication. The DON and ADON both stated that the LVN continued to work for two days after the allegation was reported to the Administrator and that this could have put residents at risk of abuse and neglect. The Administrator acknowledged that she received the report of the allegation of abuse and neglect on 02/07/2026 and did not report it to the State Agency (HHS) until 02/09/2026. She stated it was an error on her part, that she initially believed it was a personal issue between the MT and the LVN, and that she wanted to investigate before reporting. The ADON, RDO, and RNC all stated that allegations of abuse and neglect were to be reported immediately to HHS, that staff alleged to have committed abuse should be suspended pending investigation, and that the facility’s abuse and neglect policies were not implemented in this case. The RDO and RNC emphasized that personal relationships between staff could not be considered when an allegation involved resident abuse or neglect and that the Administrator did not follow facility and state guidelines for reporting and protecting residents. The noncompliance was identified as past noncompliance at the Immediate Jeopardy level, beginning on 02/07/2026 and ending on 02/11/2026, and the failure was described as one that could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Failure to Enforce Safe Smoking Policy and Supervision for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate supervision and adherence to the facility’s safe smoking policy. The resident was a 37-year-old male with paraplegia, anxiety disorder, and major depressive disorder, who had no documented cognitive impairment per an MDS assessment. His care plan included a focus on noncompliance with smoking rules and prior findings of vapes in his bed. He had signed a Resident Smoking Behavior Contract acknowledging that failure to comply with smoking safety regulations could result in suspension or revocation of smoking privileges and could jeopardize his ability to remain in the facility. Multiple progress notes and staff interviews documented repeated concerns that the resident was smoking in his room and possessing prohibited smoking materials. A DON progress note described a smell of smoke highly suggestive of cannabis from the resident’s room, with police confiscating a substance surrendered by the resident. Another note by an LVN documented finding two packs of cigarettes in the resident’s room and the resident attempting to conceal the extent of his cigarette possession. Additional documentation showed that the resident was observed smoking behind the laundry building outside of designated smoking times and that he produced a black lighter from his sock to light a cigarette after claiming he had not smoked at a scheduled smoke break. Staff interviews further described smelling cigarette smoke in the resident’s room and observing him with lighters hidden under his wheelchair cushion. CNAs reported seeing black and blue lighters in his possession and smelling smoke in his room, and they stated they informed nurses but did not escalate directly to the Administrator or DON. The DON, Administrator, ADON, LVNs, CNAs, PMHNP, NP, and RNC all acknowledged concerns or beliefs that the resident was smoking in his room or was noncompliant with smoking rules, and several stated he was not supposed to have lighters per facility policy. The facility’s Safe Smoking policy required that staff maintain all smoking materials, restrict smoking to designated times and areas, and assess residents’ ability to smoke safely, with recommended actions for infractions including a behavioral contract and potential involuntary discharge. Despite these policies and the resident’s contract, the resident continued to have access to cigarettes and lighters and was repeatedly associated with smoke odors and off-schedule smoking, demonstrating a failure to ensure adherence to the safe smoking policy and adequate supervision to prevent accidents.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper infection prevention and control practices during wound care for a male resident with multiple complex medical conditions, including multiple myeloma, paraplegia, generalized muscle weakness, anxiety disorder, and a stage 4 sacral pressure ulcer. The resident's care plan required enhanced barrier precautions, including the use of gown and gloves during high-contact care activities such as wound care. During an observed wound care procedure, the nurse sanitized her hands before entering the room and donned appropriate personal protective equipment. However, she did not perform hand hygiene between glove changes while treating multiple wounds on the resident's body. Specifically, after removing gloves and before donning new ones to treat different wounds, the nurse failed to sanitize or wash her hands. This occurred multiple times during the procedure, including after removing dressings and before applying new ones to different wound sites. Additionally, after completing the wound care and removing her gloves, the nurse did not perform hand hygiene. Interviews with the nurse revealed she believed she usually sanitized her hands or washed them, but she did not acknowledge failing to do so during the observed care. Interviews with the ADON and DON confirmed that the facility's expectation and policy require staff to perform hand hygiene between glove changes and after glove removal, even if sinks are not available in every room, with hand sanitizer as an alternative. Review of the facility's hand hygiene policy further supported the requirement for hand hygiene before putting on gloves, when changing gloves, and immediately after removing gloves, especially after contact with wounds or contaminated materials.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in the presence of roaches, rodents, and other pests in multiple areas, including resident rooms, the kitchen, common areas, and restrooms. Observations included live and dead roaches in restrooms, hallways, and conference rooms, as well as rodent droppings in a resident's dresser drawer. Pest control service invoices documented ongoing reports of roach and rodent activity in various facility locations, including the beauty salon, break room, kitchen, offices, and resident rooms. Staff and pest control personnel noted gaps and holes in the building structure that allowed pest entry, and rodent bait stations were being used on the facility's exterior. Interviews with residents revealed that several had seen roaches, spiders, and mice in their rooms and common areas, leading to feelings of discomfort and disgust. One resident, who was paraplegic and unable to move independently, reported hearing mice in his room and finding rodent droppings in his drawer, with staff confirming the presence of a rodent and nibbled food. Other residents described seeing bugs and roaches in restrooms and hallways, with one stating that the problem was improving but still present. Staff interviews corroborated these accounts, with several staff members reporting frequent sightings of roaches and at least one nurse and CNA witnessing a rodent in a resident's room. Despite regular pest control visits and emergency call-ins, the facility's pest control measures were insufficient to prevent ongoing pest activity. Facility leadership, including the Administrator, Medical Director, DON, and ADON, were aware of the pest issues through staff and resident reports, pest control invoices, and direct observation. However, there was a lack of timely and effective action to fully address the pest infestations, and some staff initially dismissed resident reports of rodents as delusional. The facility's own policy required measures to prevent, monitor, and address pest activity, but these were not adequately implemented, resulting in continued pest presence and resident exposure.
Failure to Provide Ordered Pain Medication Due to Medication Unavailability and Poor Communication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with multiple significant medical conditions, including paraplegia and several displaced fractures. The resident had a physician's order for Lidocaine Pain Relief External Patch 4% to be applied daily for pain management, but the medication was not administered on 21 documented occasions over a period of nearly a month. Medication Administration Records (MARs) indicated missed doses, often marked with a code that should have been explained in the resident's progress notes, but no such documentation was found. There were also instances of blank spaces in the MAR, indicating the medication was not given, with no explanation provided. Interviews with facility staff revealed that the missed administrations were due to the facility not having the medication available. Staff, including medication aides and nurses, acknowledged that it was their responsibility to ensure medications were in the building and to notify the appropriate personnel, such as the DON and NP, when medications were unavailable. However, there was a lack of consistent communication and documentation regarding the unavailability of the medication and the steps taken to address it. The nurse practitioner was not informed about the missed doses and stated she could have considered alternative pain management if she had been notified. The resident reported not receiving the lidocaine patch about 20% of the time and expressed feelings of neglect due to not receiving ordered medications. Staff interviews confirmed that the resident sometimes received only one patch instead of two, and that the facility occasionally attempted to purchase the patches over the counter when the pharmacy did not supply them. The facility's own policies required a medication management program to ensure residents' needs were met, but these procedures were not followed, resulting in the resident not receiving prescribed pain management as ordered.
Failure to Serve Palatable and Properly Heated Food to Residents
Penalty
Summary
The facility failed to serve palatable, attractive, and safely heated food to residents, as evidenced by observations, interviews, and record reviews. During a lunch meal observation, food items such as carrots, mashed sweet potatoes, ham, and beans were served at temperatures ranging from 114 to 120 degrees Fahrenheit, which did not meet the facility's stated requirement of 120 degrees Fahrenheit or above for hot foods. Multiple residents reported receiving cold food on several occasions, and this concern was documented in resident council meetings and individual concern reports. Staff interviews confirmed that residents frequently complained about the temperature of their meals, and some staff acknowledged that food was not always hot when served. Several residents affected by this deficiency had significant medical conditions, including diabetes, HIV, paraplegia, pressure ulcers, chronic kidney disease, and cognitive impairments. Care plans for these residents indicated risks related to nutrition and blood glucose fluctuations, making the provision of appropriate and palatable meals particularly important. Despite these needs, residents consistently reported dissatisfaction with the temperature of their food, with some refusing to eat cold meals and expressing feelings of neglect and disappointment. Interviews with dietary and nursing staff revealed a lack of clear responsibility and communication regarding the maintenance of food temperature from the kitchen to the point of service. The facility was operating without a dietary manager at the time, and staff reductions in the kitchen contributed to a hectic environment, further impacting meal service. Facility policies required food temperatures to be maintained at acceptable levels during all stages of preparation and service, but these policies were not effectively implemented, resulting in repeated instances of cold food being served to residents.
Failure to Ensure Safe and Properly Documented Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide and document adequate preparation and orientation for the transfer or discharge of a resident with severe cognitive impairment and multiple psychiatric diagnoses. The resident, who had a legal guardian due to his inability to advocate for himself, was involved in several altercations with other residents, leading the facility to seek alternate placement for his safety. Despite communication with the guardian regarding the need for transfer, the facility did not ensure that the new placement was within the jurisdiction of the resident's registered guardianship program, resulting in the resident being transferred to a location where his guardian had no authority. The facility did not provide or document a written discharge notice to the resident or his guardian, nor did they obtain the guardian's signature on the discharge paperwork indicating the destination facility. Additionally, there was no documentation that the ombudsman was notified of the discharge, and the psychiatric nurse practitioner was not consulted to determine if the resident posed a danger to himself or others. Interviews with facility staff, including the ADON, Administrator, and DON, revealed a lack of clarity regarding responsibility for following discharge procedures and acknowledged that several required steps were not completed according to facility policy. The resident's guardian was informed of the transfer by phone but was not given the opportunity to approve the final placement, as the facility proceeded with the transfer despite being notified that the guardianship program did not cover the new location. The guardian provided a list of acceptable areas, but the facility did not adhere to these guidelines. The psychiatric NP stated that the resident did not exhibit behaviors that could not be managed at the facility and was not a danger to himself or others. The failure to follow proper discharge procedures resulted in the resident being placed in a facility without an authorized representative to advocate for his needs.
Failure to Develop Timely Baseline Care Plan for Safe Transfers
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with paraplegia and multiple fractures, as required by policy and professional standards. Upon review, it was found that there was no care plan addressing the resident's transfer needs until several days after admission, despite the resident being dependent and requiring a mechanical lift for transfers. The absence of this information in the baseline care plan meant that staff did not have written instructions on how to safely transfer the resident during the initial period after admission. Interviews with facility staff, including the MDS Coordinator, DON, DOR, and other nursing staff, revealed that there was confusion and lack of clarity regarding responsibility for creating and updating the baseline care plan. Although therapy staff evaluated the resident and determined the need for maximum assistance with a mechanical lift, this information was not promptly incorporated into the care plan. Staff relied on verbal communication rather than documented instructions, and several staff members were unsure who was directly responsible for ensuring the care plan was completed and updated. The facility's own policy required that a baseline care plan be developed within 48 hours of admission, addressing initial goals and services, including transfer needs. However, the care plan for this resident did not include transfer instructions until well after the required timeframe. This deficiency was identified through record reviews and staff interviews, which confirmed that the lack of a timely and complete baseline care plan could result in staff not knowing how to safely transfer the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate altercations involving four residents. In the first incident, one resident with severe cognitive impairment and multiple medical diagnoses, including atherosclerotic heart disease and vascular dementia, was pushed and hit on the back by another resident who was frustrated by the former's slow movement. The aggressor had a history of behavioral episodes and moderate cognitive impairment, but there was no documentation of aggressive behaviors toward others in his assessment. Staff interviews revealed that the incident was witnessed and reported, but staff expressed uncertainty about how to prevent such incidents, citing the speed at which the altercation occurred. In the second incident, two other residents were involved in a physical altercation over a pair of sunglasses. One resident, with severe cognitive impairment and a history of verbal aggression, entered the dining room wearing sunglasses belonging to another resident. After a confrontation, the resident with the sunglasses smashed them on the table, prompting the other resident, who had moderate cognitive impairment and a history of behavioral issues, to physically strike him. Staff present at the scene intervened after the altercation had already escalated, and interviews indicated that staff were unsure of what could have been done differently to prevent the incident. Both residents involved had documented behavioral concerns in their care plans, but interventions primarily focused on redirection and medication review. Record reviews and staff interviews confirmed that the facility had provided abuse and neglect training to staff and maintained an abuse policy with key components such as screening, training, prevention, identification, investigation, protection, and reporting/response. However, despite these measures, the facility did not ensure that residents were free from abuse, as evidenced by the occurrence of these altercations and the lack of effective preventive interventions documented or described by staff.
Failure to Administer Scheduled Medications and Notify Providers
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering multiple scheduled, time-sensitive medications over a period of several weeks. The resident, an older adult with complex medical and psychiatric diagnoses including schizoaffective disorder, dementia, peripheral vascular disease, hypertension, and other chronic conditions, had numerous medication orders for antipsychotics, antidepressants, diuretics, antihypertensives, and supplements. Medication Administration Records (MARs) and care plans indicated that these medications were not administered on multiple occasions, with various chart codes and progress notes documenting missed doses, often citing the resident being asleep or a nurse instructing to hold medications. Staff interviews revealed that medication aides generally did not wake the resident if she was sleeping during medication pass times and would notify the charge nurse if the resident continued to sleep. However, there was a lack of consistent follow-up or documentation regarding whether the physician or nurse practitioner was notified about the missed doses. Several staff, including the psychiatric nurse practitioner and nurse practitioner, were unaware that the resident had missed multiple doses of critical medications. Progress notes often lacked specific information about which medications were not given or the rationale for withholding them, and there was no evidence that the prescribers were informed in a timely manner. The facility's medication administration policy required staff to document reasons for missed or refused medications and to notify the physician as necessary. Despite this, the documentation was incomplete, and communication lapses occurred, resulting in the resident not receiving essential medications as ordered. This pattern of missed medication administration was not addressed or escalated appropriately, as evidenced by the lack of awareness among key clinical staff and the absence of timely interventions or adjustments to the resident's medication regimen.
Failure to Administer Time-Sensitive Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by repeated failures to administer scheduled, time-sensitive medications over a period of several weeks. The resident, an older female with complex medical and psychiatric diagnoses including schizoaffective disorder, dementia, cerebrospinal fluid drainage device, and peripheral vascular disease, had multiple medication orders for antipsychotics, mood stabilizers, antidepressants, diuretics, anxiolytics, and supplements. Review of the Medication Administration Records (MAR) revealed numerous instances where these medications were not administered as ordered, with various chart codes indicating reasons such as the resident being asleep, medications being held, or no code or documentation provided at all. Progress notes and staff interviews indicated that when the resident was found sleeping during medication pass times, medication aides often did not wake her and would notify the nurse instead. Documentation was inconsistent, with some notes simply stating the resident was sleeping and the nurse was informed, but without further follow-up or clear documentation of physician notification or alternative actions taken. In several cases, there was no documentation explaining why medications were not given, and staff interviews revealed a lack of awareness among nurses and nurse practitioners regarding the missed doses. The facility's own medication administration policy required staff to document reasons for missed doses and to notify the physician as necessary, but this was not consistently followed. Interviews with the psychiatric nurse practitioner and other clinical staff confirmed they were unaware of the missed medication doses, and acknowledged that such omissions could have significant negative effects on the resident's condition, especially given her complex mental health and medical needs. The repeated failure to administer critical medications as ordered, combined with inadequate documentation and communication, constituted a significant medication error for the resident involved.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as observed during a survey. Three residents were affected by inadequate hot water supply, which impacted their ability to have comfortable bathing and ADL care. The facility's tankless water heaters required a significant amount of time to heat water, leading to residents experiencing cold and uncomfortable water during their care routines. Interviews with residents and staff confirmed the persistent issue with water temperature, and the maintenance director acknowledged the problem but noted that no formal training had been provided to staff on how to manage the water heating system effectively. Another deficiency involved a resident's wheelchair, which was not properly maintained. The wheelchair had worn armrests with exposed screws, posing a risk of skin tears and potential infection. Despite the visible damage, there was no record of a maintenance request for repairs in the facility's logs. Interviews with staff revealed a lack of communication and follow-through regarding the necessary repairs, as well as an absence of documentation in the maintenance binder. Additionally, the facility's dining room environment was found to be in disrepair, with missing and loose floor tiles, damaged baseboards, and sheetrock. These issues created a tripping hazard and an unclean, non-homelike environment. Staff interviews indicated that the maintenance concerns had been ongoing for several months, with no work orders submitted for the necessary repairs. The maintenance director admitted to being aware of the issues but had not prioritized the repairs due to other facility needs. The administrator and other staff acknowledged the safety hazards and the failure to maintain a homelike environment, as expected by the facility's policies.
Failure to Update Comprehensive Care Plans Timely
Penalty
Summary
The facility failed to develop comprehensive care plans within seven days after the completion of the comprehensive assessments for three residents. This deficiency was identified during a review of care plans for six residents, where it was found that the care plans for three residents were not updated in a timely manner. The lack of updated care plans placed these residents at risk of not receiving appropriate care and services to maintain their highest practical well-being. Resident #4, a male with multiple diagnoses including seizures, neuroleptic-induced parkinsonism, and dementia, had a significant change in condition noted on 01/18/2025, including a seizure and swallowing complications. Despite these changes, his last comprehensive care plan was completed on 11/09/2024, and no updated care plan was developed following his significant change MDS assessment dated 01/07/2025. Similarly, Resident #21, who has severe cognitive impairment and multiple health issues, had a quarterly MDS assessment on 01/05/2025, but his care plan had not been updated since 10/10/2024, despite new wound care needs identified on 01/14/2025. Resident #31, with severe cognitive impairment and a history of falls, had an annual MDS assessment on 01/15/2025, but his care plan had not been updated since 12/13/2024. He experienced a change in condition with an eye infection noted on 01/20/2025, yet no updated care plan was developed. Interviews with facility staff, including the MDS Coordinator, Director of Nurses, and the Administrator, confirmed the expectation that care plans should be completed and revised within seven days of the MDS assessment to reflect any changes in the residents' conditions. The failure to update these care plans as required was acknowledged by the staff, highlighting the potential for residents not receiving the necessary care and services.
Failure to Provide Adequate Activities on Secure Unit
Penalty
Summary
The facility failed to provide an ongoing activities program tailored to the needs of residents on the secure unit, as evidenced by the lack of scheduled activities for January 2025. The activity calendar for the secure unit was identical to that of the main unit, which did not account for the specific needs and preferences of the secure unit residents. Observations and interviews revealed that scheduled activities, such as church services, did not occur, and there was no documentation of in-room or group activities for the entire month. Interviews with staff, including an RN, CNA, and LVN, confirmed the absence of activities on the secure unit. They noted that while the main unit had activities, the secure unit residents were often left with limited options, such as coloring or watching television, which did not cater to all residents' preferences. The Activity Director admitted to not following up on the activity assistant's documentation and acknowledged that the secure unit required a separate activity calendar to meet its residents' needs. The Administrator, who had recently joined the facility, stated that it was the Activity Director's responsibility to ensure activities were based on residents' interests and documented accordingly. The lack of documentation meant there was no evidence of activities being conducted, which could lead to negative outcomes for residents. The facility's policy emphasized the importance of meaningful, person-centered activities, but this was not reflected in the secure unit's programming for January 2025.
Medication Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 9.68% during the survey. This deficiency involved two residents and two medication aides. Resident #17, who has hypertensive heart disease with heart failure, did not receive her blood pressure medications, Lisinopril and Losartan, due to the absence of blood pressure parameters in the physician's orders. Medication Aide F held these medications when Resident #17's blood pressure was low, without consulting a physician or nurse, as there were no parameters provided for when to hold the medications. Resident #29, diagnosed with schizophrenia and vitamin D deficiency, did not receive the correct dosage of vitamin D as per physician orders. Medication Aide G administered a 25 mcg tablet instead of the prescribed 50 mcg. This error occurred because the aide misunderstood the dosage requirement, believing that one tablet was sufficient to meet the prescribed dose. The facility's policy on medication administration and management requires staff to adhere to the '8 Rights' of medication administration, which includes giving the right dose and following physician orders. The Director of Nursing expressed that staff are expected to administer medications according to these orders and parameters, and the failure to do so could lead to negative outcomes for residents. The pharmacy consultant also acknowledged the need for blood pressure parameters for medications but was unsure why they were missing for Resident #17.
Failure to Maintain Food Safety Standards in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. Dietary Aide O was seen standing over the food prep table and clean dishes without wearing a hair net, and Dietary Aide M was observed without a beard guard while standing over plates of food. Both aides acknowledged the potential risk of hair contamination, which could lead to residents ingesting hair and potentially becoming ill. Despite being trained on the importance of wearing hair restraints, both aides failed to comply with the facility's policy. Additionally, Dietary Aide O did not follow proper hand sanitation procedures during food preparation. He was observed wearing gloves while opening a kitchen door, then handling meal trays and silverware without changing gloves or washing his hands. This improper glove use and lack of hand hygiene could lead to cross-contamination of food and utensils, posing a risk of foodborne illness to residents. The Dietary Manager confirmed that staff were expected to change gloves between tasks and wash hands before donning new gloves, but these protocols were not followed. The facility's policies on employee sanitation and hand washing were not adhered to, as evidenced by the actions of the dietary aides. The Dietary Manager and Administrator both acknowledged the potential for contamination and illness due to these lapses in protocol. The report highlights the failure of the dietary staff to maintain proper hygiene standards, which could compromise the safety and well-being of the residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in the care provided to residents. RN A did not use aseptic techniques during tracheotomy suctioning and care for a resident with a tracheostomy. The nurse placed trach care supplies on an unclean surface, failed to perform hand hygiene between glove changes, and contaminated sterile gloves by touching unsterile items. These actions were contrary to the facility's policy, which required aseptic techniques to prevent infection and maintain a patent airway. Additionally, RN A did not adhere to proper hand hygiene and sterile techniques during wound care for the same resident. The nurse failed to sanitize hands between glove changes and did not wash hands between different wound sites. The nurse also placed a clean dressing on the bed, which became contaminated, and then used it on the resident's wound. These actions were inconsistent with the facility's policy on dressing changes and hand hygiene, which emphasized the importance of preventing cross-contamination and infection. Furthermore, MA G did not sanitize the blood pressure cuff between residents during medication pass, which could lead to cross-contamination and the spread of infection. The facility's infection control program policy required the sanitization of resident equipment between uses to maintain a healthy living environment. The Director of Nursing acknowledged the importance of following protocols to prevent cross-contamination and infection, highlighting the facility's failure to enforce its own policies effectively.
Failure to Address Contracture in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with a right-hand contracture, which is a permanent tightening of muscles and tissues that decreases range of motion. The resident, who has severe cognitive impairment and requires dependent assistance for all activities of daily living (ADLs), was observed with her right hand in a contracted position without any splints or palm guards. Despite being assessed to have functional limitations in range of motion, the resident's care plan did not include interventions for her contractures. Interviews with facility staff revealed that the MDS coordinator had not received any information from therapy services regarding the resident's contractures, and thus, it was not included in the care plan. The facility's administrator and director of nursing acknowledged that the care plan should have been updated to reflect the resident's current needs, including interventions to prevent worsening of contractures. The oversight in updating the care plan could potentially place residents with contractures at risk for decreased mobility and worsening of their condition.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain grooming and personal hygiene. Specifically, the facility did not clean Resident #58's fingernails from January 26, 2025, through January 28, 2025. Resident #58, a male with multiple health conditions including type 2 diabetes, chronic kidney disease, and moderate cognitive impairment, was dependent on staff for personal hygiene. Despite his requests for assistance, staff either claimed to be too busy or did not have time to address his needs. Observations revealed that his fingernails were long and dirty, with a dark substance underneath, which was not adequately addressed by the facility's staff or hospice services. Interviews with staff, including a Hospice Aide, a CNA, the DON, and the Administrator, highlighted a lack of consistent nail care for Resident #58. The Hospice Aide admitted to trimming the nails but forgetting to clean underneath them, while the CNA acknowledged that nail care was performed only during downtime. The DON and Administrator both expressed expectations that nursing staff should provide ADL care, including nail care, especially when hospice services are not present. The facility's policy stated that staff should assist residents with nail care as needed, but this was not adhered to, resulting in the deficiency.
Failure to Follow Proper Wound Care and Hand Hygiene Protocols
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in maintaining professional standards of care. The resident, a male with paraplegia, respiratory failure, and anoxic brain damage, was in a persistent vegetative state and had four Stage IV pressure ulcers. During a wound care procedure, RN A did not perform hand hygiene between glove changes and used a cleaning technique that risked cross-contamination of the pressure ulcers. Specifically, RN A cleaned the left heel pressure ulcer by swiping across the area and then dabbing over the already cleaned wound, repeating the same technique on the right heel. Additionally, RN A placed a clean dressing on the bed, which became contaminated and was then applied to the resident's right ischial pressure ulcer. The facility's policies on dressing changes and hand hygiene were not followed, as RN A admitted to missing hand hygiene steps and acknowledged the risk of cross-contamination. The Director of Nursing (DON) confirmed that nurses are expected to sanitize their hands between glove changes and wash their hands between different procedures or wound sites. The facility's policy emphasized the importance of hand hygiene in preventing infection, but RN A's actions during the wound care procedure did not align with these guidelines, potentially placing the resident at risk for worsening pressure ulcers and infection.
Failure to Address Contracture Management in Resident Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, specifically for a right-hand contracture. The resident, who has severe cognitive impairment and requires assistance for all activities of daily living, was observed without any interventions in place to prevent further decline in her hand's range of motion. The comprehensive care plan did not include any strategies for managing the resident's contractures, and there were no physician orders related to her hand contractures or therapy services. Observations revealed that the resident's right hand was contracted, with long and jagged fingernails causing indentations in her palm. The Director of Nursing (DON) acknowledged the need for a device to prevent skin injury and increased contracture. The MDS coordinator confirmed that the contractures were not included in the care plan, and the COTA DOR noted the need for therapy. The facility lacked a policy for contracture management, and the administrator expected contractures to be identified and treated by therapy or referred by nursing, which was not done in this case.
Improper Catheter Care Leads to Risk of Infection
Penalty
Summary
The facility failed to provide appropriate care for a resident with a catheter, leading to a risk of urinary tract infections. During an observation, a registered nurse (RN A) placed the resident's catheter bag on the bed during wound care, which was against the care plan's instructions to keep the bag below bladder level to ensure proper drainage. This improper placement resulted in the catheter not draining correctly, as the condom catheter was observed to be full of urine and not draining into the collection bag. The resident, who was in a persistent vegetative state and had multiple diagnoses including paraplegia and anoxic brain damage, was at risk for urinary tract infections and skin breakdown due to this oversight. Interviews with RN A, the Administrator, and the Director of Nursing (DON) confirmed that the catheter bag should have been kept below the bladder to prevent backflow and ensure proper drainage. The facility's policy on catheter use emphasized the importance of maintaining catheter bags below bladder level to prevent bacterial growth and potential infections. The failure to adhere to these guidelines placed the resident at risk for urinary tract infections and skin complications.
Failure to Maintain Aseptic Technique in Tracheostomy Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring tracheostomy care and suctioning, as observed during a survey. The resident, a male with paraplegia, respiratory failure, and anoxic brain damage, was in a persistent vegetative state and required regular tracheostomy care and suctioning. During an observation, RN A did not adhere to aseptic techniques while performing tracheostomy care. RN A placed supplies on an unclean overbed table, did not perform hand hygiene before donning gloves, and used contaminated gloves to handle sterile equipment and perform procedures, including changing the inner cannula and suctioning the resident. RN A admitted to not following the facility's policy, which required hand hygiene between glove changes and maintaining a sterile field. The Director of Nursing (DON) confirmed the expectation for nurses to maintain sterile techniques during such procedures to prevent respiratory infections. The facility's policy on tracheostomy care emphasized aseptic procedures, but RN A's actions deviated from these standards, potentially placing the resident at risk for respiratory infections and distress.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically in the case of a male resident who was on prophylactic antibiotic therapy. The resident, who had a history of cerebral infarction, paranoid schizophrenia, encephalopathy, and urinary retention, was placed on Macrobid for chronic urinary tract infection prophylaxis. Despite the ongoing administration of the antibiotic, there were no orders for tracking side effects, and the resident was not included in the facility's monthly infection surveillance or the list of antibiotics dispensed. Interviews with facility staff revealed a lack of awareness and monitoring of the resident's antibiotic use. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware that the resident was on prophylactic antibiotics until the state surveyor's inquiry. The ADON acknowledged that the prolonged use of antibiotics without a clear end date was inappropriate and that the situation should have been investigated further. The Pharmacist Consultant also stated that she was not aware of the resident's antibiotic use and would have recommended a review for potential discontinuation if she had known. The facility's Infection Control policies and procedures, including the Antibiotic Stewardship Program, were not effectively implemented in this case. The program's core elements, such as tracking antibiotic use and monitoring for adverse drug events, were not followed. The failure to monitor the resident for adverse effects of the antibiotic use could place residents at risk of nausea, diarrhea, and secondary infections, as noted in the report.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking an antibiotic stewardship program that included protocols and a system to monitor antibiotic use. This deficiency was identified in the case of a resident who was on prophylactic antibiotic therapy for a urinary tract infection without a specified duration, contrary to the facility's policy. The resident, a male with a history of cerebral infarction, paranoid schizophrenia, encephalopathy, and urinary retention, was admitted and readmitted to the facility, and his care plan included antibiotic therapy initiated and revised in mid-2024. The resident's physician order summary indicated an indefinite duration for the antibiotic Macrobid, which was administered daily from July 2024 through January 2025. Despite the facility's policy requiring monitoring and documentation of antibiotic use, the resident was not included in the facility's monthly infection surveillance or the list of antibiotics dispensed. The consultant pharmacist's medication reviews did not recommend any changes to the resident's antibiotic order, and the facility's infection control team was unaware of the resident's prolonged antibiotic use until it was brought to their attention by a state surveyor. Interviews with facility staff, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the pharmacist consultant, revealed a lack of awareness and oversight regarding the resident's antibiotic regimen. The DON and ADON acknowledged the oversight and the potential risks associated with long-term antibiotic use without proper monitoring. The facility's infection control policies emphasized the importance of tracking and reporting antibiotic use, yet these protocols were not followed in the resident's case, leading to the deficiency identified by the surveyors.
Inaccessible Call System for Resident
Penalty
Summary
The facility failed to ensure that the call system was accessible to Resident #58, which is a critical component for residents to call for assistance. Observations revealed that the call light, a yellow string attached to a pull lever, was not within reach of the resident. Despite the resident's need for assistance due to his medical conditions, including type 2 diabetes, chronic kidney disease, and morbid obesity, the call light was positioned behind the head of the bed, making it inaccessible. Interviews with the resident and staff confirmed the deficiency. Resident #58 expressed that he could not reach the call light and had to wait for staff to check on him for assistance. A CNA acknowledged that call lights should be within reach and admitted that Resident #58 required significant assistance for daily activities, including the use of a mechanical lift for mobility. The CNA had to adjust the call light to make it accessible after providing care, indicating a lapse in ensuring the call system was consistently within reach. The Director of Nursing (DON) and the Administrator both stated that it was their expectation for call lights to be accessible and functional at all times. They emphasized the importance of the call system in preventing delays in care and addressing immediate needs. The facility's policy also reflected the requirement for call lights to be accessible, yet this was not adhered to in the case of Resident #58, leading to the deficiency.
Deficiency in Resident Room Size Compliance
Penalty
Summary
The facility failed to provide adequate room sizes for residents, as required by regulations. Specifically, the facility did not ensure that resident bedrooms measured at least 80 square feet per resident in multiple-resident rooms and at least 100 square feet in single-resident rooms. This deficiency was observed in 7 out of 50 resident rooms, namely Rooms 21, 23, 24, 25, 26, 27, and 35. The measurements of these rooms were found to be below the required square footage per resident, with room sizes ranging from approximately 72.84 to 75.43 square feet per resident in two-person rooms, and 73.06 square feet per resident in a three-person room. During an interview, the Administrator acknowledged that the dimensions of the specified rooms were less than the required 80 square feet per resident. The facility expressed a desire to continue with a room size waiver for these rooms and indicated that they would provide the state surveyor with the waiver documentation. The record review showed that a total of 10 residents were living in the affected rooms at the time of the survey.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a history of elopement, leading to two incidents where the resident exited the facility undetected. The first incident occurred when the resident, who was in a wheelchair, left through a malfunctioning gate that was not properly secured by staff after a smoking session in the yard. The resident was found two blocks away and returned to the facility without injury. The second incident happened when the resident accessed the kitchen through an unlocked door and exited to the street through the back door of the kitchen. The resident was located four blocks away by the police and returned to the facility. The resident involved had a history of Parkinson's, dementia, and other cognitive impairments, which increased his risk of elopement. Despite being identified as a moderate risk for elopement in a previous assessment, the facility did not implement adequate supervision or secure the environment to prevent the resident from leaving the premises. The resident's care plan was not updated to reflect the increased risk until after the incidents occurred. Interviews with staff revealed lapses in ensuring that doors and gates were properly secured, contributing to the resident's ability to leave the facility. Staff members admitted to not checking if doors were locked, and new staff were not adequately trained on the importance of securing exits. These oversights allowed the resident to elope twice, highlighting a failure in maintaining a safe environment and providing adequate supervision for residents at risk of wandering.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, resulting in an Immediate Jeopardy (IJ) situation. The incident involved a female resident with severe cognitive impairment, who was found in a male resident's room, disrobed, and being sexually assaulted. The male resident, who had a history of being a registered sex offender, was observed with his hand penetrating the female resident's private area. Despite the severity of the incident, the facility's administration did not take immediate action to report the abuse or send the victim for medical evaluation. Interviews with staff revealed that the incident was witnessed by multiple staff members, who reported the inappropriate behavior to the administration. However, the Administrator instructed staff not to document the incident or take further action, including contacting law enforcement or sending the victim to the hospital. The Administrator's inaction and failure to report the incident to the appropriate authorities were significant factors contributing to the deficiency. The facility's policies on abuse and neglect were not followed, as the incident was not reported to the state agency within the required timeframe, and the victim was not provided with immediate medical attention. The staff expressed outrage and concern for the safety of all residents, indicating a lack of trust in the facility's leadership to handle such serious matters appropriately. The failure to protect the resident and the inadequate response to the incident highlighted significant lapses in the facility's abuse prevention and reporting protocols.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse, resulting in a serious incident involving two residents. Resident #1, a female with severe cognitive impairment and a history of dementia, was sexually assaulted by Resident #2, a male resident with no cognitive impairment and a history as a registered sex offender. The incident occurred when Resident #1 was found naked in Resident #2's room, with Resident #2's hand between her legs. Despite the severity of the situation, the facility's Administrator (ADM) failed to take immediate action to protect Resident #1 from further abuse or psychosocial harm, did not thoroughly investigate the incident, and did not report it to the Health and Human Services Commission (HHSC). Multiple staff members, including a CNA, an MA, and an LVN, witnessed the incident or its aftermath and reported it to the ADM. However, the ADM instructed staff not to document the incident or take any further action, including sending Resident #1 to the hospital for evaluation. The ADM also failed to notify Resident #1's responsible party or the appropriate authorities, as required by the facility's abuse and neglect policy. Staff members expressed outrage and concern for the safety of all residents, particularly given Resident #2's history and the ADM's inaction. The facility's failure to follow its abuse and neglect policy resulted in the identification of an Immediate Jeopardy (IJ) situation. The ADM's lack of response and failure to report the incident in a timely manner were significant factors in the deficiency. The facility's policies clearly outlined the steps to be taken in the event of suspected abuse, including immediate protection of the resident, reporting to authorities, and conducting a thorough investigation, none of which were adequately followed in this case.
Failure to Report and Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency related to the handling of a serious incident involving two residents. Resident #2, a male with a history of being a registered sex offender, was observed sexually assaulting Resident #1, a female with severe cognitive impairment. The incident was witnessed by multiple staff members, including CNAs and an LVN, who reported seeing Resident #2 with his hand between Resident #1's legs. Despite the severity of the situation, the facility's Administrator failed to investigate or report the incident to the Health and Human Services Commission (HHSC) as required by policy. The Administrator also instructed LVN A not to document the incident, notify law enforcement, or send Resident #1 to the hospital for evaluation. This lack of action was compounded by the alteration of a witness statement by the Administrator, which misrepresented the events as described by CNA B. The Administrator's inaction and mismanagement of the situation led to the identification of an Immediate Jeopardy (IJ) situation, indicating a serious threat to the health and safety of the residents. Resident #1, who was severely cognitively impaired and unable to consent to any sexual interaction, was left vulnerable due to the Administrator's failure to act. The incident was not reported to Resident #1's responsible party, and the facility did not take immediate steps to protect her or other residents from potential harm. The Administrator's actions, or lack thereof, were in direct violation of the facility's policies on abuse and neglect, which require immediate reporting and investigation of such incidents.
Failure to Maintain a Homelike Environment Due to Plumbing Issue
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident due to a persistent plumbing issue in the resident's closet. This issue, which had been ongoing for approximately six months, resulted in a musty/moldy odor that permeated the resident's clothing, causing embarrassment and humiliation. The resident, who had no cognitive impairment and was diagnosed with multiple sclerosis, depression, and muscle wasting, repeatedly requested repairs. Despite these requests, the issue remained unresolved, with maintenance staff only able to temporarily manage the situation by mopping up water and replacing wet towels. Interviews with staff revealed that the problem was known but not adequately addressed. The maintenance staff indicated that the issue was related to a leaking AC unit, and the Director of Operations, who was covering as the Interim Administrator, acknowledged the problem and the need for a plumber. The facility's policy on resident rights and dignity emphasized the importance of a clean, safe, and homelike environment, which was not upheld in this case. The failure to address the plumbing issue in a timely manner compromised the resident's quality of life and dignity.
Failure to Provide Cigarettes to Residents
Penalty
Summary
The facility failed to uphold the rights of residents to a dignified existence and self-determination by not providing cigarettes for approximately five days to three residents who were smokers. This deficiency was identified through observations, interviews, and record reviews. The residents involved were a male with severe cognitive impairment, a male with moderate cognitive impairment, and a female who was cognitively intact. All three residents had care plans that acknowledged their smoking habits and the potential for injury, with interventions related to smoking policies. During observations and interviews, the residents were found in the smoking area but were unable to smoke, leading to visible agitation and verbal expressions of frustration. The residents expressed that their money was used to purchase cigarettes, but they often ran out before more were bought. The residents had been without cigarettes since the previous Friday, and this was not the first occurrence of such an issue. The MDSC acknowledged that smoking was one of the few pleasures for these residents and that the lack of cigarettes could lead to behavioral issues. Interviews with staff revealed that the process for purchasing cigarettes involved the ADM or DON signing a check, which had not been done, resulting in the residents going without cigarettes. The BOM was responsible for purchasing the cigarettes but was unable to do so without the necessary funds. The DO was unaware of the situation and stated that it did not meet her expectations, acknowledging the potential negative effects on residents who had been long-time smokers. The facility's Safe Smoking Policy outlined the commitment to providing a safe environment and the guidelines for smoking privileges.
Deficiency in Food Palatability and Preparation
Penalty
Summary
The facility failed to provide food that was palatable, aesthetically appetizing, and prepared by methods that conserve nutritive value, flavor, and appearance for three residents. Resident #5, a male with moderate cognitive impairment and a history of depression, anxiety, bipolar disorder, and stroke, expressed dissatisfaction with the food, describing it as terrible, lacking flavor, and monotonous. Resident #7, a male with severe cognitive impairment, depression, hypertension, and pain, also criticized the food, stating that it was terrible and that the staff did not care about the residents' dining experience. A confidential resident, CR #8, echoed these sentiments, describing the food as bland and non-appetizing, with a specific complaint about a pasta and meat dish that was unidentifiable and flavorless. An observation by the surveyor on a test tray revealed that the lunch items, beef stroganoff and steamed broccoli, were unappetizing, with the beef stroganoff appearing as a mush-like substance and the broccoli being overcooked and mushy, both lacking taste or flavor. An interview with the Dietary Manager was attempted but was unsuccessful. The Director of Operations (DO) acknowledged the importance of serving palatable and visually appealing food to prevent negative outcomes such as weight loss, lack of nutrition, lack of wound healing, and depression. The facility's Food Palatability policy, dated 12/31/19, emphasized the need for nutrient-dense, flavorful, colorful, aromatic, and culturally appropriate foods prepared by methods that conserve nutritive value, flavor, and appearance.
Failure to Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of sexual abuse involving two residents to the Health and Human Services Commission (HHSC) within the required timeframe. Resident #1, a female with severe cognitive impairment and a BIMS score of 0, was found in Resident #2's room, disrobed, and visibly distressed. Resident #2, a male with no cognitive impairment and a history as a registered sex offender, was observed by staff with his hand between Resident #1's legs. Despite the seriousness of the incident, the facility's administration did not report the event to the appropriate authorities as mandated by their policy. Multiple staff members, including CNAs and an LVN, witnessed the incident and reported it to the facility's administration. However, the Administrator (ADM) instructed staff not to document or report the incident, and Resident #1 was not sent to the hospital for evaluation. The ADM's decision not to report the incident was based on her belief that there were no witnesses to the abuse, despite staff testimonies to the contrary. The ADM also failed to interview all relevant staff and dismissed the severity of the situation, attributing fault to Resident #1 for being in Resident #2's room. The facility's policies on abuse and neglect require immediate reporting of such incidents to state agencies and law enforcement, as well as the provision of medical care to the victim. The ADM's actions were in direct violation of these policies, as she did not take the necessary steps to protect Resident #1 or ensure a thorough investigation. This failure to act appropriately placed all residents at risk and demonstrated a significant lapse in the facility's duty to safeguard its residents from abuse and neglect.
Unauthorized Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications, as evidenced by an incident involving a resident who was administered an injection of diphenhydramine HCl without a physician's order. The resident, a male with diagnoses including epilepsy, bipolar disorder, major depressive disorder, and anxiety disorder, was involved in an altercation after being caught smoking outside of designated times. The resident became agitated and threatened to cause disruption, prompting LVN A to administer a Benadryl injection to calm him down. However, there was no documented physician's order for this medication at the time of administration. The Director of Nursing (DON) stated that LVN A claimed to have obtained a verbal order from the nurse practitioner (NP) and used the medication from the emergency kit, although this was not documented in the progress notes. The NP recalled the incident and suggested that LVN A likely contacted her for the order, as was common practice. Despite attempts to interview LVN A, no response was received. The facility's medication administration policy requires reviewing and confirming medication orders prior to administration, which was not adhered to in this case.
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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