Paradigm At Westbury
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 5201 S Willow Dr, Houston, Texas 77035
- CMS Provider Number
- 675612
- Inspections on file
- 46
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Paradigm At Westbury during CMS and state inspections, most recent first.
A resident who was fully dependent on staff for ADLs and had multiple serious medical conditions was discharged to the hospital in dirty clothing and a soiled brief, with unclean skin and an odor. Hospital staff and family members reported ongoing issues with the resident's grooming and hygiene, including tangled hair and soiled garments. Facility staff on duty did not recall preparing the resident for discharge, and leadership was unaware of the incident until after it occurred.
A resident with significant cognitive and physical impairments was discharged to the hospital in a soiled and unclean state, despite being fully dependent on staff for ADLs. Hospital staff and family reported the resident arrived in dirty clothing, with unclean skin and an odor, and had a history of inadequate hygiene and grooming while at the facility. Facility staff interviews did not identify who was responsible for preparing the resident for discharge, and facility policies required staff to maintain resident hygiene and dignity.
Several rooms on one hall experienced sustained high temperatures due to HVAC failure, with temperatures recorded above 81°F for multiple days. Residents and staff reported discomfort, and not all residents received fans or adequate cooling. Staff provided water, ice, and offered relocation to cooler areas, but some residents declined. The facility did not meet its policy requirements for proper temperature and ventilation.
The facility failed to ensure accurate medication administration and availability, resulting in multiple residents not receiving prescribed medications as ordered, including missed doses, incorrect dosages, and administration of medications outside of physician-set parameters for blood pressure and blood sugar. Staff did not consistently follow established medication administration protocols, leading to deficiencies in pharmaceutical services.
A medication error rate of 16% was identified when a medication aide nearly administered an incorrect dose of antihypertensive medication, and five prescribed medications for a resident with multiple chronic conditions were not available or administered as ordered. Staff interviews confirmed delays in medication delivery and lack of timely communication with the DON, while required post-administration blood pressure monitoring was not performed until prompted by a surveyor.
Two residents experienced significant medication errors when staff failed to follow physician-ordered parameters for administering Midodrine and Insulin Glargine. One resident received blood pressure medication multiple times despite her systolic BP being above the ordered threshold, while another was given insulin when his blood sugar was below the prescribed limit. Documentation and staff interviews confirmed that these medications were administered outside of the specified parameters.
Surveyors found that the facility did not properly label and seal food items, such as an open bag of shredded cheese and an unsealed bag of flour, and observed a staff member with facial hair working in the kitchen without a beard guard. Staff interviews confirmed awareness of the requirements for food labeling, sealing, and use of beard guards, but these standards were not consistently followed.
The facility did not ensure proper disposal of garbage and refuse, as the dumpster lid was left open and debris was observed outside the dumpster. Staff reported difficulty closing the lid and sometimes used a stick to operate it, despite facility policy requiring dumpsters to be closed at all times to prevent disease transmission and rodent attraction.
A resident with severe cognitive impairment and mobility issues fell from their bed and sustained a minor head injury when a CNA attempted a bed bath alone, despite the resident's care plan requiring a two-person assist. The incident highlighted a failure in following established safety protocols, as the CNA believed she could manage without assistance, leading to the fall.
The facility failed to maintain a safe and comfortable environment due to malfunctioning HVAC units, resulting in cold air blowing in resident rooms and common areas. Temperatures fell below the required 71 degrees Fahrenheit, with some areas as low as 57 degrees. Staff interviews revealed a lack of communication and action to address the issue, and residents expressed feeling cold, with some observed shivering. The facility's emergency preparedness policy was not effectively implemented, leading to an unsafe environment.
A resident's weight was inaccurately documented in the MDS at an LTC facility, with the admission weight recorded as 119 pounds instead of the facility's recorded 99 pounds. The resident experienced significant weight loss, which was not reflected in subsequent MDS assessments. Interviews revealed the absence of an MDS nurse and acknowledged inaccuracies in the documentation.
A resident with multiple medical conditions experienced significant weight loss, which was not reflected in her care plan. Despite weight fluctuations and a notable loss of 7.9%, the care plan was not updated to address this issue. Interviews revealed that the facility lacked an MDS nurse, and the nurse responsible for care plans was no longer employed, leading to the deficiency.
A facility failed to provide a safe, clean, and homelike environment for two residents, as observed in their shared room. Issues included a stained toilet base, cracked bathroom tiles, a wobbly doorknob, bent window blinds, and a dirty floor. One resident, with moderate cognitive impairment and mobility challenges, expressed dissatisfaction with the room's condition, which contradicted her care plan's emphasis on a clutter-free environment to prevent falls. Interviews with staff revealed a lack of awareness and accountability for the room's upkeep.
The facility was found deficient in food safety practices, with unlabeled and undated food items in storage and improper glove use by dietary staff. Observations revealed that food items in the freezer and refrigerator were not properly labeled or sealed, and a staff member failed to change gloves between tasks, risking cross-contamination. The Dietary Manager acknowledged these lapses, which were contrary to the facility's sanitation policies.
A CNA failed to perform proper hand hygiene while retrieving ice for a resident, touching high-touch areas without sanitizing her hands, which could lead to cross-contamination. Interviews with the CNA, ADMIN, and DON confirmed the breach of the facility's hand hygiene policy, which mandates handwashing before and after resident contact.
The facility failed to provide scheduled showers for several residents due to the absence of shower technicians on weekends. Residents reported not receiving showers on their designated days, and staff interviews confirmed inconsistencies in the shower schedule. This deficiency affected residents' grooming and hygiene care.
The facility failed to remove controlled medications from the medication cart after the discharge of two residents, CR #40 and CR #41, leading to potential drug diversion. CR #40's hydrocodone/APAP was signed out post-discharge, and CR #41's Modafinil remained in the cart for two weeks. The facility's policy on controlled substances was not followed, as medications were not securely stored until destruction.
The facility failed to maintain food safety standards, including improper labeling and dating of food items, inadequate temperature control of milk and steam table items, and improper handling of ready-to-eat foods. These deficiencies were observed in the kitchen, with the Dietary Manager acknowledging the lapses.
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in their treatment. One resident with multiple respiratory and cardiac conditions had an oxygen humidifier bottle with insufficient water, while another resident with a tracheostomy had an oxygen concentrator with a nearly empty water bottle and a dirty filter. Staff interviews revealed lapses in routine checks and maintenance of oxygen equipment, contrary to the facility's policy and care plans.
The facility failed to secure medication carts, leaving them unlocked and unattended on two occasions. On one occasion, RN B left the Hall 100 cart unlocked for 12 minutes, with three residents nearby. On another occasion, RN T left the Hall 300 cart unlocked for 15 minutes, with two residents nearby. The DON confirmed that carts should be locked to prevent unauthorized access to medications.
The facility failed to maintain an effective pest control program, as numerous gnats were observed in four resident rooms on the 300 and 400 halls. Residents reported the gnats as a persistent issue, particularly during meal times. The facility's administrator was unaware of the problem, and the maintenance log showed no recent pest control requests related to gnats, despite the facility's policy requiring immediate reporting of pest sightings.
A resident's dignity and privacy were compromised when the facility failed to place a privacy cover over the resident's urinary catheter bag. The resident was admitted to the facility, and staff interviews revealed that the oversight was due to the resident being a new admission. The ADON and Administrator acknowledged the failure, and the facility's policies on catheter care and resident dignity were not followed.
A resident with legal blindness and severe cognitive impairment was at risk of injury due to broken window blinds and a damaged bed handrail in her room. The facility staff failed to report these issues for repair, despite procedures in place for identifying and addressing such concerns during Angel Rounds. The Administrator and Director of Support Services acknowledged the oversight, noting that no maintenance request had been made.
Failure to Provide Dignified and Hygienic Discharge for Dependent Resident
Penalty
Summary
A deficiency occurred when a female resident with end stage renal disease, acute kidney failure, protein-calorie malnutrition, hypertensive heart and chronic kidney disease, cognitive communication deficit, and aphasia was not provided with appropriate personal grooming and hygiene prior to her discharge to the hospital. The resident was totally dependent on staff for bathing and required moderate assistance for dressing, as documented in her care plan. On the night of her discharge, the resident was sent to the hospital in dirty clothes and a soiled brief, with unclean skin and an odor, as reported by hospital staff upon her arrival. Interviews with hospital staff confirmed that the resident arrived in an unkempt state, requiring immediate cleaning and a change of clothing and brief. Family members also reported ongoing issues with the resident's grooming during her stay, including tangled hair that eventually had to be cut, unbrushed teeth, and frequent observations of the resident in soiled briefs and dirty gowns. Family members stated they had to request clean gowns from staff multiple times per week, though no formal complaint was filed with the facility. Interviews with the facility's CNAs and nursing staff revealed that none of the CNAs on duty during the relevant shift recalled assisting the resident with preparation for discharge or were aware of her transfer to the hospital. The RN responsible for the discharge stated that a CNA should have changed the resident, but could not recall who performed the task. The DON and Administrator both stated that it was their expectation that residents be clean and appropriately dressed when discharged, but neither was aware of the incident until after the fact. Review of the facility's policy confirmed the resident's right to dignity and proper care.
Failure to Provide Necessary ADL Assistance and Hygiene Prior to Hospital Discharge
Penalty
Summary
A resident with multiple complex medical conditions, including acute kidney failure, end stage renal disease, protein-calorie malnutrition, dysphagia, cognitive communication deficit, and aphasia, was admitted to the facility and required significant assistance with activities of daily living (ADLs). The resident's care plan indicated total dependence on staff for bathing and showering, and partial to moderate assistance for dressing. The care plan also addressed oral and dental health, with interventions for monitoring and maintaining oral hygiene. The resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment and a need for staff support in daily care tasks. On the date of a change in condition, the resident was sent to the hospital. Upon arrival, hospital staff observed that the resident was in dirty clothes, a soiled brief, had unclean skin, and an odor, requiring immediate cleaning and changing. Family members also reported multiple instances prior to the hospital transfer where the resident was found in soiled briefs, with unbrushed and tangled hair, unbrushed teeth, and dirty gowns, necessitating requests to staff for basic hygiene care. The family stated that the resident's hair had to be cut due to lack of grooming by facility staff. These observations were corroborated by hospital staff interviews, which indicated the resident was non-communicative and fully dependent on staff for all ADLs. Interviews with facility staff, including CNAs and the RN on duty, revealed that none of the CNAs on the shift when the resident was discharged to the hospital recalled assisting with changing the resident's brief or clothing. The RN stated that a CNA had changed the resident, but could not recall who it was. The Director of Nursing and Administrator both stated that it was their expectation that residents be clean and appropriately dressed when discharged, but were unaware of any issues with this resident's discharge. Review of facility policies confirmed the requirement to provide necessary care for residents unable to perform ADLs, including maintaining proper grooming and hygiene.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents on Hall D, as required by resident rights regulations. Multiple rooms (404, 405, 406, and 407) were observed to have temperatures exceeding 81 degrees Fahrenheit, with some readings as high as 88 degrees. These elevated temperatures persisted for several days, as documented in maintenance logs and confirmed by direct observation. The HVAC system began experiencing cooling issues, and the chillers required replacement, resulting in inadequate cooling for the affected rooms. Residents and staff reported discomfort due to the heat. One resident stated his room had been hot for 6-8 days and did not have a fan, although he did not request one. Another resident reported the air conditioning had been out for several days and had requested and received fans, but still felt hot and preferred to remain minimally clothed. Staff interviews confirmed that residents and staff were aware of the heat issue, with some staff and residents sweating and expressing discomfort. Staff attempted to mitigate the situation by offering water, ice, and the option to move to cooler areas, but some residents declined to leave their rooms or have their doors opened for privacy reasons. Maintenance logs and staff interviews indicated that portable cooling units and fans were distributed, but not all residents received fans, and the cooling provided was insufficient to maintain comfortable temperatures. The facility's own policy required proper temperature and ventilation to create a homelike environment, but this standard was not met during the period in question. No incidents were reported to the state agency, and no residents were hospitalized as a result of the heat, but the deficiency was clearly documented through observations, interviews, and record reviews.
Failure to Provide Pharmaceutical Services and Adhere to Medication Orders
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by multiple medication administration errors and unavailability of prescribed medications. For one resident with diagnoses including major depressive disorder, muscle weakness, and hypertension, several prescribed medications were not available at the time of administration, including Eliquis, Amlodipine, Isosorbide Mononitrate, Duloxetine, Calcium with Vitamin D, Fenofibrate, and Vitamin D. Medication Aide J nearly administered an incorrect dosage of Amlodipine, initially dispensing only 5 mg instead of the ordered 10 mg, and was only corrected after surveyor intervention. The resident did not receive several of his prescribed medications on the following day due to continued unavailability, and his blood pressure was not rechecked as required after medication administration. Another resident with a history of hypertension and medically complex conditions received Midodrine, a blood pressure medication, outside of the physician-ordered parameters on multiple occasions. The order specified that Midodrine should be held if the systolic blood pressure (SBP) was greater than 110, but the medication was administered 17 times when the SBP exceeded this threshold. Nursing staff interviews confirmed that the medication was given outside of parameters, and documentation on the Medication Administration Record (MAR) supported these findings. The facility's Director of Nursing and other staff acknowledged that the medication should not have been administered under these circumstances. A third resident with Type 2 Diabetes Mellitus and chronic kidney disease was administered insulin outside of the physician-ordered blood sugar parameters. The order specified to hold insulin if blood sugar was less than 120, but insulin was administered when the resident's blood sugar was recorded at 98 and 65. Staff interviews confirmed that insulin was given outside of the prescribed parameters, and the risks of such actions were acknowledged by nursing staff and administration. The facility's policy required adherence to the '8 Rights' of medication administration, but these were not consistently followed in the cases reviewed.
Medication Error Rate Exceeds Acceptable Threshold Due to Dosing and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate based on 6 errors out of 37 opportunities. During medication administration, a medication aide (MA) was observed preparing to give an incorrect dose of a blood pressure medication, and surveyor intervention was required to prevent the error. Additionally, five prescribed medications for a resident with diagnoses including major depressive disorder, muscle weakness, and hypertension were not available and were not administered as ordered. These medications included Isosorbide Mononitrate, Duloxetine HCl, Calcium 600 + Vitamin D, Fenofibrate, and Vitamin D. The resident did not receive these medications on the specified date, and the medication administration record confirmed the omissions. Interviews with staff revealed that the medications would not be delivered until the following day and that the Director of Nursing was not made aware of the situation. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not met. Blood pressure monitoring after medication administration was also not performed as required until prompted by the surveyor.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
Two residents experienced significant medication errors due to staff failing to follow physician-ordered parameters for medication administration. One resident, a female with a history of traumatic subdural hemorrhage, hypertension, and cognitive impairment, was prescribed Midodrine to manage hypotension, with explicit instructions to hold the medication if her systolic blood pressure (SBP) exceeded 110. Despite this, the medication was administered 17 times in March when her SBP was above the ordered threshold, as documented in the Medication Administration Record (MAR). Interviews with nursing staff and the Director of Nursing (DON) confirmed that the medication was given outside the prescribed parameters, and staff could not explain why the orders were not followed. Another resident, a male with Type 2 Diabetes Mellitus, metabolic encephalopathy, and chronic kidney disease, had a physician's order for Insulin Glargine to be held if his blood sugar (BS) was less than 120. The MAR showed that insulin was administered on two occasions when his BS was below the ordered parameter, with readings of 98 and 65, respectively. The resident reported experiencing low blood sugar and needing to eat candy to correct it. Nursing staff interviews confirmed that insulin was given outside the prescribed parameters, and staff acknowledged the risk of hypoglycemia associated with such errors. Record reviews and staff interviews revealed that both residents had care plans and physician orders specifying medication administration parameters, but these were not consistently followed. The facility's policy required staff to adhere to the '8 Rights' of medication administration, including following physician orders and documenting interventions when parameters were not met. Despite these policies, the errors occurred, as confirmed by MAR documentation and staff statements.
Failure to Adhere to Food Storage and Staff Hygiene Standards in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, surveyors observed an open bag of shredded cheddar cheese in the refrigerator that was not dated, and a 50-pound bag of flour in the dry storage room that was not properly sealed. The Dietary Manager confirmed that food should be dated and sealed, and acknowledged that the unsealed flour was leftover and not properly stored, which could lead to contamination. Additionally, a staff member with facial hair was observed in the kitchen without a beard guard while preparing food. Interviews with the Dietary Manager and other staff confirmed that all kitchen personnel with facial hair are required to wear beard guards, and that in-service training on this requirement had recently occurred. The facility's policy on beard guards was requested but not provided before the survey exit. The FDA Food Code was referenced, indicating the requirement for hair restraints to prevent contamination.
Improper Disposal of Garbage Due to Unsecured Dumpster Lid
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that the dumpster lid was secured. During an observation, the dumpster lid was found open with debris present on the outside of the dumpster. Staff interviews revealed that kitchen staff were responsible for closing the dumpster lid, but some had difficulty doing so and resorted to using a stick to open and close it. The expectation among staff was that the dumpster should always be closed and the surrounding area kept clean, but this was not consistently achieved. The Administrator acknowledged that the dumpster was difficult to close and stated that efforts were being made to obtain a new one. Facility policy required that waste containers and dumpsters be covered and closed at all times to prevent the transmission of disease and to avoid attracting rodents and other vermin. The failure to keep the dumpster closed and the area clean was directly observed and confirmed through staff interviews and policy review.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who required a two-person assist. On the day of the incident, CNA A attempted to perform a bed bath alone for the resident, who had severe cognitive impairment and was dependent on staff for mobility. Despite knowing the resident's need for a two-person assist, CNA A proceeded without assistance, resulting in the resident falling from the bed and sustaining a minor head injury. The resident, who had a history of falls and was on anticoagulant medication, was at risk for increased bleeding and bruising. The resident's care plan clearly indicated the need for a two-person assist due to his impaired cognition and physical limitations. However, CNA A, believing she could manage alone, attempted to reposition the resident, leading to the fall. The incident was witnessed, and the resident was assessed and sent to the hospital for further evaluation. Interviews with facility staff, including the Administrator and RN A, confirmed that CNA A was aware of the two-person assist requirement. The Administrator noted that all CNAs were trained on this protocol, and RN A highlighted the potential risks of not adhering to it. The facility's investigation revealed that CNA A had been suspended and in-serviced following the incident, but the deficiency occurred due to the initial failure to follow the established care plan and safety protocols.
Failure to Maintain Safe and Comfortable Environment Due to HVAC Malfunction
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in three hallways and common areas due to malfunctioning HVAC units. The heating system was not functioning properly, resulting in cold air blowing from the vents in resident rooms and common areas. Observations revealed that temperatures in these areas were below the required 71 degrees Fahrenheit, with some areas as low as 57 degrees Fahrenheit. The outside temperatures during this period ranged from 33 to 53 degrees Fahrenheit, exacerbating the issue. Interviews with the Acting Maintenance Director and other staff indicated that the HVAC system had been malfunctioning for several weeks, and parts were needed for repairs. However, there was a lack of communication and action to address the immediate discomfort of residents. The Acting Maintenance Director was not instructed to place portable heaters, and the Administrator was not fully aware of the extent of the issue until surveyor intervention. Residents expressed feeling cold, with some observed shivering and inadequately covered with blankets. The facility's policy on emergency preparedness for loss of heating was not effectively implemented. The policy required immediate notification of maintenance and administration, temperature monitoring, and provision of additional clothing and blankets to residents. However, these measures were not adequately executed, leading to an unsafe and uncomfortable environment for residents. The deficiency was identified as Immediate Jeopardy, indicating a severe risk to resident health and safety.
Removal Plan
- DON assessed Residents #1, #2, #3, #4 affected by the uncomfortable temperature and were provided extra blankets and nursing added layers of clothing on affected residents. Residents were offered to be taken to the dining room where the HVAC is operating. Nursing staff immediately began monitoring resident's vitals, temperature, and any other cold-related health concerns. MD was notified and no new orders were given.
- DON assessed 100% of the residents and identified that no other residents were to be at risk.
- Facility purchased anti-tip portal heaters HVAC vendor was contacted to request industrial portable heaters. HVAC vendor arrived and installed 4 industrial portable heaters to compensate for the HVAC failure and will remain in place until HVAC is repaired.
- The administrator and maintenance supervisor routinely rechecked temperatures on Hall B 72, Hall C 70, Hall D 75, room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Common Area B, room [ROOM NUMBER], room [ROOM NUMBER] and readjusted the temporary HVAC unit until the temperatures reached 71 degrees. The maintenance director/trained designee will conduct the temperature checks every 2 hours and make adjustment to the temporary heating unit as needed until HVAC is fixed. The administrator will oversee the temperature log for accuracy.
- A regional contractor assessed the HVAC unit and determined the heater exchange was not functioning, and a certified HVAC specialist conducted a follow-up assessment. Contractor revealed transmitter conductor was not connected. When contractor connected the conductor the HVAC unit started working and hot air started blowing out in the front section of Hall B. The shorter section of Hall B and Hall C require a higher voltage electric wire, requiring electrician to install and then heater exchanger needs to be installed. Electrician will come to the facility to connect the higher voltage that is required on hallway B and C. Anticipated repair date for when the heater exchange needs to be installed and when the contractor connected the conductor.
- Administrator and DON reviewed Policies and Procedures for Emergency Preparedness on Loss of Heating Element which will include Educating Staff on Initial Response, How to Monitor Temperature, Ensuring Resident Safety and Comfort, Completing Resident Assessment and Monitoring, Staffing Coordination, Notifying families, and Regulatory Compliance. No change was needed.
- The Regional Nurse Consultant educated DON and Administrator on emergency preparedness- loss of heating element- topics to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance.
- The Administrator and DON educated all staff on emergency preparedness heating elements to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance, and reporting failure of HVAC system and temperatures outside of normal range to administrator immediately. Staff will receive education before start of their next shift and new hires will receive education at orientation.
- The Administrator educated the Acting Maintenance Director on routine temperature check for HVAC failure and reporting temperature outside of normal range. Educated to also include emergency preparedness heating elements.
Inaccurate Resident Weight Assessment in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate assessments of a resident's weight, which led to discrepancies in the Minimum Data Set (MDS) documentation. The resident, a female with multiple medical conditions including hypotension, hypertension, multiple myeloma, and vascular dementia, was admitted with an initial weight recorded inaccurately on the MDS. The admission MDS incorrectly documented the resident's weight as 119 pounds, based on a hospital discharge report, while the facility's records showed an admission weight of 99 pounds. Additionally, the resident experienced significant weight loss, which was not reflected in the quarterly MDS assessments, as they continued to list the weight as 119 pounds with no or unknown weight loss. Interviews with facility staff revealed that there was no MDS nurse at the time, and the previous MDS nurse had left the facility. The Unit Manager acknowledged the inaccuracies in the MDS documentation and noted that the resident had experienced gradual weight loss. The Director of Nursing, who was new to the facility, also recognized the inaccuracies and stated that they were working on addressing MDS and care plan issues. The facility's policy requires a registered nurse to conduct or coordinate each assessment with the interdisciplinary team, ensuring comprehensive and accurate assessments, which was not adhered to in this case.
Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plan for a resident after each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for one resident whose records were reviewed. The resident, a female with multiple medical conditions including hypotension, hypertension, multiple myeloma, vascular dementia, and mild protein-calorie malnutrition, experienced significant weight loss that was not reflected in her care plan. The resident's weight records showed fluctuations and a notable weight loss of 7.9% between early July and August. Despite this, the care plan was not updated to address the risk or occurrence of weight loss. The resident's admission MDS and subsequent quarterly MDS assessments did not indicate any weight loss, despite the resident's weight dropping from 119 pounds at admission to 78.04 pounds by October. The facility's policy required that care plans be developed and revised by the interdisciplinary team, but this was not adhered to in this case. Interviews with facility staff, including an LVN and the DON, revealed that there was no MDS nurse at the time, and the nurse responsible for MDS and care plans was no longer employed at the facility. The DON acknowledged the oversight and stated that the facility was aware of issues with care plans, which they intended to address with the hiring of a new MDS nurse. The facility's policy emphasized the need for comprehensive care plans to be developed within seven days of assessment, but this was not followed, leading to the deficiency.
Facility Fails to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as observed in one of the six rooms reviewed. Specifically, the room shared by two residents had several issues, including a toilet base with stains and dirt, a bathroom with cracked and missing tiles, a wobbly doorknob, bent window blinds, and a floor littered with dirt and debris. These conditions were noted during an observation and interview process, highlighting the facility's failure to uphold the residents' right to a dignified living environment. Resident #1, a female with moderate cognitive impairment and mobility challenges, expressed dissatisfaction with the state of her room. Her care plan emphasized the need for a clutter-free environment to prevent falls, yet the room's condition contradicted this requirement. The resident's family member corroborated the concerns, noting persistent trash on the floor and unacceptable stains around the toilet. The resident also mentioned using her cane to navigate around the cracked tiles, indicating a potential safety hazard. Interviews with facility staff, including the ADON, HK A, and the DON, revealed a lack of awareness and accountability for the room's condition. The ADON acknowledged the need for cleaning and repairs, while HK A admitted to not having cleaned the room yet and was unaware of the broken tiles and dirt. The DON, new to her position, was uncertain about the staff responsible for recent room checks. The Regional Consultant Nurse identified the chipped tile as a safety hazard, emphasizing the need for a clean and well-maintained environment, as outlined in the facility's policies.
Deficiencies in Food Safety and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the kitchen's walk-in freezer, several food items were found without proper labeling, dating, or sealing. Specifically, a bag of frozen corn and multiple bags of personal-sized pizzas lacked labels and open dates. Additionally, a bag of shredded mozzarella cheese and a half onion in the refrigerator were not labeled or dated. The Dietary Manager acknowledged the oversight and admitted that opened food items should have been labeled, dated, and sealed to prevent food contamination. Further observations revealed that a dietary staff member, referred to as [NAME] A, did not follow proper glove usage protocols. While working at the steam table, [NAME] A used the same gloves to handle a binder and pen, touch the plate warmer, and then plate food, including bread, for residents. The Dietary Manager confirmed that this practice could lead to cross-contamination, as the gloves had come into contact with unclean surfaces before handling food. The facility's policies on employee sanitation and food handling were reviewed, indicating that employees must wash hands and change gloves between tasks to prevent contamination. Despite having a food handler's certificate and training on hand hygiene, [NAME] A admitted to forgetting to change gloves during the food preparation process. The facility's in-service training records also emphasized the importance of proper handwashing and labeling of food items to ensure safety and prevent foodborne illnesses.
Inadequate Hand Hygiene by CNA Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A, who did not perform appropriate hand hygiene while retrieving ice for a resident. During the observation, CNA A was seen responding to a resident's request for ice without washing or sanitizing her hands before or after entering the resident's room. She touched high-touch areas such as the resident's door handle, bathroom door handle, and the ice chest lid without performing hand hygiene, which could lead to cross-contamination and the spread of infections. Interviews with CNA A, the Administrator (ADMIN), and the Director of Nursing (DON) confirmed the failure to adhere to the facility's hand hygiene policy. CNA A admitted to forgetting to sanitize her hands and acknowledged the risk of spreading germs to residents. The ADMIN and DON reiterated the importance of hand hygiene before providing care and handling items like the ice scoop, emphasizing that staff were trained to prevent cross-contamination. The facility's policy, revised in June 2019, clearly outlines the necessity of hand hygiene before and after resident contact and when handling food or resident items.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in five residents who did not receive showers as per their scheduled days. The residents were supposed to receive showers three times a week, but due to the absence of shower technicians on weekends, showers were not provided on Saturdays. This lack of service was confirmed through interviews with the residents, who reported not receiving showers on their designated days. Resident #5, a cognitively intact individual with multiple health issues including pulmonary hypertension and chronic heart failure, reported not receiving showers on weekends due to the absence of a shower technician. Similarly, Resident #6, who was moderately cognitively impaired, also confirmed missing showers on weekends. Both residents' electronic health records corroborated their statements, showing no documentation of showers on the missed days. Observations confirmed that these residents were clean and groomed at the time of the survey, but the lack of adherence to the shower schedule was evident. Interviews with staff, including a shower technician and CNAs, revealed inconsistencies in the shower schedule and responsibilities. The shower technician confirmed that she did not work on Saturdays, and CNAs were expected to cover these duties. However, CNAs admitted to not providing showers on the weekends, with no reasons given for this lapse. The facility's policy required that residents receive showers according to a set schedule, but this was not adhered to, leading to the deficiency in care for the residents involved.
Failure to Remove Controlled Medications Post-Discharge
Penalty
Summary
The facility failed to maintain a proper system for the receipt and disposition of controlled drugs, leading to potential drug diversion. For two residents, CR #40 and CR #41, controlled medications were not removed from the medication cart after their discharge. CR #40 was discharged to an acute care hospital, but her hydrocodone/APAP was still signed out after her departure, indicating possible diversion. The facility's Provider Investigation Report noted that medications for discharged residents were not promptly removed, and staff were subsequently educated on this procedure. Similarly, CR #41 was discharged to a hospital, yet his Modafinil remained in the medication cart for two weeks post-discharge. During an interview, RN T acknowledged the presence of CR #41's medication in the cart, and the DON confirmed that controlled substances should be securely stored until destroyed. The facility's policy on controlled substances was not adhered to, as evidenced by the continued presence of medications in the cart, which were vulnerable to diversion.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas within the kitchen. Observations revealed that food items were not properly labeled and dated, with instances of frozen peas and other items in the dry storage room lacking appropriate labeling. Additionally, the temperature of milk in the refrigerator was found to be above the required holding temperature, and the temperature of menu items on the steam table was below the acceptable level. These lapses in food storage and temperature control could potentially expose residents to foodborne illnesses. Furthermore, during meal preparation, a cook was observed handling baked rolls without wearing gloves, which is against the facility's policy for handling ready-to-eat foods. The Dietary Manager acknowledged these issues during interviews, admitting that the milk temperature was not checked upon delivery and that the steam table items were not maintained at the correct temperature. The facility's policies, which emphasize maintaining safe food temperatures and proper labeling, were not followed, leading to these deficiencies.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in their treatment. Resident #5, a female with multiple respiratory and cardiac conditions, was observed with an oxygen humidifier bottle that contained insufficient water to function properly. Despite her care plan emphasizing the need for supplemental oxygen and monitoring for respiratory distress, the resident reported that staff did not regularly check the water level in her oxygen tank, and she was instructed to notify them when it was empty. An LVN admitted to not checking the oxygen tank that morning due to being busy, highlighting a lapse in routine checks. Resident #4, who has a tracheostomy and requires continuous oxygen therapy, was found with an oxygen concentrator that had a nearly empty water bottle and a dirty filter. The resident's care plan and physician's orders specified the need for continuous oxygen therapy, yet the equipment was not maintained according to these guidelines. A family member noted the absence of water in the bottle during a visit, and a CNA confirmed that nurses were responsible for maintaining the oxygen equipment. An RN acknowledged the oversight and the potential impact on the resident's health, including issues with oxygen concentration and potential respiratory complications. Interviews with facility staff, including the DON, revealed that RNs were expected to check and maintain the oxygen equipment during their rounds. However, the observations and interviews indicated that these responsibilities were not consistently fulfilled, leading to the deficiencies noted in the care of Residents #4 and #5. The facility's policy on respiratory training and oxygen therapy maintenance was not adhered to, as evidenced by the dirty filter and insufficient water levels in the oxygen equipment.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with currently accepted professional principles, specifically in locked compartments. During an observation on June 4, 2024, the Hall 100 medication cart was found unlocked and unattended by the nursing station for approximately 12 minutes. Three unidentified residents were observed near the cart during this time. RN B, who had retrieved items from the cart, left it unlocked and entered a resident's room. In an interview, RN B admitted to not realizing the cart was left unlocked and acknowledged the potential danger of such an oversight. A similar incident occurred on June 6, 2024, when the Hall 300 medication cart was observed unlocked and unattended for 15 minutes. Two unidentified residents were near the cart, and a resident in a wheelchair was propelled past it by a family member. RN T, who was assisting a resident in a room, was responsible for the cart at that time. The Director of Nursing (DON) confirmed in an interview that medication carts should be locked at all times to prevent unauthorized access to narcotics and regular medications. The facility's Nursing Policies and Procedures, revised in June 2019, also state that medication carts must be kept in sight or locked at all times.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats in four out of ten rooms reviewed on the 300 and 400 halls. Observations revealed gnats in the rooms of several residents, including those on their food trays and personal items such as training cup spouts. Interviews with residents indicated that the gnats were a persistent issue, particularly aggravating during meal times, and had been more noticeable with the warmer weather. Despite these observations, the facility's maintenance log showed no recent requests for pest control related to gnats, with the last request dating back to October 2023. The facility's administrator was unaware of the gnat issue, stating that staff conducted daily rounds to address resident concerns and that pest control services were contracted to treat the building monthly or as needed. However, the facility's pest control policy, revised in 2009, mandates immediate reporting of live pest sightings to request emergency services. The lack of communication and action regarding the gnat infestation suggests a breakdown in the facility's pest control program, potentially placing residents at risk of residing in an environment with pests.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident by not placing a privacy cover over the resident's urinary catheter bag. The resident, a male admitted to the facility, was observed lying in bed with his catheter drainage bag exposed and without a privacy cover. This oversight was noted during an observation, and the resident did not respond to questions during an attempted interview. The Assistant Director of Nursing (ADON) acknowledged that the privacy cover should have been placed at the time of admission, and it was the responsibility of the admitting nurse or CNA to ensure this was done. Interviews with staff, including the CNA and the Administrator, confirmed that the lack of a privacy cover was due to the resident being a new admission and the task not being completed. The CNA admitted to seeing the catheter bag earlier but did not place a cover over it, despite being trained on resident rights and catheter care. The Administrator also confirmed that the resident's privacy and dignity were not honored, and it was expected that all nursing staff should ensure the privacy cover was in place. The facility's policies on catheter care and resident dignity emphasize the importance of maintaining privacy and dignity, which were not adhered to in this instance.
Failure to Maintain Safe Environment for Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, specifically in maintaining the window blinds and bed handrail in good repair. The resident, who is legally blind and has severe cognitive impairment, was observed in a room with broken blinds that had sharp, jagged edges within her reach. Additionally, the plastic handrail on her bed was damaged, with plastic peeled upward, creating pointy sharp edges. These conditions posed a risk of injury to the resident, who was seen reaching towards the window blinds while holding onto the damaged handrail. Interviews with the facility's Administrator and Director of Support Services revealed that the staff failed to report the need for repairs through the maintenance log, which is supposed to be updated during Angel Rounds. The Administrator acknowledged that the damaged items could cause injury and stated that staff entering the room should have made a maintenance request. However, the Director of Support Services confirmed that no work order had been received for the repairs, and the last maintenance request was recorded before the resident's admission. The lack of communication and follow-through on maintenance requests contributed to the unsafe environment for the resident.
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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