Paradigm At Woodwind Lakes
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 7215 Windfern Rd, Houston, Texas 77040
- CMS Provider Number
- 675085
- Inspections on file
- 59
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Paradigm At Woodwind Lakes during CMS and state inspections, most recent first.
A resident with severe dementia, impaired communication, gait instability, and a history of wandering and walking into objects was care planned for frequent checks and supervised ambulation. In the memory care dining area, a CNA placed the resident on a couch and left to care for another resident without handing off supervision, while another CNA and an LVN were at the nurses’ station charting and not maintaining direct visual observation of the dining room. The resident, who was known to walk continuously and not remain seated, sustained an unwitnessed fall and was later found on the floor; a hematoma developed on the right forehead, and the resident was sent to the hospital. Leadership and staff acknowledged that residents in memory care required constant supervision and that the nurses’ station did not allow full visibility of the dining room, but supervision expectations and facility policies on dementia care, fall management, and safety were not followed at the time of the incident.
A resident with severe cognitive impairment, neurogenic bladder, and an indwelling Foley catheter experienced a progressive slit on the penis and urine leakage into an incontinent brief due to inadequate catheter monitoring and care. Orders and the care plan required every-shift assessment of the catheter site for redness, irritation, urethral erosion, leakage, and urine characteristics, but nursing documentation showed no reported issues while the penile slit enlarged from a small, non-bleeding area to a beefy red, bleeding wound extending from the meatus down the shaft. During observed care, the resident’s brief was saturated with urine, dressings were wet and non-adherent, and the catheter tubing contained sediment with cloudy, sediment-filled urine in the bag. Staff interviews revealed that some staff had known about the slit for weeks, the assigned nurse had not assessed the penis or recognized leakage despite making rounds, and the NP had not been informed of the worsening condition or catheter leakage, demonstrating failures to monitor, recognize, and report catheter-related complications.
Two residents did not receive fully developed and implemented person-centered care plans consistent with their assessed needs. One resident with dementia, parkinsonism, and bilateral hand contractures had physician orders for a restorative program that might have included a resting hand splint and specific ROM/stretching interventions, but these device-based interventions were not incorporated into the care plan and were inconsistently applied, with staff unable to locate the devices or documentation of their use. Another resident with advanced dementia, severe cognitive impairment, gait impairment, and documented wandering had a care plan calling for supervision and safety measures, yet she continued to wander with frequent loss of balance and sustained an unwitnessed fall with a facial hematoma, while staff reported only general supervision and non-skid socks as active interventions and uncertainty about specific supervision measures in the care plan.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive and physical impairments was transferred by a single CNA instead of the required two-person assist, resulting in the resident's head striking the wall. The CNA admitted to performing the transfer alone, contrary to the care plan and facility policy, and staff assessments confirmed the resident sustained a minor injury. Documentation and interviews verified that the transfer was not conducted according to established procedures.
A resident with end-stage renal disease and multiple comorbidities did not have required Dialysis Hand Off Communication Report forms completed or properly maintained for the majority of her dialysis sessions. Despite physician orders and facility policy mandating the use of these forms to ensure communication between facility staff and the dialysis center, the forms were either missing or incomplete, and oversight by nursing management was inconsistent.
A resident with multiple chronic conditions developed a sacral wound that progressed to a stage 4 pressure injury with infection and severe sepsis after staff failed to follow wound care orders and did not consistently document or perform required treatments. The wound worsened over several weeks, and the resident was ultimately transferred to the hospital after family intervention.
Two residents dependent on staff for ADLs did not consistently receive required showers, baths, or nail care, as evidenced by missed scheduled care and observations of poor hygiene. Staff interviews and documentation revealed lapses in following care plans and facility policy, resulting in unaddressed grooming and hygiene needs.
A Wound Care Nurse failed to change gloves between cleansing a wound and applying treatment and dressing for a resident with a stage 3 pressure ulcer, contrary to facility policy. The resident, who was fully dependent and had multiple health issues including sepsis and chronic pain, received wound care without proper infection control practices, as observed by surveyors.
Two residents requiring oxygen therapy did not receive care consistent with physician orders and facility policy. One resident received continuous oxygen without a current physician order, while another received oxygen at a higher flow rate than ordered. Staff interviews and record reviews confirmed these discrepancies, and the facility's policy requiring verification and documentation of oxygen therapy was not followed.
Surveyors identified that the facility's medication error rate exceeded five percent due to three errors involving two residents. In one case, a nurse administered a stool softener and a multivitamin with minerals instead of the specific medications ordered for a resident with dementia and constipation, citing stock issues. In another case, a medication aide applied a new Rivastigmine patch before removing the old one for a resident with dementia, contrary to facility policy and physician orders. These errors were attributed to staff not following established medication administration protocols.
Two residents in a facility experienced discomfort due to drafty windows in their room, which were not properly sealed, allowing cold air to enter. Despite complaints and the provision of extra blankets, the issue was not addressed promptly, affecting the residents' comfort and safety. The residents, both with severe cognitive impairments and other health conditions, reported feeling cold, and staff interviews confirmed awareness of the problem.
The facility failed to provide palatable and appetizing meals, as observed during a survey. The lunch meal served was bland and poorly prepared, with mushy pasta and chewy squash. Residents expressed dissatisfaction, and there was an increase in requests for alternative meals. The Dietary Manager noted the cook's inexperience and the need for more staff and training to improve meal quality.
The facility failed to follow professional standards for food service safety, as observed in their kitchen. Drinks were stored in the fridge without lids or labels, a pitcher of chopped fruit lacked a date or label, and a bin of flour was not completely sealed. The Assistant Dietary Manager acknowledged these oversights, which could risk foodborne illness.
A resident with multiple health conditions, including dementia and frequent incontinence, did not receive appropriate incontinent care, as a CNA cleaned from back to front and failed to change gloves, contrary to facility policy. This action posed a risk of urinary tract infections, as confirmed by staff interviews and facility procedures.
A medication error occurred when a resident was given blood pressure medications outside of the physician's prescribed parameters, resulting in a 7% medication error rate at the facility. The resident, with a history of hypertension, received Isosorbide and Carvedilol despite a blood pressure reading below the hold threshold. The error was acknowledged by the medication aide, who had recently started working at the facility, and was reported to the nursing staff. The facility's policy required adherence to physician orders, and the management team was responsible for ensuring compliance.
A resident in an LTC facility received blood pressure medications outside the prescribed parameters, leading to a significant medication error. The resident, with a history of heart failure and hypertension, was given Isosorbide and Carvedilol despite having a blood pressure of 107/71 and a heart rate of 67, which were outside the ordered parameters. The error was realized post-administration, and the nursing staff acknowledged the potential risks involved.
A resident with multiple medical conditions and frequent incontinence did not receive proper infection control during care. CNA A failed to change gloves and perform hand hygiene after cleaning the resident's perineal area, risking cross-contamination. Interviews with staff confirmed the breach, and facility policies were reviewed, highlighting the need for proper glove removal and handwashing.
The facility failed to maintain a clean and sanitary environment in a secured unit, with observations of dirty, sticky floors in the hallway, dining room, and activity room. A resident was seen walking barefoot on the dirty floor. The Housekeeping Supervisor and Maintenance Manager acknowledged the issues, citing inadequate oversight and accountability for floor cleanliness. The Director of Nursing was aware of the problem and mentioned plans to address it.
Unwitnessed Fall and Head Injury Due to Inadequate Supervision in Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a cognitively impaired resident in the memory care unit. The resident was an elderly female with dementia with psychotic disturbance, severe cognitive impairment (BIMS score of 00), altered mental status, restlessness and agitation, gait impairment, lack of coordination, and a history of unintentionally walking into objects and removing footwear. Her care plan identified ADL deficits, the need for staff to anticipate needs and provide prompt assistance, supervision with one staff for walking in the room and corridor, limited assistance for locomotion on and off the unit, frequent checks during high‑risk times, maintaining safety during increased wandering, and offering engaging activities to reduce restlessness. The care plan also noted impaired communication, risk for further decline and injury, and the need to reduce environmental stimuli and use communication tools the resident could understand. On the day of the incident, the resident was wandering in the memory care dining room and was known by staff to walk continuously, not remain seated, and be unable to communicate needs verbally. CNA A reported placing the resident on a couch in the dining area and then leaving to provide care to another resident without notifying other staff or providing a handoff of supervision, despite the expectation that residents in the memory care unit be supervised at all times and that staff verbally pass on supervision responsibilities before leaving an area. CNA B stated she was at the nurses’ station charting and was not directly observing the resident, did not see or hear the fall, and was unaware of the exact whereabouts of other staff. She reported that she had been charting for about five minutes before noticing the resident on the floor in the dining room and was unsure how long the resident had been on the floor. LVN A stated she was seated at the nurses’ station documenting, could only see a portion of the dining room from that position, and was notified by CNA B that the resident was on the floor. The fall was unwitnessed, and the resident was found on the floor in a seated position on her bottom in the dining room. Initial assessment by LVN A documented stable vital signs and no visible injuries or pain at that time, and the environment around the fall was noted to have no notable findings. Later, swelling and a nodule/hematoma developed on the right side of the resident’s forehead, with subsequent discoloration to the right side of the face above the eyebrow, below the eye, and toward the nose. The resident was sent to the hospital, where imaging and tests were described as reassuring, and instructions were given to ice the hematoma. Facility leadership, including the ADON, DON, and Administrator, stated that residents in the memory care unit, and this resident in particular, required constant or continuous supervision due to wandering, inability to ensure their own safety, and communication deficits, and that staff were expected to maintain direct visual observation and communicate supervision coverage. Staff interviews and observations confirmed that at the time of the incident, the resident was not under continuous direct observation, supervision responsibilities were not properly handed off, and the nurse’s station position did not allow full visibility of the dining room, leading to the unwitnessed fall and resulting head injury. Subsequent observation of the resident by the surveyor showed that she ambulated independently but experienced brief losses of balance every few steps or when stopping, did not respond verbally, and did not allow staff to assist for more than a few seconds before moving away. LVN C confirmed that the resident never sat still, including during meals, did not communicate verbally, and required continuous direct observation to ensure safety. The facility’s own policies on Dementia Care, Fall Management, and Standards of Care required person‑centered care, individualized fall prevention plans, supervision during high‑risk activities such as ambulation, and safety measures to prevent accidents and injuries. Despite these policies and the resident’s documented risks and care plan interventions, staff actions and inactions at the time of the incident resulted in the resident being unsupervised in the dining room, an unwitnessed fall, and a hematoma to the forehead requiring hospital evaluation.
Failure to Monitor and Manage Indwelling Catheter Leading to Worsening Penile Injury and Urine Leakage
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring for a male resident with an indwelling urinary catheter, resulting in worsening penile injury and leakage of urine into his incontinent brief. The resident had significant medical conditions including hypertension, stage 3 pressure ulcers, neurogenic bladder, obstructive and reflux uropathy, and used an indwelling catheter. His MDS showed severe cognitive impairment, total dependence for toileting, and incontinence of bowel and bladder. His care plan and physician orders required staff to follow catheter-related orders, monitor the catheter site every shift for signs of infection, irritation, urethral erosion, and leakage, and to monitor urine characteristics and report abnormalities to the physician. Surveyor review of prior documentation showed that during an earlier survey, the resident’s penis had a small slit measuring 0.3 cm by 0.1 cm with slight redness, and there was no leg strap or Statlock securing the catheter. CNAs at that time reported they had not previously seen the slit. Despite ongoing orders to monitor for complications each shift, the March MAR entries indicated nurses signed off that there were no issues with the Foley and skin area. However, during a later observation of catheter and incontinent care, the resident’s penis was found to be slit from the meatus down the shaft, with a beefy red color and fresh bleeding. The slit had increased in size to 1.5 cm by 0.5 cm. When the area was wiped, the wipes showed a substantial amount of blood. Staff interviews indicated that the slit had been present and known to some staff for weeks, but they described it as smaller and not bleeding previously. During the same observation, the resident’s brief was saturated with urine, the wetness indicator was not visible, and the wound dressing near the buttock was wet and non-adhesive, with a second dressing soaked. The Foley tubing contained smears of sediment with no urine visible in the tubing, and the Foley bag held cloudy urine with a significant amount of sediment. The nurse assigned to the resident stated he had made rounds twice that day but had not noticed Foley leakage or assessed the penis, and he acknowledged he was aware of the slit from prior orientation but believed it was regular wear and tear from Foley use. He also stated he was not aware of the leakage until he saw the soaked brief and sediment in the tubing and bag, and he did not identify when to obtain an order to flush the catheter. The NP later reported she had not been informed that the slit had worsened, had not been notified of leakage or balloon issues, and had not given the ointment order the nurse described. Other staff, including CNAs, the ADON, DON, and Corporate Nurse, confirmed the slit had been smaller previously, that the Foley had been leaking onto the brief, and that sediment and potential clogging could cause leakage and skin breakdown, but these changes and complications were not consistently recognized, monitored, or reported as required by the resident’s orders and care plan.
Failure to Integrate and Implement Contracture and Wandering Interventions in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents whose needs had been identified in their assessments. For one male resident with Alzheimer’s disease, parkinsonism, stroke history, muscle weakness, and dependence in ADLs, the comprehensive assessment and care plan identified bilateral hand contractures and risk for skin breakdown, pain, and worsening contractures. The care plan interventions focused on keeping contractured areas clean and dry, providing PROM without forcing the joints, monitoring for pain and stiffness, and providing medications and treatments as ordered. However, the resident’s physician orders included a restorative nursing program that might have included a left resting hand splint and specific ROM and stretching exercises to prevent further contractures, and these splint/hand device interventions were not incorporated into the care plan. Observations and interviews showed that the ordered hand splint/hand roll interventions were not consistently implemented. During observation, the resident was noted to have contractures in both hands with no splint or hand roll in place, and the resident reported that staff applied the devices only when they wanted and that he had not received them that day. The assigned RN stated he had not seen any hand roll in place, acknowledged the resident was supposed to have one, and indicated that restorative aides or CNAs were responsible for applying them. CNAs and restorative aides confirmed the resident was supposed to have “carrots” or rolled towels in both hands for specified on/off intervals, but reported that the devices were not present in the room at times, that they relied on restorative aides or CNAs to apply them, and that documentation of this care was inconsistent. Facility leadership, including the DON, ADON, and MDS Coordinator, acknowledged that the hand device intervention was not on the care plan, that restorative documentation was not integrated into the electronic plan of care, and that they could not locate documentation showing the ordered intervention had been consistently provided. The deficiency also involves a female resident with dementia with psychotic disturbance, gait impairment, lack of coordination, altered mental status, restlessness, and agitation, who had severe cognitive impairment (BIMS score of 0), fluctuating inattention and disorganized thinking, and documented wandering behavior. Her care plan identified ADL deficits, need for staff to anticipate needs and provide prompt assistance, limited assistance for locomotion, supervision for walking, PROM as needed, and a history of unintentionally walking into objects. Interventions included frequent checks, maintaining safety during increased wandering, offering engaging activities, reducing environmental stimuli, using communication tools she could understand, and addressing her history of removing footwear. Despite these care-planned needs, the resident experienced an unwitnessed fall in the dining room after wandering, later presenting with a hematoma and discoloration on the right side of the face that required hospital evaluation. Subsequent observation showed the resident ambulating independently with frequent brief losses of balance, not responding verbally, and continuing to walk away from staff attempts to assist. Staff interviews indicated that CNAs and nursing staff recognized the resident as nonverbal, continuously walking, not remaining seated, and at high fall risk, and that she required staff to watch her while walking. However, staff also reported there were no specific interventions beyond general supervision and non-skid socks to address her constant movement and wandering, and one CNA was unsure whether the care plan specifically included supervision interventions. Leadership interviews confirmed that staff were expected to follow care plans, that the resident was care planned for supervision due to wandering and fall risk, and that failure to follow or individualize care-planned interventions could result in residents not receiving necessary services. The care plan was only updated after the fall to add non-skid socks, indicating that at the time of the incident, the care plan and its implementation did not fully address the resident’s persistent wandering and supervision needs as identified in her assessments.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required extensive assistance from two staff members for transfers. The resident, a female with severe cognitive impairment, multiple physical and neurological diagnoses, and limited mobility, was transferred by a single CNA instead of the required two-person assist. During the transfer from her wheelchair to her bed, the CNA lifted the resident alone, resulting in the resident's head bumping against the wall. The CNA admitted to performing the transfer alone, despite the care plan specifying the need for two staff, and stated that he had done so in the past. The incident was witnessed by the resident's roommate, who reported being awakened by the sound of the resident's head hitting the wall. The CNA immediately reported the incident to the unit manager and nurse, who assessed the resident and found a small raised area on the back of her head but no bleeding or discoloration. The resident's vital signs and mentation were at baseline, and she did not display signs of pain or distress during the assessment. The facility's policy and care plan documentation confirmed that the resident required a two-person assist for transfers, and this information was available in the resident's chart and point of care system. Interviews with staff, including the CNA, nurses, unit manager, and director of nursing, confirmed that the transfer was not performed according to the resident's care plan and facility policy. The CNA acknowledged not following the required procedure and indicated that he had previously transferred the resident alone. The facility's transfer and lift policy emphasized the importance of individualized care plans and appropriate staff assistance to ensure resident safety during transfers, which was not adhered to in this case.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the Dialysis Hand Off Communication Report forms, which are intended to facilitate ongoing communication between the facility and the dialysis center, were either not completed or were incomplete for 22 out of 23 opportunities. Record review showed that for the months reviewed, there were no report forms accounted for in May and only five out of nine forms in July, with only one of those being fully completed. The process required the charge nurse to complete the top portion of the form before sending the resident to dialysis, and the dialysis center to complete the bottom portion upon return, but this process was not consistently followed. The resident involved was a female with multiple diagnoses, including end-stage renal disease, diabetes with neuropathy, heart failure, and atrial fibrillation. She was cognitively intact and required assistance with activities of daily living. Her care plan and physician orders specified regular dialysis sessions and the need for pre- and post-dialysis vital signs. Despite these orders and the facility's policy requiring the use of the Dialysis Communication Form, the forms were not properly completed or maintained in the resident's medical record as required. The interim DON confirmed the process and acknowledged that it was the unit manager's responsibility to ensure compliance, but this was not consistently done.
Failure to Follow Wound Care Orders Resulting in Stage 4 Pressure Injury and Sepsis
Penalty
Summary
Facility staff failed to provide pressure ulcer care and prevent new ulcers from developing for a resident with multiple comorbidities, including heart disease, respiratory failure, COPD, diabetes, and end-stage renal disease. The resident was admitted without pressure ulcers but was identified as being at risk for skin breakdown. Despite care plan interventions such as weekly skin checks and use of a pressure-reducing device, the resident developed a sacral wound during her stay. Physician orders for wound care were not followed on multiple documented occasions, as evidenced by gaps in the treatment administration record. The wound, initially noted as a small opening, progressed in size and severity over several weeks. Documentation and interviews revealed that wound care was either not performed or not documented as performed on several dates, and the wound deteriorated to an unstageable and then stage 4 pressure injury. The resident's family ultimately intervened, resulting in the resident's transfer to the hospital, where she was diagnosed with a stage 4 pressure injury, infection, and severe sepsis. Interviews with facility staff, including the ADON, DON, wound care nurses, and other nursing staff, confirmed that there was a failure to follow physician orders for wound care and to document treatments provided. Staff acknowledged the risks associated with not following wound care protocols and the importance of documentation. The wound care nurse responsible for the resident's care was no longer employed at the facility at the time of the investigation, and staff reported recent in-services on wound care and skin assessments.
Failure to Provide Consistent ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, a male with Alzheimer's Disease, dementia, muscle weakness, and impaired mobility, was dependent on staff for all ADLs. Despite a care plan goal for the resident to be well-groomed and clean, observations revealed greasy hair, dirty sheets, and the resident reported not receiving showers or baths three times a week as required. Review of shower sheets confirmed that the resident missed 13 scheduled baths over a two-month period, with only a few bed baths documented and some refusals noted. Staff interviews indicated a lack of clarity regarding shower schedules and issues with linen delivery, but no prior awareness of missed showers. Another resident, with diagnoses including chronic metabolic acidosis, muscle wasting, and a chronic skin ulcer, required supervision or assistance for personal hygiene and bathing. Observation showed this resident had long, yellow fingernails with a dark substance underneath, and the resident reported waiting for a bath and nail care. Documentation revealed missed or unverified showers and nail care, with staff acknowledging the resident could be difficult to bathe or provide nail care for, but also indicating that ADL care should have been provided prior to the resident leaving for a medical appointment if not refused. Record reviews and staff interviews confirmed that the facility's policy required providing necessary care for residents unable to perform ADLs to maintain proper grooming and hygiene. However, the facility did not ensure consistent delivery of showers, baths, and nail care for these dependent residents, as evidenced by missed care opportunities and incomplete documentation.
Failure to Change Gloves During Wound Care
Penalty
Summary
A deficiency was identified when the facility failed to ensure proper infection prevention and control practices during wound care for a resident. Specifically, the Wound Care Nurse did not change gloves between cleansing the wound and applying honey treatment and dressing, instead using the same gloves throughout the procedure. This was observed during a wound care session, where the nurse cleansed the wound, reused gauze on different areas, and then applied the prescribed honey treatment and dressing without changing gloves. The nurse acknowledged during an interview that not changing gloves could lead to infection, and the Director of Nursing confirmed that cross-contamination could occur if gloves are not changed at appropriate stages of wound care. The resident involved was a male with multiple diagnoses, including chronic pain, cellulitis, muscle wasting, cognitive impairment, and sepsis. He was totally dependent on staff for activities of daily living, always incontinent, and had a stage 3 pressure ulcer on his sacrum, with care plans and treatment orders in place for wound management. The facility's own dressing change policy required glove changes and hand hygiene at specific steps, which were not followed during the observed incident.
Failure to Provide Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with a history of COPD, dependence on supplemental oxygen, and other significant medical conditions, there was no current physician order for oxygen therapy despite the resident receiving continuous oxygen via nasal cannula. The care plan indicated a need for oxygen at 4L/min, and records showed ongoing use of oxygen since readmission, but the last documented physician order for oxygen had been discontinued months prior. The Director of Nursing confirmed that an order should have been in place and was not. For another resident with COPD exacerbation and congestive heart failure, the physician's order specified oxygen at 2 LPM via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set at 3.5 LPM, exceeding the ordered flow rate. Multiple staff interviews confirmed that nurses were responsible for setting the oxygen flow rate according to physician orders, but the actual setting did not match the order. There was also confusion among staff regarding standing orders and titration parameters, but documentation and orders reviewed did not support the higher flow rate being used at the time of observation. The facility's own oxygen therapy policy required verification of physician orders for oxygen administration, including method of delivery and flow rate, and documentation of the resident's response. In both cases, the facility did not ensure that oxygen therapy was provided in accordance with physician orders and professional standards of practice, as required by the residents' care plans and the facility's policy.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent based on three errors out of thirty-five opportunities. These errors involved two residents and were identified through observation, interview, and record review. The first incident involved a resident with dementia, protein-calorie malnutrition, and constipation, who was dependent on staff for activities of daily living. The resident was administered Sennoside 8.6 mg instead of the ordered Sennoside 8.6 mg with Docusate 50 mg, and Multivitamins with minerals instead of the prescribed Multiple Vitamins without minerals. The nurse administering the medication stated that the correct medications were not available in the facility and that substitutions were made based on what was in stock, despite the differences in formulation. The medication supply room was found to have the correct Multiple Vitamins available, but the Sennoside with Docusate was on back order, and staff had been instructed to purchase it from an outside source. The second incident involved a resident with dementia who required assistance with activities of daily living. The medication aide applied a new Rivastigmine transdermal patch before removing the old one, contrary to the physician's order and facility policy, which required the old patch to be removed prior to applying a new one. The aide stated that she believed placing the new patch first would prevent contamination, and did not perceive a risk in having two patches on simultaneously if the old one was removed immediately after. The Director of Nursing confirmed that the correct procedure was to remove the old patch before applying the new one to avoid multiple patches being present at the same time. Facility policy reviews indicated that staff were required to confirm medication orders and follow specific procedures for oral and transdermal medication administration, including removing old patches before applying new ones. The errors observed were due to staff not following these established protocols, either by substituting medications without proper verification or by not adhering to the correct sequence for patch application.
Facility Fails to Maintain Safe and Comfortable Environment Due to Drafty Windows
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in one of the rooms reviewed. Specifically, the windows in the room occupied by two residents were not properly sealed, allowing cold air to enter. Observations revealed that the windows, made of plexiglass, were not secured to the frame, resulting in a strong draft of cool air. This issue was noted during a time when the outside temperature was 38 degrees Fahrenheit, and the residents expressed feeling cold in their room. The residents involved had significant medical conditions that could be exacerbated by the cold environment. One resident, a female with severe cognitive impairment, anemia, and reduced mobility, reported feeling constantly cold and was observed wearing multiple layers of clothing to stay warm. The other resident, a male with severe cognitive impairment, dementia, and other health issues, also reported feeling a draft and expressed a desire for a warmer room. Both residents had their beds positioned approximately four feet away from the drafty window. Interviews with staff, including an LVN, maintenance personnel, and the DON, revealed that complaints about the cold room had been made previously, but the window issue had not been addressed. Maintenance staff acknowledged the need for window repairs, and the facility's grievance records confirmed prior complaints about the room's temperature. Despite the provision of extra blankets, the facility did not take timely action to repair the windows, which compromised the residents' comfort and safety.
Deficiency in Meal Quality and Palatability
Penalty
Summary
The facility failed to ensure that the food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. During a survey, it was observed that the lunch meal served on October 15, 2024, consisting of Beef and Macaroni Casserole, Squash Medley, Peach Shortcake, and Coffee/Hot Tea, was not up to standard. The test tray revealed that the pasta was mushy and bland, the squash was chewy and bland, and the juice was diluted and watery. Interviews with residents confirmed that the meals were subpar, and the lunch served on that day was described as "nasty," leading to a lack of desire to eat it. The Assistant Dietary Manager acknowledged that the cook overcooked the pasta and mentioned the need for more staff and training to improve meal service. The Dietary Manager, who had been at the facility for two weeks, noted that the cook was new and inexperienced, which contributed to the poor quality of the meal. Although no direct complaints were received from residents, there was an unusual increase in requests for alternative meals, such as grilled cheese sandwiches, indicating dissatisfaction with the main meal. The Dietary Manager recognized the need for higher meal quality to ensure residents receive adequate nutrition.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their dietary services, as observed during a kitchen inspection. Specifically, drinks poured into individual cups were stored in the refrigerator without lids or covers and lacked labels. Additionally, a pitcher of chopped fruit was found without a date or label, and a bin of flour was not completely sealed, with gaps in its cover. These lapses in food storage practices could potentially expose residents to foodborne illnesses. During an interview, the Assistant Dietary Manager acknowledged the oversight, stating that the chopped fruit was intended for use as a garnish but was unsure of how long it had been stored in the fridge. She confirmed that all kitchen staff were responsible for ensuring that drinks and flour bins were properly sealed and covered to prevent contamination. A review of the facility's food storage policy, dated December 1, 2011, indicated that all opened and bulk items should be stored in tightly covered containers, labeled, and dated, which was not followed in this instance.
Inappropriate Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infections. During an observation, a CNA was seen cleaning a female resident from back to front during perineal care, which is against the facility's policy of cleaning from front to back to prevent infection. The CNA also failed to change gloves after cleaning the resident and before touching clean items, which could lead to cross-contamination. The resident involved was a female with multiple health conditions, including stroke, end-stage renal disease, heart failure, and dementia. She was frequently incontinent of bowel and bladder and required substantial assistance with personal hygiene. Her care plan included interventions to monitor and change her promptly to prevent skin breakdown and infection. Interviews with facility staff, including CNAs and LVNs, confirmed that the facility's policy was to cleanse from front to back to prevent infections such as E. coli. The staff acknowledged the importance of changing gloves and performing hand hygiene to prevent the spread of germs. The facility's policy and procedure documents also emphasized the need for proper perineal care to maintain hygiene and reduce infection risk.
Medication Error Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7% due to two errors out of 28 opportunities. One of the errors involved a resident who was administered medications for high blood pressure outside of the physician's prescribed parameters. The resident, who had a history of multiple health issues including heart failure and hypertension, was given Isosorbide and Carvedilol despite having a blood pressure reading below the threshold set by the physician's orders. The medication aide, MA B, administered the medications to the resident even though the blood pressure reading was 107/71, which was below the hold parameter of 110/60. MA B acknowledged the mistake after the surveyor left and reported it to the nurse and unit manager. The medication aide had recently received training and had been working at the facility for a month. The error was recognized as a potential risk for causing low blood pressure and related complications. Interviews with the nursing staff, including LVN D and LVN E, confirmed that the error was reported and the resident's blood pressure was rechecked. The Director of Nursing (DON) emphasized the responsibility of the nursing staff to follow physician orders and the risks associated with administering medications outside of prescribed parameters. The facility's policy required medications to be administered as prescribed, and the management team was responsible for ensuring compliance through periodic audits and reeducation.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of blood pressure medications. A medication aide, identified as MA B, administered Isosorbide and Carvedilol to a resident despite the resident's blood pressure and heart rate being outside the ordered parameters. The resident's blood pressure was recorded at 107/71, and the heart rate was 67 beats per minute, which did not meet the required parameters of holding the medication if the blood pressure was less than 110/60 and the heart rate was below 60. The resident involved was an elderly male with a history of multiple health issues, including heart failure, hypertension, and the presence of a cardiac pacemaker. His care plan indicated a risk for fluctuations in blood pressure and other complications, with specific interventions to monitor blood pressure and administer medications as ordered. Despite these precautions, the medication aide proceeded with administering the medications, later realizing the error and notifying the nursing staff. Interviews with the nursing staff, including LVN D and LVN E, confirmed that the medication was given outside the ordered parameters. The staff acknowledged the potential risks associated with this error, such as hypotension and dizziness, which could increase the risk of falls. The facility's policies and procedures emphasized the importance of administering medications as prescribed and highlighted the common types of medication errors, including administration errors due to staff shortages or miscommunication.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinent care for a resident, leading to a potential risk of infection. The incident involved a resident who was frequently incontinent of bowel and bladder and required substantial assistance with personal hygiene. The resident had a history of multiple medical conditions, including stroke, end-stage renal disease, heart failure, and dementia, and was at risk for skin breakdown and infections. On the morning of October 16, 2024, CNA A provided incontinent care to the resident but did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before touching clean items such as the brief and clothing. This lapse in protocol was observed during the care process, where CNA A used cleansing wipes to clean the resident but failed to remove the soiled gloves before handling clean items, thereby risking cross-contamination. Interviews with the CNA and other nursing staff, including LVNs and the DON, confirmed the breach in infection control practices. The staff acknowledged that gloves should be removed and hands washed after the dirty part of the procedure to prevent the spread of infection. The facility's policies on perineal care and hand hygiene were reviewed, which clearly outlined the need for proper glove removal and handwashing to maintain infection control standards.
Failure to Maintain Clean and Sanitary Environment in Secured Unit
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in a secured unit. Observations revealed that the hallway, dining room, and activity room floors were dirty, sticky, and covered with dust, dirt, debris, and spilled beverages. A resident was seen walking barefoot on the dirty hallway floor, indicating a lack of cleanliness and sanitation. The Housekeeping Supervisor and Maintenance Manager acknowledged the issues, with the former noting that floor techs were responsible for cleaning and should mop at least once a day, while the latter admitted to not verifying the floor techs' work adequately. Interviews with facility staff revealed a lack of proper oversight and accountability for floor cleanliness. The Housekeeping Supervisor mentioned that floor techs were moved to the maintenance department three months prior, and the Maintenance Manager admitted to only conducting visual checks when complaints arose. The Director of Nursing was aware of the sticky floors and mentioned plans to address the issue with new cleaning products and flooring. The facility's Operations Policies and Procedures manual emphasized the need for a safe and sanitary environment, which was not upheld in this instance.
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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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