Park Manor Bee Cave

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences and to ensure staff were not distracted by personal earbuds while working on the floor. An 86-year-old female resident with morbid obesity, type 2 diabetes with neuropathy, generalized anxiety disorder, monoplegia of an upper limb, gait and mobility abnormalities, and a need for assistance with personal care was care planned as requiring substantial/maximal assistance of one staff member for transfers, including chair-to-bed transfers. On the date in question, this resident was seated at a dining table after lunch and expressed feeling tired and wanting to return to bed. Another resident reported that he repeatedly requested assistance from a CNA for this resident, but the CNA was wearing earbuds and appeared to be talking on her cell phone. According to this resident, the CNA responded that she heard him and would get to the resident when she got to her, then walked off without assisting and did not return. The reporting resident stated they waited approximately 35 minutes to one hour without assistance before he located another CNA, who then helped transfer the resident back to bed. The resident who needed assistance later stated she did not recall asking for help to go to bed but reported having seen a CNA on her hallway wear earbuds and said she did not like it because the CNA could not hear her requests for help and it made her feel ignored and not good. Multiple staff interviews confirmed that personal cell phone use and earbuds were not allowed on the floor because they could interfere with resident care, although the DON and ADM acknowledged there was no direct written policy addressing earbuds specifically. Several staff, including LVNs, CNAs, and a medication aide, stated they had been trained that personal cell phones and earbuds were not permitted while working. In contrast, the CNA identified in the incident stated she had not received training on cell phone or earbud use, admitted to using earbuds on the floor, particularly in the mornings, and acknowledged she might have been in a resident’s room with earbuds in or around her neck. Another CNA reported having seen this CNA wear earbuds “all the time” and not respond to residents’ requests for assistance because she was talking on her cell phone, and stated she had reported this behavior to a nurse. The DON stated she had not been aware of the specific incident but agreed that earbuds could prevent staff from hearing residents’ requests for help.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during kitchen meal preparation. During an observation in the kitchen, [NAME] A began preparing puree foods while wearing gloves, placed menu item food into a blender, and after pureeing bread removed the gloves, rinsed hands off, and put on new gloves without washing hands or using hand sanitizer. [NAME] A then washed, rinsed, and sanitized the blender, removed the gloves, discarded them, put on another pair, and continued pureeing additional menu item foods. The observation further showed [NAME] A finished pureeing pasta noodles and cleaned the blender while wearing the same pair of gloves. [NAME] A did not remove the gloves or perform proper hand hygiene between washing the blender and starting the next menu item of alfredo sauce. [NAME] A continued using the same pair of gloves until the alfredo sauce was finished. The KM stated that staff are trained on hand hygiene and the puree process, and described the expectation to wash hands between tasks and when entering the kitchen. Interviews with the KM, [NAME] A, the DON, and the ADM confirmed that proper hand hygiene was expected before service, after service, and between tasks in the kitchen. [NAME] A stated he had received training on hand hygiene and acknowledged that he kept the gloves on while preparing food after washing dishes because he forgot and was nervous. The record review included a document stating food employees must clean their hands before engaging in food preparation and during food preparation as often as necessary to prevent cross contamination when changing tasks, including before donning gloves for a food task.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to meet the needs of residents by not ensuring that medications and supplies in medication carts were accurately acquired, received, dispensed, and administered. Surveyors found expired or improperly labeled medications in 2 medication carts and identified deficiencies affecting 3 residents: Resident #44, Resident #45, and Resident #74. Resident #44, who had diagnoses including unspecified dementia, memory deficit following cerebral infarction, dysphagia, and major depression, had an active order for Refresh P.M. Ointment for dry eyes. On observation of the 600-hall med aide medication cart, surveyors found one tube of sterile lubricant eye ointment with an open date of 08/10/2025. The MA stated the ointment was expired and confirmed that eye ointments should be removed and discarded after one month of opening, but the tube remained in the cart past that timeframe. Resident #74, who had unspecified dementia, heart failure, chronic kidney disease, and type 2 diabetes mellitus, had an active order for Lantus insulin. Surveyors observed one insulin pen in the 100/300-hall nurses medication cart that was opened but not labeled with an open date. Resident #45, who had spinal stenosis, type 2 diabetes mellitus, and heart failure, had an active order for nitroglycerin sublingual tablets. Surveyors found one bottle of nitroglycerin tablets in the 100-hall nurses medication cart with an expiration date, and the DON stated staff were responsible for checking carts for expired medications each shift. The facility policy stated outdated, contaminated, or deteriorated medications were to be removed from stock and disposed of according to medication destruction procedures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure drugs and biologicals were stored in locked compartments and that access to medication and treatment carts was limited to authorized personnel for 1 of 6 medication and treatment carts. During an observation on 09/15/2025, a nurse's treatment cart located in the activity room area between the 100 and 200 halls was found unlocked and unattended, with the keys left on top of the cart. The surveyor observed multiple nursing staff pass the cart without securing it, and the cart drawers were opened to verify that it was unlocked. At 10:05 AM, the MDS nurse secured the cart and took the keys with her. During interviews, the MDS nurse stated she did not know who left the keys on the spare treatment cart and confirmed that leaving it unlocked could allow residents to access hazardous items such as sharp tools and strong cleaning solutions. LVN G stated nursing staff assigned to medication or treatment carts were responsible for locking them, and MA E stated she always secured her medication cart when not in use. The DON stated staff were expected to lock medication or treatment carts when walking away and not leave keys unattended, and she could not identify who was assigned to the spare treatment cart. Record review of the facility policy on Medication Access and Storage stated that only licensed nurses, the consultant pharmacist, and other lawfully authorized personnel may access medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized persons.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including transfers and incontinence care, was left in a geriatric chair for approximately nine hours without being changed or repositioned. The resident had significant medical conditions, including dysphagia, aphasia, tracheostomy status, chronic respiratory failure, muscle wasting, and was always incontinent of bowel and bladder. The care plan identified the resident as being at risk for pressure ulcers and required frequent turning, repositioning, and incontinence care, with interventions such as use of an alternating air mattress and pressure-reducing overlay. On the day of the incident, the occupational therapist transferred the resident from bed to a geriatric chair in the morning, confirming the brief was dry at that time. Video footage and documentation revealed that the resident remained in the chair from approximately 8:45 AM until around 6:00 PM, with no evidence of being transferred back to bed or having incontinence care provided during this period. Staff interviews confirmed that perineal care could not be performed while the resident was in the chair and that residents requiring mechanical lifts for transfers should not remain in a chair for extended periods without being repositioned or changed. Documentation logs and staff statements indicated gaps in care, with some staff unaware of the resident's status or assuming care had been provided by others. As a result of this lapse in care, the resident developed skin breakdown in the sacral area, as observed in photographs and confirmed by subsequent assessments. The resident's family raised concerns about the frequency of checks and new redness to the perineal area, leading to further review. The facility's own policies and staff interviews acknowledged that residents with similar needs should be checked and changed at least every two hours, and that prolonged periods in a chair without care could lead to skin integrity issues. The failure to provide timely incontinence care and repositioning directly contributed to the resident's skin breakdown.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a registered nurse (RN) failed to adhere to infection prevention and control protocols during tracheostomy care for a resident with significant medical needs, including anoxic brain damage, acute respiratory failure, dysphagia, and a tracheostomy. The RN did not perform hand hygiene before donning gloves or between glove changes, and handled various items in the environment, such as the medication cart and light switch, with contaminated gloves before providing direct care. The RN also failed to sanitize the bedside table before placing sterile supplies and placed sterile items on a surface that was not properly prepared, with other non-sterile items present. During the tracheostomy care procedure, the RN used a yankauer suction device that was tested in an open, unlabeled, and undated container of clear fluid at the resident's bedside, rather than using sterile water or saline as required. The yankauer was then used to attempt suctioning and subsequently returned to its packaging without proper disinfection. The RN also donned sterile gloves without performing hand hygiene, allowed the gown to touch the outside of the gloves, and turned away from the sterile field, all of which compromised the sterility of the procedure. Additionally, the RN did not monitor the resident's oxygen saturation during care, as ordered, and adjusted the oxygen flow without following established protocols. Interviews with other staff members, including licensed vocational nurses, certified nursing assistants, the assistant director of nursing, and the director of nursing, confirmed that the observed practices did not align with facility policy or accepted standards for infection control. Staff acknowledged that hand hygiene should be performed before and after care, between glove changes, and before handling sterile supplies. The facility's in-service records showed no recent training on tracheostomy care, and the policies reviewed emphasized the importance of hand hygiene and proper handling of sterile supplies, which were not followed in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and appropriate respiratory care to residents requiring tracheostomy care, as evidenced by multiple observed lapses in infection control and adherence to professional standards. For three residents with tracheostomies, staff did not follow proper procedures during tracheostomy and suctioning care. Specifically, a registered nurse (RN) was observed testing a yankauer suction device in an open, unlabeled, and undated container of water at the bedside prior to suctioning a resident's tracheostomy, rather than using sterile saline as required. The same RN did not monitor the resident's oxygen saturation during tracheostomy care, despite physician orders to do so, and continued with care even when the yankauer was not functioning properly. The RN also failed to perform hand hygiene at critical points, such as before donning gloves, between glove changes, and after touching potentially contaminated surfaces, and did not maintain the sterility of the field or supplies during the procedure. Observations revealed that open containers of clear liquid, which were undated and unlabeled, were present at the bedsides of multiple residents with tracheostomies. These containers were used for testing or priming suction devices, contrary to infection control protocols that require the use of sterile, single-use saline or water. Staff interviews confirmed inconsistent understanding and application of proper tracheostomy care procedures, including the use of sterile technique, hand hygiene, and the correct method for testing suction equipment. Some staff believed it was acceptable to use open water at the bedside, while others stated that only sterile saline should be used and that containers should be covered, dated, and replaced every 24 hours. Record review showed that residents had physician orders for regular tracheostomy care, suctioning, and oxygen saturation monitoring, and care plans aimed to prevent infection and maintain adequate oxygenation. However, the observed practices did not align with these orders or with the facility's own policies, which specify that tracheostomy care is a sterile procedure and require hand hygiene before and after care, as well as the use of sterile supplies. Facility in-service records indicated that no recent training on tracheostomy care had been conducted. Interviews with facility leadership, including the DON and ADON, confirmed that the observed practices did not meet facility expectations or policy requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program as required, resulting in the omission of timely submission of the Nursing Facility Specialized Services (NFSS) request for a resident with multiple complex diagnoses, including aphasia, chronic kidney disease, muscle wasting, generalized weakness, dysphagia, malnutrition, anemia, and a history of cerebral infarction. The resident's PASRR Level II evaluation recommended specialized services such as physical therapy (PT), occupational therapy (OT), and speech therapy (ST), along with specialized assessments for each therapy. However, the facility did not submit a complete and accurate NFSS request in the LTC Online Portal within the required 20 business days after the Interdisciplinary Team (IDT) meeting, instead submitting it 217 days later. Interviews with facility staff revealed a lack of clarity regarding the required timeframe for NFSS submission, with the Director of Rehabilitation (DOR) acknowledging the importance of timely completion to maintain therapy services and the Administrator expressing uncertainty about the process. Record reviews confirmed that the recommendations from the PASRR evaluation were not incorporated into the resident's assessment, care planning, or transition of care as required, and duplicative testing and efforts were not avoided. This failure was cited under 26 TAC Chapter 554, Subchapter BB S554.2704(i)(7).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately notify the resident's physician when there was a significant change in a resident's mental and psychosocial status, specifically following a self-harm attempt. The resident, a 52-year-old woman with a history of bipolar disorder, generalized anxiety disorder, mild cognitive impairment, paranoid schizophrenia, schizoaffective disorder, paranoid personality disorder, and legal blindness, was found by staff with the belt of her robe tied around her neck and attached to her bed rail. The incident was discovered by a CNA, who alerted the RN on duty. The RN assessed the resident, found no injuries or changes in vital signs, and contacted the on-call ADON, who instructed the RN to initiate 15-minute checks. However, the resident's physician or nurse practitioner was not notified of the incident at that time. Documentation and interviews revealed that the resident had previously shown no signs of suicidal ideation or self-harm in recent assessments and psychological notes. After the incident, the resident was placed on increased supervision, including 15-minute checks and later 1:1 monitoring. Multiple staff interviews confirmed that the RN did not consider the event an emergency due to the resident's stable condition and lack of physical injury, and therefore did not notify the provider. The ADON, upon being informed, was not told the full extent of the incident and also did not contact the provider. The provider was only notified the following morning, after further review by the DON. Staff interviews indicated that they had received in-service training on recognizing and responding to signs of depression, suicidal ideation, and self-harm, and that the expectation was to notify the provider immediately in the event of a self-harm attempt. The facility's policy also required immediate notification of the physician in urgent situations. Despite these protocols, the failure to notify the provider immediately after the self-harm attempt constituted a deficiency in ensuring timely medical intervention and continuity of care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and appropriate respiratory care for a resident with complex respiratory needs, including chronic respiratory failure, COPD, and heart disease. Despite physician orders specifying oxygen therapy parameters and the need to avoid excessive oxygen due to CO2 retention, nursing staff did not consistently document the oxygen flow rate or the resident's response to oxygen therapy. The medical record lacked ongoing monitoring of oxygen saturations, even as the resident experienced repeated drops below 92%, increased shortness of breath, and a critically high CO2 lab value. The resident's ability to participate in therapy declined, and she developed new symptoms such as fatigue, headache, and lower extremity edema in the days leading up to her hospitalization. Interviews and record reviews revealed that staff did not maintain adequate documentation or monitoring practices as required by facility policy and professional standards. The resident's care plan and physician orders called for close observation of respiratory status and oxygen therapy, but nurses failed to record essential information such as the method and flow rate of oxygen delivery, as well as the resident's response to interventions. Multiple staff members, including the DON and NP, acknowledged the importance of this documentation and monitoring, but it was not consistently performed or recorded in the electronic medical record. The resident ultimately experienced a significant decline, with oxygen saturations dropping as low as 54% and visible signs of respiratory distress, prompting emergency transfer to the hospital. Hospital records confirmed diagnoses of acute and chronic hypoxic and hypercapnic respiratory failure and CHF exacerbation. Family and therapy staff reported concerns about the resident's deteriorating condition and the lack of timely escalation or intervention by facility staff. The facility's own oxygen administration policy required documentation of oxygen therapy details and resident response, which was not followed in this case.

Penalty

Inspection fine: $6,338

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering prescribed medications, including Keppra (anticonvulsant), Buprenorphine (for pain), and Buspirone (for depression and anxiety), until five hours after the scheduled administration time. The resident, a cognitively intact female with diagnoses of cerebral palsy, major depressive disorder, post-traumatic stress disorder, chronic pain, and generalized anxiety disorder, was scheduled to receive her morning medications at 8:00 AM, but they were not administered until after 12:55 PM. Record review showed that the resident’s medication administration records (MAR) reflected significant delays in the administration of all three medications. Interviews with the resident revealed that late medication administration was a frequent occurrence, causing her increased pain, anxiety, and uncontrollable leg spasms. She reported being unable to function or get out of bed and described the experience as extremely uncomfortable and distressing. Staff interviews indicated that the ADON, who was new to the facility and being trained by the DON, was responsible for the late administration on the day in question. The ADON attributed the delay to the training process and the time spent explaining medications to residents. The facility’s policy required medications to be administered within 60 minutes of the scheduled time, but this was not followed. Both nurse practitioners interviewed confirmed that such a delay could result in increased pain and anxiety for the resident, especially given her medical conditions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's transfer status was accurately reflected in the Minimum Data Set (MDS) assessment. Specifically, the MDS for a resident did not indicate the need for a mechanical lift, despite the resident requiring such assistance due to her inability to bear weight. This discrepancy was identified during a review of the resident's records, which included an admission MDS assessment and a care plan that did not align with the resident's actual needs as observed in a later mobility assessment. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that the resident required a mechanical lift with two staff members for transfers. The DON acknowledged the responsibility of the nursing department to ensure that the MDS and care plan accurately reflected the resident's transfer status and emphasized the importance of maintaining up-to-date and accurate assessments for the safety and care of residents. The facility's policy on Nursing Services - ADLs also highlighted the need for accurate assessments and appropriate interventions based on residents' needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not accurately reflect the resident's transfer status, as it failed to indicate the requirement for a mechanical lift. This discrepancy was identified during a review of the resident's admission MDS assessment and care plan, which showed inconsistencies in the documentation of the resident's transfer needs. The resident, a female with a history of a displaced comminuted fracture of the right femur, unsteadiness on feet, and muscle wasting, was assessed to require total assistance with transfers. However, the care plan did not reflect the need for a mechanical lift, which was confirmed by an LVN during an interview. The DON acknowledged the responsibility of the nursing department to ensure that the MDS and care plan matched the resident's transfer status and emphasized the importance of accurate documentation for safety reasons.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor the residents' rights to retain and use personal possessions, as well as to be treated with respect and dignity. This deficiency was identified for three residents who were reviewed for rights. The former administrator of the facility conducted searches of the residents' rooms without introducing herself or obtaining permission from the residents. Resident #56 reported that the former administrator searched her room and confiscated personal items such as body spray and lotion without prior notification or consent. Resident #68 stated that the former administrator entered her room without permission, searching for e-cigarettes, which she did not possess. Resident #74 recounted an incident where the former administrator entered her room without knocking or introducing herself, searching for a missing black purse, which led to a misunderstanding and feelings of insult. The residents involved in these incidents had intact cognition, as indicated by their BIMS scores, and were capable of understanding and responding to the situation. The facility's actions placed the residents at risk of misappropriation and feelings of indignity. The ADM acknowledged that searching a resident's room required permission and that confiscating items without consent was a violation of residents' rights. Despite a request, the facility did not provide a policy on Personal Privacy by the time of the survey exit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consider and act upon the grievances and recommendations of the resident council, as evidenced by the lack of documented responses to concerns raised during meetings from May 2024 through June 2024. The resident council minutes highlighted several issues, including dietary concerns such as lack of condiments, overcooked and unhealthy food, and communication barriers in the kitchen. Maintenance issues were also noted, with reports of inadequate repairs and residents having to clean their own air conditioning filters. Nursing concerns included understaffing, with CNAs being overworked and residents expressing dissatisfaction with the care provided. During a resident council meeting in August 2024, residents expressed frustration over the facility's failure to address their concerns, stating that they were often told issues were being worked on but saw no changes. They reported feeling powerless and referred to themselves as inmates rather than residents, indicating a significant level of dissatisfaction with the facility's management. The residents noted that the facility had experienced a high turnover of administrators, which contributed to the lack of continuity in addressing their grievances. Interviews with facility staff, including the Activities Director (AD) and the new Administrator (ADM), revealed that there was no formal system in place for documenting and resolving resident council concerns. The AD stated that she had been responsible for recording the minutes and passing concerns to department heads, but there was no follow-up or feedback provided to the residents. The ADM, who had just started, acknowledged the need for a system to ensure that resident concerns were addressed and communicated back to the council. The facility's policies on grievances and resident council meetings were not effectively implemented, leading to residents feeling ignored and their preferences not being honored.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive person-centered care plans for five residents, which included measurable objectives and time frames to address their mental and psychosocial needs. The care plans lacked specific interventions related to activities that the residents enjoyed, which placed them at risk of not having their recreational and social needs met. The residents involved had various diagnoses, including major depressive disorder, dementia, anxiety, and cognitive communication deficits, which necessitated personalized care plans to address their unique needs. Resident #14, a female with intact cognition, had no care planning for activities despite her diagnoses of major depressive disorder and dementia. Her care plan only included general goals such as maintaining social contact and encouraging family involvement. Similarly, Resident #32, with moderate cognitive impairment, had a care plan that did not specify activities she enjoyed, despite being dependent on staff for social interaction and cognitive stimulation. Resident #74, with intact cognition and multiple diagnoses including anxiety and depression, also lacked activity-related care planning, with her care plan focusing on psychosocial well-being without specific interventions. The facility's MDSN, who was new to the position, acknowledged the lack of personalized care plans and stated that the care plans should have been specific and consistent with the facility's policy. The ADM also recognized that care plans should have been personalized and involved the interdisciplinary team. The facility's policy emphasized the need for comprehensive person-centered care plans that include measurable objectives and time frames to meet residents' needs, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate respiratory care for three residents by not ensuring that their oxygen tubing and humidifier bottles were dated and changed weekly as per the facility's policy. This oversight was observed in Residents #20, #46, and #298, all of whom required oxygen therapy due to various medical conditions such as COPD, chronic respiratory failure, and other serious health issues. The lack of dating on the equipment made it impossible to verify compliance with the weekly change requirement, potentially exposing the residents to the risk of respiratory infections due to contamination. Resident #20, a male with multiple diagnoses including COPD and obesity, was observed with undated oxygen tubing and humidifier bottle, despite orders to change them weekly. Similarly, Resident #46, a female with COPD and chronic respiratory failure, and Resident #298, a male with a tracheostomy and severe impairments, were also found with undated respiratory equipment. Interviews with the DON and ADM confirmed the importance of timely changes to prevent infections, yet the facility's policy did not address the need for labeling or dating the equipment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper storage of drugs and biologicals in the Hall 200 medication storage room. During an observation, it was found that there were expired medical supplies, including two I.V. PICC Line Stat lock Plus Stabilizations devices, one expired Covid-19 test, and three expired laboratory bacterial swabs. These items were not removed from the medication storage room as required by the facility's policy. The presence of these expired items indicates a lapse in the facility's adherence to its medication storage policy, which mandates the removal and proper disposal of expired supplies. Interviews with staff, including an LVN and the DON, revealed that the use of expired items poses risks such as ineffective treatment, inaccurate lab results, and increased infection risk. The ADM confirmed that the policy for expired medical supplies is to dispose of them according to the manufacturer's recommendations. The facility's policy on medication storage, although undated, clearly states that expired or deteriorated medications should be removed and disposed of properly. The failure to adhere to this policy could potentially compromise resident safety and care quality.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a nourishing snack was served at bedtime when more than 14 hours elapsed between the evening meal and breakfast the following day for residents in the 100, 200, and 300 halls. On the evening in question, dinner was served at 5:15 PM, and breakfast was not served until 8:00 AM the next day, resulting in a 14.75-hour gap between meals. Although a snack tray containing sandwiches, bananas, oatmeal cream pies, pudding, juice, and peanut butter crackers was placed at the nurse's station, it was positioned behind a wall where residents could not see it. Consequently, the snacks were not offered to any residents, and no residents requested them. Interviews with CNAs and residents revealed that snacks were not regularly offered at bedtime, and residents were unaware of their availability. The CNAs stated that they did not typically offer snacks to each room, and if all residents wanted a snack, there would not be enough for everyone. The Dietary Manager acknowledged that snacks should have been offered due to the extended time between meals, and the Assistant Director of Nursing confirmed that snacks should be more accessible to residents. The facility did not provide a policy on snacks by the time of the survey exit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the failure to promptly replace flickering lightbulbs in their rooms. Resident #56, a female with intact cognition, reported that the middle light bulb in her vanity had been flickering for a couple of months, despite multiple reports to aides and nurses. The maintenance log indicated that the issue was marked as closed, yet the problem persisted, leading the resident to ask a CNA to unscrew the bulb to stop the flickering. Similarly, Resident #40, also with intact cognition, experienced a flickering overhead light in her room for months, which she reported, but no action was taken to resolve the issue. During a Resident Council meeting, multiple residents expressed dissatisfaction with the facility's maintenance of the physical environment, citing a lack of response to their concerns. The maintenance staff acknowledged having a list of rooms needing new lightbulbs and mentioned a delay in ordering supplies due to administrative transitions. The new administrator recognized the importance of promptly addressing such maintenance issues to prevent potential dangers, such as falls, but the facility failed to provide a policy on maintaining a safe, clean, comfortable, and homelike environment by the time of the survey exit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, who was unable to perform activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not provide scheduled showers to a resident from July 22, 2024, to August 8, 2024. The resident, a female with diagnoses including rheumatoid arthritis, chronic pain syndrome, major depressive disorder, unsteadiness on feet, dementia, cognitive communication deficit, and muscle weakness, was totally dependent on caregivers for bathing. Despite being scheduled for showers three times a week, records indicated that showers were not provided on multiple occasions, and one instance was marked as a refusal. Observations and interviews revealed that the resident had greasy, mussed hair, indicating a lack of proper hygiene care. Staff interviews showed confusion and lack of clarity regarding who was responsible for providing the resident's showers. The Director of Nursing acknowledged issues with the shower schedule but had not yet implemented a new system to address the problem. The facility's administration confirmed that residents should receive showers according to the schedule and that refusals should be managed by offering showers at alternative times. However, a facility policy on ADL care was not provided by the time of the survey exit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an ongoing program of activities tailored to the interests and needs of a resident, as required by the comprehensive assessment and care plan. The resident, a male with multiple medical conditions including cognitive communication deficit and reduced mobility, was not provided with activities from August 6 to August 8, 2024. Despite having a BIMS score indicating intact cognition, the resident was completely dependent on staff for transfers and required assistance for activities. His care plan indicated a need for cognitive stimulation and social interaction, yet the facility did not document any activities for him from January to August 2024. Interviews revealed that the resident had not participated in any activities or been offered specific activities during the survey period. The resident expressed a desire to spend time outside, which he had not done in a year except for medical appointments. The Director of Nursing and the Activity Director acknowledged the lack of activities provided to the resident, with the Activity Director noting that the resident mostly entertained himself. The Administrator recognized the importance of tailored activities and outdoor time for the resident but confirmed that the Activity Director needed additional support to meet these needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not follow the wound care orders for a resident with a right arm skin tear. The resident's care plan required monitoring and documentation of the wound's location, size, and treatment, with wound care to be performed as ordered. However, the treatment was not administered as scheduled on a specific date, despite being documented as completed in the Treatment Administration Record (TAR). The resident, a female with a history of left femur fracture, left side paralysis following a stroke, diabetes, malnutrition, and anxiety, was observed with a bandage dated several days prior to the missed treatment. The Wound Nurse (WND) admitted to not performing the treatment and mistakenly signing the TAR. The Director of Nursing (DON) and the Administrator (ADM) emphasized the importance of following doctor's orders and accurately documenting care to prevent negative outcomes such as infection and disease spread. The facility's policy on wound management requires adherence to physician-ordered treatments and evaluation if no improvement is observed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's pressure-relieving low air loss mattress was consistently plugged in and functioning, which is crucial for preventing and managing pressure ulcers. The resident, an elderly female with dementia and a stage 4 pressure ulcer on her sacral region, was dependent on staff for all activities of daily living and was at high risk for skin breakdown due to immobility and incontinence. Despite having a care plan in place that included the use of a low air loss mattress as a pressure-relieving intervention, the mattress was found unplugged and non-functional during an observation. The deficiency was identified when the wound nurse discovered that the mattress's power cord was not plugged into the wall outlet, rendering the mattress inoperable. This oversight was noted during a routine check, and the mattress was subsequently plugged in, restoring its functionality. Interviews with staff revealed that while they were trained to ensure the mattress was plugged in and functioning, there were no specific safeguards or protocols in place to regularly verify the power supply to the mattress. The lack of a functioning low air loss mattress placed the resident at risk of worsening her existing pressure ulcer and developing new ones. Staff interviews indicated that while they were aware of the importance of the mattress and the need for regular repositioning of the resident, there was a gap in ensuring the mattress was always operational. The facility's policies and training emphasized the use of pressure-relieving devices, but the failure to maintain the mattress's functionality highlighted a critical lapse in care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pharmaceutical services for a resident, resulting in a deficiency related to the management of controlled drugs. Specifically, the facility did not remove a discontinued medication, APAP/Codeine Tab 300-30 mg, from the medication cart after it was discontinued. This oversight led to one tablet being unaccounted for, as the medication was still present in the narcotics drawer despite being discontinued. The discrepancy in the narcotic log, with an illegible signature and crossed-out entries, further complicated the tracking of the medication's administration. The resident involved was a female with multiple medical conditions, including spinal stenosis, radiculopathy, and chronic pain syndrome, who had been receiving pain management medications. Despite the discontinuation order, the medication remained accessible, posing a risk of drug diversion or administration errors. Interviews with staff revealed a lack of a specific system to ensure discontinued medications were properly removed, and the Director of Nursing acknowledged the absence of a method to track signatures on the narcotic log, which contributed to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate the food preferences of a resident, identified as Resident #60, who was reviewed for food preferences. Despite having iced tea listed as a dislike on his meal ticket, Resident #60 received iced tea on his lunch tray on three consecutive days. This oversight occurred on 08/06/24, 08/07/24, and 08/08/24. The resident's medical history includes cerebral infarction, hemiplegia, major depressive disorder, chronic kidney disease stage four, and cognitive communication deficit. The resident's BIMS score indicated moderate cognitive impairment, and he required supervision with eating. Interviews revealed that the dietary aide responsible for preparing the drinks spoke only Spanish, and there was uncertainty about her ability to read English on the meal tickets. The dietary manager stated that he explained the importance of honoring resident preferences to the kitchen staff, emphasizing that dislikes were particularly important. The administrator mentioned that it was the dietary manager's responsibility to ensure preferences were followed, and the floor nurse was also responsible for checking the trays for accuracy. The facility's policy on Food and Nutrition Services emphasizes the importance of meeting residents' nutritional needs and preferences, including dislikes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during wound care for a resident. The resident, an elderly female with severe cognitive impairment and multiple health issues including a Stage 4 pressure ulcer, was observed receiving wound care without the healthcare worker changing gloves and sanitizing hands between the removal of soiled dressings and the application of clean ones. This lapse in protocol occurred during the care of both the resident's coccyx pressure ulcer and her feeding tube site, despite the facility's policy requiring hand hygiene before, during, and after wound care. Interviews with the wound nurse, Director of Nursing (DON), and Administrator (ADM) confirmed the breach in protocol. The wound nurse admitted to forgetting to perform hand hygiene between the dirty and clean steps, acknowledging the risk of cross-contamination and potential infection. The DON and ADM reiterated the importance of hand hygiene in preventing infections, aligning with the facility's policy that emphasizes hand hygiene as a critical measure to prevent the spread of infection. The facility's policy, last revised in December 2023, mandates the use of an alcohol-based hand rub before handling dressings and between moving from contaminated to clean body sites.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter, leading to a deficiency in care. The resident, a male with quadriplegia and a neurogenic bladder, was admitted with a history of urinary tract infections and was on antibiotic therapy. Despite physician orders to secure the catheter with a leg strap or anchor to prevent trauma and ensure proper catheter care every shift, the resident reported that the catheter was not secured, and he frequently experienced UTIs. During an observation, it was noted that the resident's Foley catheter was not secured with a leg strap as ordered, and CNA B improperly performed catheter care by wiping in the wrong direction, which could introduce infection. The resident expressed discomfort and concern about the catheter pulling out, and it was observed that the urethral area had some split or tear. RN A confirmed the absence of a stat-lock to secure the catheter and acknowledged that central supply was aware of the shortage. The Director of Nursing (DON) stated that catheter care should be performed every shift and emphasized the importance of securing the catheter to prevent trauma. Despite the facility's policy requiring proper catheter care and infection control measures, the necessary supplies were found in the nurse's supply closet, indicating a failure in ensuring their availability and use. This deficiency highlights the facility's failure to adhere to its own policies and physician orders, resulting in inadequate care for the resident.

Penalty

Inspection fine: $13,270

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide effective pain management for two residents, resulting in them experiencing prolonged periods of excruciating pain. Resident #1, a cognitively intact female with chronic pain syndrome, missed multiple doses of her prescribed opioid medication due to it being unavailable. This occurred on two separate occasions, with the resident missing five doses from July 5 to July 7 and eleven consecutive doses from July 14 to July 17. Despite the resident's high pain ratings, ranging from 7 to 10, the nursing staff failed to ensure the timely reordering and administration of her medication. Similarly, Resident #2, who has severe cognitive impairment and chronic pain, went without her prescribed Fentanyl patch from July 7 to July 10 and again on July 16 due to the medication being unavailable. The resident's pain scale during these periods reached a high of 8. The nursing staff did not take adequate steps to reorder the medication in a timely manner, and the resident was left without her pain management regimen, leading to unnecessary suffering. Interviews with the nursing staff revealed a lack of communication and follow-up regarding the reordering of medications. Several nurses admitted to not contacting the pharmacy or the nurse practitioner when medications were unavailable, relying instead on assumptions that others had taken care of the issue. The facility's Director of Nursing acknowledged that it was not acceptable for residents to go without their pain medications and emphasized the importance of reordering medications when there were seven days remaining. The facility's failure to adhere to its pain management policy resulted in an Immediate Jeopardy situation, highlighting significant lapses in medication management and communication among the staff.

Removal Plan

• Medical Director was notified of the IJ. The Pharmacist was notified of the IJ.
• Resident #1 and #2 had pain assessments completed and medication audited by a sister facility DON.
• 100% audit of every MAR/TAR for pain triggers and that appropriate interventions were completed by a sister facility DON. If pain triggers are noted the auditing nurse will ensure that the appropriate pain meds are available and administered per MD orders or notify the MD to obtain any needed additional orders and ensure the patient is reassessed immediately by the nursing staff and pain is no longer triggering in the assessment.
• 100% audit that all ordered pain medications are in house, and facility has minimum seven-day supply. Any needed re-orders were initiated by a sister facility DON. Pain medications are stored on nursing and CMA carts and in the e-kits. If a pain medication is not available CMA's are to notify the charge nurse and licensed nurses are to notify the MD or NP immediately.
• In-servicing began for Licensed Nurses and CMA's to include reordering of medications and what to do if a medication is not available and will be completed by DON or designee. Any Nurse or CMA who has not received the in-service will not be allowed to work until in-service has been completed. Any agency, PRN or new CMA or licensed nurse will be in-serviced prior to their shift. In-service completed by DON/Designee. The DON was in-serviced and quizzed by regional consultant via phone. The staffing schedule will be assessed daily prior to each shift by the ED/DON or designee to ensure compliance. All staff will be in-serviced regarding the process of re-ordering pain medications and signs and symptoms of pain in residents upon hire, annually, and as needed by administrator/DON/designee and will be ongoing.
• DON or Designee will monitor MAR/TAR and pain medications stored on carts 2 times per week to ensure pain medication availability. This practice will be ongoing.
• Train the trainer in-servicing was given to the ED, DON, and RN/ED Cluster Partners by the regional consultant. The training consisted of Process for Reordering Pain Medications, Signs and Symptoms of Pain in Residents.
• Summary of IJ and corrective action to be reviewed by QAPI Committee weekly or until substantial compliance established and continue monthly to ensure ongoing compliance.

Penalty

Inspection fine: $13,270

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in an Immediate Jeopardy situation. Resident #1, a cognitively intact female with chronic pain syndrome, missed multiple doses of her prescribed opioid medication due to unavailability. This led to her experiencing severe pain, with documented pain scales reaching a maximum of 10. The facility's staff, including several Licensed Vocational Nurses (LVNs), failed to reorder the medication in a timely manner, and there was a lack of communication with the pharmacy and the Nurse Practitioner (NP) to resolve the issue. Resident #2, a female with severe cognitive impairment and chronic pain, also experienced a lapse in her pain management regimen. She went without her prescribed Fentanyl patch for several days due to the medication being unavailable. The Registered Nurse (RN) responsible for her care did not contact the NP to address the issue promptly, resulting in the resident experiencing significant pain, with pain scales reaching a maximum of 8. The NP was not informed of the medication shortage in a timely manner, which contributed to the delay in resolving the issue. The facility's failure to reorder medications when a seven-day supply remained, as outlined in their Controlled Medications Policy, contributed to the residents' prolonged pain and suffering. Interviews with staff revealed a lack of adherence to the policy and inadequate communication among staff members and with the pharmacy. The Director of Nursing (DON) acknowledged that it was not the facility's expectation for residents to go without pain medications and recognized the potential negative outcomes of such failures.

Removal Plan

• Medical Director was notified of the IJ. The Pharmacist was notified of the IJ.
• Resident #1 and #2 medications audited by a sister facility DON.
• 100% audit that all ordered pain medications are in house, and facility has minimum seven-day supply and any needed re-orders are completed by sister facility DON.
• In-servicing for Licensed Nurses and CMA's to include reordering of medications and what to do if a medication is not available. All nurses and CMA's will receive in-service training. Any Nurse or CMA who has not received the in-service will not be allowed to work until in-service has been completed. Any agency, PRN or new CMA or licensed nurse will be in-serviced prior to their shift. In-service completed by DON/Designee. If medication is not available CMA's are to notify the charge nurse and licensed nurses are to notify the MD or NP immediately. The staffing schedule will be assessed daily prior to each shift by the ED/DON or designee to ensure compliance.
• DON or Designee will monitor MAR/TAR and pain medications stored on carts weekly to ensure pain medication availability. This will practice will be ongoing.
• DON/ADON or Designee will review order listing report daily to ensure medication availability. This process will be ongoing.
• DON/ADON or Designee will review pain medication every Wednesday and order any that have a supply of 7 days or less. This process will be ongoing.
• Train the Trainer in-servicing was given to the ED, DON, and RN/ED Cluster Partners by the regional consultant.
• Summary of IJ and corrective action to be reviewed by QAPI Committee weekly or until substantial compliance established and continue monthly to ensure ongoing compliance.