Park Place Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Georgetown, Texas.
- Location
- 121 Fm 971, Georgetown, Texas 78626
- CMS Provider Number
- 675915
- Inspections on file
- 53
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 8 (6 serious)
Citation history
Health deficiencies cited at Park Place Care Center during CMS and state inspections, most recent first.
A resident with prior stroke, hemiplegia, and documented fall risk experienced an unwitnessed fall, after which an LVN assessed him and gave PRN pain medication but did not immediately notify the physician, DON, or family, did not initiate neuro checks, and did not complete timely incident documentation. Over the following days, staff observed that the resident became more withdrawn and less active, and an NP later identified bruising and pain in the resident’s right arm and ordered imaging. A subsequent unwitnessed fall was reported and neuro checks were started, but fall interventions were limited and delayed. Imaging later revealed a shoulder dislocation and a nondisplaced hip fracture requiring surgical repair, and surveyors cited the facility for failing to immediately consult the physician and respond appropriately to the resident’s fall and significant change in condition.
A resident with stroke-related hemiplegia, aphasia, and significant mobility deficits experienced two unwitnessed falls while attempting transfers between bed, wheelchair, and bathroom. After the first fall, an LPN assessed the resident and gave PRN pain medication but did not complete an incident report, initiate neuro checks, notify the NP, DON, or family, or document the fall until much later. No new fall-prevention interventions or increased monitoring were implemented despite the resident becoming more withdrawn and less mobile. Following a second fall, staff notified the NP and responsible party and started neuro checks, but only repeated an existing intervention to encourage call-light use, and therapy evaluation was delayed. Subsequent imaging revealed soft tissue injuries and a nondisplaced proximal femur fracture requiring surgery, and interviews confirmed that required fall protocols, timely monitoring, and care plan updates were not followed.
A resident with severe cognitive impairment and mobility needs exited the facility unsupervised through a hallway door with a malfunctioning alarm system, crossed a parking lot and busy road, and was found in the median. The care plan did not address elopement risk, and staff were unaware of the resident's exit until notified by a passerby. The incident was classified as Immediate Jeopardy due to inadequate supervision and unreliable exit alarms.
A deficiency occurred when controlled medications awaiting destruction, along with the Drug Destruction Log, went missing from a locked cabinet. The keys to the cabinet were inconsistently managed between the DON and ADON, and the office code was accessible to multiple staff. The process for counting and securing discontinued narcotics was not consistently followed, and the DON was unfamiliar with the facility's medication disposal policy. As a result, an unknown quantity of controlled medications and documentation could not be accounted for.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as evidenced by gaps in staff training, oversight, and reporting mechanisms. This created an environment where such incidents could occur without prompt detection or intervention.
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.
Two residents with cognitive impairment were involved in an alleged incident of resident-to-resident abuse, which was not thoroughly investigated or reported to the State Survey Agency within the required five working days. Although the incident was documented and some immediate actions were taken, the Provider Investigation Report was submitted nearly three weeks late, contrary to facility policy and state regulations.
The facility did not maintain a clean and comfortable environment, as mold was found under the wallpaper in the rooms of three residents, despite staff being aware of the issue for several months and failing to take action. Affected residents had significant medical conditions and some were unable to communicate their needs. The facility's policy requiring a safe and sanitary environment was not followed.
The facility did not complete or document thorough investigations for two residents following allegations of neglect and injury of unknown origin. Required staff interviews were missing, and findings were not reported to the state agency within the mandated five-day period, contrary to facility policy.
A resident with multiple chronic conditions was transferred to police custody without receiving a written discharge notice, as required by facility policy. Staff relied on verbal notifications and voicemails to inform the resident's representative and the ombudsman, but did not provide written documentation of the discharge or its reasons. The facility cited its policy on registered sex offenders as the basis for refusing the resident's readmission after the arrest.
A resident with Alzheimer's and dementia was left unattended for six hours, resulting in a fall and injury. CNA A and LVN B failed to perform required checks, leaving the resident on the floor overnight. The facility's video footage confirmed the neglect, leading to the termination of both staff members.
A facility failed to ensure proper PICC line management and IV fluid administration for two residents, leading to deficiencies. One resident's PICC dressing was not changed for over three weeks, and there were no orders for flushing or monitoring the site. Another resident lacked orders for PICC care and was later hospitalized with sepsis. Nursing staff were not adequately trained, contributing to these issues.
A resident with a PICC line did not receive proper care due to the facility's failure to ensure nurses were competent in central line procedures. The resident's central line was not monitored, flushed, or had its dressing changed according to policy, leading to potential risks of infection and improper medication administration. Interviews revealed that the nursing staff lacked training and competency in central line care.
The facility failed to maintain sanitation and food safety standards in the kitchen, with issues such as mold in the ice machine, dirty equipment, unlabeled and undated food items, and inadequate hair restraints. Leaking handwashing sinks and a lack of proper cleaning logs were also observed, potentially putting residents at risk of foodborne illness.
The facility failed to maintain infection control standards, as observed in wound care and catheter care practices. An LPN did not label wound dressings for several residents, and another LPN provided catheter care without wearing required PPE. These actions increased the risk of infection transmission among residents with chronic wounds and indwelling catheters.
A resident with significant physical impairments was unable to reach her call light bell, which was found on the floor, out of reach. This prevented her from calling for assistance when in pain. Staff confirmed that call light bells should be within reach, but the facility lacked a specific policy on their placement. The deficiency highlights a failure to accommodate the resident's needs, potentially leading to unmet needs and psychosocial harm.
A resident with multiple medical conditions was unable to access her personal funds in time for a dental appointment due to the facility's inadequate management of trust funds. The BOM was unavailable, and the process for special requests was not clearly communicated, leading to the cancellation of the appointment. The facility's policy required funds to be accessible during business hours, but this was not effectively implemented.
Two residents reported that their packages were often opened before they received them, violating their rights. The facility's staff, including the BOM and ADM, acknowledged that packages should be delivered unopened, but any staff member could receive them, leading to inconsistencies. The residents expressed concerns about privacy and receiving all ordered items.
A facility failed to develop a comprehensive care plan for a resident with multiple health issues, including Parkinson's and cognitive impairment. The resident's care plan lacked documentation for daily activities, leading to social isolation. Observations showed the resident often stayed in bed, with limited participation in activities. Staff noted the resident sometimes refused care and preferred to stay in bed, but no care plan was in place to address these issues.
A resident with significant health issues, including hemiplegia and stroke, experienced a delay in the repair of her custom wheelchair, which had been awaiting repair since August. Despite initial contact with the repair company, the facility failed to follow up, leaving the resident to use a loaner wheelchair that did not meet her specific needs. The facility lacked a specific policy for addressing such equipment issues, contributing to the deficiency in care.
A facility failed to maintain a resident's BiPAP machine in a usable condition, despite the resident's need for respiratory care due to respiratory failure and sleep apnea. The machine was missing essential components, preventing the resident from using it as needed. The facility's policy indicated responsibility for the machine's upkeep, but it was returned to the resident without necessary parts, leading to a deficiency in care.
A resident with a history of strokes and other medical conditions did not receive a timely neurologist appointment as ordered by their cardiologist. The facility's social worker initially faxed the referral with incorrect diagnoses, leading to a refusal from the neurologist. Despite multiple attempts to contact the neurologist, no appointment was scheduled, and the facility did not adequately follow up, failing to adhere to the resident's care plan and preferences.
A resident with sleep apnea was not provided with a CPAP machine as required by their care plan. The resident, who has multiple health conditions, expressed concerns about not having access to the CPAP machine after a room change. Facility staff, including the DON and administrator, were unaware of the resident's need for the CPAP and the details of the care plan. The facility's policies on resident rights and care planning were not followed, leading to a deficiency in providing necessary respiratory care.
The facility failed to maintain a homelike environment by not replacing a missing countertop in the dining room for about a year. Observations showed the area was covered with plywood and tablecloths, with exposed drawers containing debris. Staff and a resident noted the unhomelike appearance, and complaints had been made. The facility's policy emphasizes a safe, clean, and comfortable environment, which was not upheld.
A resident with severe cognitive impairment and a history of falls experienced a metacarpal fracture, but the facility failed to notify the resident's representative until ten days after the x-ray results were received. The DON confirmed that immediate notification is part of the facility's protocol.
A resident with severe cognitive impairment and no preexisting mental illness was administered Zyprexa, an antipsychotic, without a warranted diagnosis. The facility's psychiatrist cited aggression as the reason, but the DON disagreed, stating Zyprexa should be for conditions like bipolar disorder or schizophrenia. The facility's policy requires psychotropic drugs to treat specific diagnosed conditions.
A facility failed to obtain written consent from a resident's representative before administering Xanax, a psychotropic medication, to a resident with cognitive impairments. Despite the facility's policy and in-service training on obtaining consents, the medication was given multiple times without documented consent, as acknowledged by the DON.
A facility failed to limit PRN orders for Xanax, a psychotropic medication, to 14 days for a resident with dementia and anxiety. The resident received Xanax on multiple occasions without a documented stop date or rationale for extended use, contrary to facility policy. The DON confirmed that PRN orders should be short-term to assess medication necessity and effectiveness.
Failure to Notify Physician and DON After Fall and Behavioral Change
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult the resident’s physician and notify the DON and responsible party when a resident experienced a fall and subsequent significant changes in mental and psychosocial status. The resident was an older man with a history of right femur fracture, hemiplegia/hemiparesis following a stroke, type 2 diabetes, aphasia, dysphagia, gait abnormalities, and unsteadiness on his feet. His care plan identified him as at risk for falls and requiring assistance with ADLs and transfers, and his MDS assessments showed moderate to severe cognitive impairment. Despite these identified risks and functional limitations, there was no documentation of neurological checks or incident documentation for a fall that occurred on 12/07/2025, and no immediate notification to the physician, NP, DON, or family. On the night of the initial fall, a CNA found the resident on the floor by his bed after he apparently attempted to transfer to his wheelchair. The CNA reported that the resident complained of pain and pointed to his chest, and LVN A assessed him, took vital signs, administered PRN tramadol, and assisted him back to bed. However, LVN A did not notify the NP, MD, DON, or family, did not initiate neurological checks for this unwitnessed fall, and did not complete timely documentation of the incident. A late entry note was not entered until 12/17/2025, and there were no updated fall interventions documented between 12/07/2025 and 12/13/2025. Staff interviews confirmed that facility protocol required immediate assessment, notification of provider, DON, responsible party, completion of an incident report, and initiation of neurological checks for unwitnessed falls, but these steps were not followed for this event. In the days following the unreported fall, multiple staff observed changes in the resident’s behavior and function. The NP noted on 12/12/2025 that the resident had been more withdrawn over the past week, that he reported a fall approximately four days earlier that had not been reported, and that he had pain and bruising of the right arm with difficulty moving it. Radiology studies were ordered and completed on several areas of the right extremity, showing soft tissue swelling but no acute fracture. Staff, including CNAs and LVNs, reported that before the fall the resident was more independent with transfers, ambulation, and toileting, and that after the fall he required more assistance and became incontinent. Another unwitnessed fall occurred on 12/13/2025, for which the NP and responsible party were notified and neurological checks were initiated, but the interventions documented were limited to encouraging the resident to use the call light and obtaining a therapy evaluation several days later. Ultimately, further imaging on 12/17/2025 revealed a right shoulder dislocation and a nondisplaced fracture of the greater trochanter of the right proximal femur, and the resident underwent surgical repair of the hip. The surveyors determined that the facility failed to immediately consult the physician and appropriately respond to the initial fall and subsequent behavioral changes, leading to an Immediate Jeopardy finding related to notification of changes in condition.
Removal Plan
- Conduct in-service training for all licensed nursing staff (including PRN, agency, and new staff) on the facility's Notification of Physician Change in Condition policy, emphasizing mandatory immediate reporting of any resident falls or significant changes in condition to the physician and DON, including documentation requirements and timelines.
- Provide in-service training for the DON and Administrator on the Risk Management protocol by the Area Director of Operations and Regional Compliance Nurse.
- Implement a revised notification protocol requiring the nurse discovering or responding to a fall to conduct an immediate assessment of the resident and notify the DON and treating physician/NP.
Failure to Implement Timely Post-Fall Assessment and Interventions After Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents for a cognitively impaired male resident with significant mobility and neurologic deficits. The resident had a history of right-sided hemiplegia/hemiparesis following a stroke, aphasia, muscle weakness, gait and mobility abnormalities, dysphagia, unsteadiness on his feet, and used a wheelchair. His care plan identified him as at risk for falls, with interventions such as keeping the call light within reach, educating him about safety reminders, and re-educating him to lock wheelchair brakes prior to transfers. Assessments showed he required varying levels of assistance for transfers and mobility and had moderate to severe cognitive impairment, yet he was often treated as mostly independent in transfers and ambulation. On or about early December, the resident experienced an unwitnessed fall near his bed at night. A CNA found him on the floor by the bed, with his feet under the bed, apparently having fallen while trying to transfer to his wheelchair. The CNA notified the LVN, who assessed the resident, took vital signs, administered PRN tramadol for reported pain, and assisted him back to bed. However, the LVN did not notify the NP, MD, DON, responsible party, or administration, did not initiate neurological checks despite the fall being unwitnessed, and did not complete an incident report or timely documentation of the fall. A late entry note documenting the fall was not entered until 12/17, and there was no evidence of post-fall monitoring, neurological assessments, or new fall-prevention interventions being implemented after this initial fall. Staff later reported that the resident became more withdrawn, stopped going to the dining room, and changed his usual routine, but these changes were not documented or communicated as potential signs of injury or change in condition. Subsequently, the resident sustained another unwitnessed fall near the bathroom when he missed sitting on his wheelchair after using the bathroom. This second fall was reported to the NP and responsible party, and neurological checks were initiated, but the only documented intervention was to encourage the resident to use the call light or ask for assistance—an intervention that was already in place prior to the fall. A therapy evaluation was not ordered until several days after the second fall, and there was no evidence of immediate, enhanced fall-prevention measures or increased monitoring following either fall. Radiology studies ordered after the delayed recognition of bruising and pain revealed multiple areas of soft tissue swelling and ultimately a nondisplaced fracture of the greater trochanter of the right proximal femur, requiring surgical repair. Interviews with multiple staff, including CNAs, LVNs, the RN, DON, ADM, DOR, and NP, confirmed that facility policy required immediate assessment, neurological checks for unwitnessed falls, timely incident reporting, and prompt notification of providers, DON, and family after any fall, as well as 72-hour monitoring and review for new interventions. These required actions were not carried out after the first fall, and new or enhanced interventions were not promptly implemented after either fall, leading to the identified deficiency. The facility’s own staff acknowledged that the resident’s functional status declined after the first fall, with increased need for assistance and incontinence, yet this change was not linked to a documented fall event or followed by appropriate reassessment and care plan revision. The DON and ADM both stated that they were not informed of the initial fall until days later and that interventions were not added until after the delay. The NP reported that she discovered bruising and swelling on the resident’s arm and noted his withdrawal and pain before any fall had been reported to her, and she ordered x-rays based on her findings rather than on timely fall notification. Review of facility policies and staff interviews showed that the expected fall protocol—immediate assessment, neurological checks for unwitnessed falls, incident reporting, timely notification, and prompt implementation of individualized interventions—was not followed for this resident, resulting in delayed identification and treatment of injuries and failure to implement timely, effective fall-prevention measures after repeated falls.
Removal Plan
- Effective immediately, all licensed nursing staff including PRN, Agency and New Staff will be in-serviced by the Director of Nursing (DON) and Administrator (ADM) on the facility's Fall Prevention Policy, emphasizing mandatory post-fall assessments including neurological checks, vital signs monitoring, and timely notification of providers and administration for every fall.
- Orientation for all new hires will include Fall Prevention Policy training before assuming duties.
- Facility Administrator and DON will be in-serviced on the Risk Management protocol by the Area Director of Operations and Regional Compliance Nurse.
- The facility will implement a fall follow-up protocol requiring the nurse assigned at the time of the fall to complete a detailed incident report immediately and document all neurological and vital signs assessments in the resident's medical record within the same shift.
- The DON or designee will ensure consistent compliance with the fall follow-up protocol.
- The interdisciplinary team including the DON, Medical Director, and Therapy Director will review and update Resident #1's care plan to incorporate individualized fall prevention interventions tailored to his multiple fall risks and clinical status, including frequent monitoring, assistance with transfers, and immediate post-fall interventions.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Faulty Door Alarms
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple neurological diagnoses exited the facility unsupervised. The resident was able to leave through a door at the end of a hallway, descend eight steps, cross a parking lot and two traffic lanes, and reach the center median of a road with a 40 MPH speed limit. At the time of the incident, the resident's care plan did not include interventions for elopement risk, and her most recent elopement assessment indicated she was not at risk for elopement. Staff statements and documentation confirmed that the resident was not being directly supervised when she left the building, and the door alarm system was not functioning reliably, as it would automatically shut off after 15 seconds and was not always audible to staff in nearby offices. Interviews with staff revealed that prior to the incident, the facility's elopement prevention measures were insufficient. Staff were not alerted to the resident's exit until a passerby notified them after seeing the resident in the road median. The alarm system on the exit doors was described as inconsistent, with alarms sometimes failing to sound or being inaudible. Staff also reported that the resident was not previously identified as high risk for elopement, and her care plan did not reflect any elopement interventions. The lack of supervision and inadequate alarm system allowed the resident to leave the premises unnoticed. Documentation showed that the resident was able to walk with supervision or touching assistance and had a history of cognitive impairment, including a BIMS score indicating severe impairment. Despite these risk factors, the facility did not have appropriate elopement precautions in place for her. The incident was identified as Immediate Jeopardy, as the resident was exposed to significant danger by being unsupervised outside the facility and in proximity to a busy road.
Misappropriation of Controlled Medications Awaiting Destruction
Penalty
Summary
The facility failed to ensure the security and proper handling of controlled medications awaiting destruction, resulting in the misappropriation of an unknown quantity of these medications and the associated Drug Destruction Log. The controlled medications, which included narcotics, were stored in a locked cabinet within the DON/ADON shared office. The keys to this cabinet were inconsistently managed, with the DON initially responsible but later transferring the responsibility to the ADON, who kept the keys on her person. The office itself was secured with a keypad lock, but the code was accessible to multiple staff members. At some point between 09/22/25 and 09/26/25, the ADON placed discontinued narcotics in the cabinet and organized the medication cards, but could not specify the exact number of medications present, as this information was only recorded on the missing log. On 09/30/25, when a nurse attempted to add more narcotics to the discontinued medication cabinet, it was discovered that all but one card and a few bottles of liquid medication were missing, along with the Drug Destruction Log. The facility's process required that discontinued controlled medications be counted and signed by two nurses, with the medication and log then locked in the cabinet. However, the lack of a consistent and secure key management system, as well as unclear responsibility for the storage and documentation, contributed to the loss. The DON, who had only recently started working at the facility, was unfamiliar with the facility's medication disposal policy and relied on the ADON for guidance, further compounding the lack of oversight. Interviews with staff revealed that the expectation was for controlled medications awaiting destruction to be double-locked and accessible only to authorized personnel. However, the actual practice deviated from policy, with keys being shared and stored in unsecured locations, and the office code being known to several individuals. The missing medications and log could not be accounted for, as the control drug count sheets were also missing, making it impossible to determine the exact quantity of medications lost. The facility's policies required strict adherence to federal and state regulations regarding controlled medication handling, but these procedures were not followed, resulting in the misappropriation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training and oversight, as well as a lack of clear reporting mechanisms for suspected incidents. The absence of these preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
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 Timely Investigate and Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated and reported within the required timeframe. Specifically, when a resident reported that her roommate hit her and twisted her arm, the incident was not fully investigated and the Provider Investigation Report (PIR) was not submitted to the State Survey Agency within the mandated five working days. The PIR, which was due within five days of the incident, was instead submitted nearly three weeks later. The residents involved included one with moderately impaired cognition due to dementia and another with severely impaired cognition and a history of agitation. The initial allegation was documented by an LVN, who assessed the resident and notified the DON, administrator, responsible party, and nurse practitioner. The resident's arm was examined, and an X-ray was ordered, but there was no evidence of injury. The roommate denied the allegation. Despite these actions, the required comprehensive investigation and timely reporting were not completed as per facility policy and state regulations. Interviews with facility staff revealed confusion regarding the roles and responsibilities for investigating and reporting the incident. The DON and administrator both acknowledged delays and gaps in the investigation process, including late completion of safe surveys and failure to locate or submit the PIR on time. Review of facility policy confirmed the requirement for thorough investigation and reporting of all allegations within five working days, which was not met in this case.
Failure to Maintain Sanitary and Comfortable Resident Rooms Due to Mold
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on one of its halls. Observations revealed a black circular substance, identified as mold, under the wallpaper in the rooms of three residents. The housekeeper reported that mold had been present in the housekeeping storage room for three to four months and had informed the maintenance director, but no action had been taken. The maintenance director confirmed the presence of mold behind the wallpaper in the residents' rooms and stated that he had notified the administrator, but had not received a response. The director of nursing and the administrator both stated they had not been informed about the mold, and neither had taken steps to address the issue prior to the survey. The residents affected included individuals with significant medical histories, such as dementia, hypertension, diabetes, kidney disease, Alzheimer's disease, heart failure, and metabolic encephalopathy. Some residents were unable to communicate effectively due to cognitive impairment or other conditions. The facility's own policy requires the provision of housekeeping and maintenance services to ensure a safe, clean, and comfortable environment, but this was not upheld, resulting in residents being exposed to an unclean and potentially hazardous environment.
Failure to Thoroughly Investigate and Timely Report Alleged Neglect and Injury Incidents
Penalty
Summary
The facility failed to thoroughly investigate and report two separate incidents involving allegations of neglect and injury of unknown origin for two residents. For one resident with severe cognitive impairment and multiple diagnoses including dementia, Alzheimer's disease, and a history of falls, an incident involving injury of unknown origin was reported. However, the investigation lacked documented interviews with the RN and MA who were present at the time of the incident, and the findings were not submitted to the state agency within five working days. Similarly, for another resident with intact cognition and multiple chronic conditions, an allegation of neglect was reported, but there were no documented interviews with the CNAs involved, and the findings were also not submitted within the required timeframe. Record reviews revealed that the facility's investigation reports and self-reporting checklists indicated interviews were either not completed or not documented, despite being checked off as done. The administrator stated that interviews had been conducted and were either in the binder or her office, but only one staff interview was found, and the remaining interviews were not provided to the surveyor upon request. The facility's policy requires a thorough investigation and timely reporting to the state agency, but these steps were not followed for the incidents involving both residents.
Failure to Provide Written Discharge Notice Upon Resident Transfer to Police Custody
Penalty
Summary
The facility failed to provide written notification of discharge to a resident and the resident's representative when the resident was transferred into police custody. The resident, who had a history of diabetes, chronic pain, and repeated falls, was cognitively intact as indicated by a BIMS score of 15. On the day of the incident, law enforcement arrived at the facility to take the resident into custody, and the Director of Nursing (DON) documented that all belongings and medical information were sent with the resident. However, there was no evidence that a written discharge notice was provided to the resident or their representative at the time of transfer. Interviews with facility staff, including the Social Worker, Administrator, and DON, revealed that the decision to discharge the resident was made based on information from law enforcement that the resident would remain in custody until trial. The staff acknowledged that the usual 30-day written notice for facility-initiated discharges was not given, and instead, verbal notifications and voicemails were left for the resident's Power of Attorney (POA) and the ombudsman. The facility also did not provide written documentation of the reasons for discharge in a language and manner understandable to the resident and their representative. Further review indicated that the facility's policies require written notice of discharge or transfer, including in emergency situations, and that such notices should be provided to the resident, their representative, and the ombudsman. Despite these policies, the facility did not issue the required written notice when the resident was taken into police custody and subsequently discharged. The ombudsman confirmed that the resident had previously appealed a discharge and won, and expressed that the resident should have been accepted back after the arrest and hospital stay, but the facility refused readmission based on its policy regarding registered sex offenders.
Neglect Leads to Resident's Unattended Fall
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in a significant deficiency. On the night in question, a resident was left unattended for approximately six hours, during which time he fell and remained on the floor without assistance. The resident, who had a history of Alzheimer's disease, generalized anxiety disorder, and dementia, was found with an abrasion on his left arm and was combative and speaking Spanish when discovered. His care plan indicated he required supervision or assistance with toileting and was at high risk for falls. The incident occurred when CNA A and LVN B did not perform the required checks on the resident throughout the night. CNA A admitted to not checking on the resident during her rounds and only discovered him on the floor at around 4:30 am. LVN B also confirmed that she did not see the resident again until notified by CNA A. Both staff members acknowledged that failing to check on residents every two hours constituted neglect. The facility's video footage confirmed that no staff entered the resident's room for the six-hour period, during which the resident attempted unsuccessfully to get back up after his fall. The Director of Nursing (DON) and the Administrator reviewed the video footage and confirmed the timeline of events. The DON noted that the resident made several attempts to reposition himself but was unsuccessful. The Administrator stated that the staff should have seen the resident on the floor if they had opened the door, indicating that the required checks were not performed. Both CNA A and LVN B were suspended and later terminated following the investigation. The facility's policy on abuse and neglect emphasized the importance of frequent checks, but there was no specific policy on the frequency of these checks.
Deficiencies in PICC Line Management and IV Fluid Administration
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for two residents, leading to deficiencies in the management of peripherally inserted central catheter (PICC) lines. Resident #1 did not have orders to change her PICC line dressing after it was placed, resulting in the dressing not being changed from 12/18/24 until 01/09/25. Additionally, there were no orders to flush the PICC or monitor the insertion site for signs of infection during this period. The nursing staff, including the Assistant Director of Nursing (ADON), were not trained or competent in managing PICC lines, as evidenced by the ADON's improper dressing change technique and lack of sterile procedure. Resident #2 also experienced deficiencies in PICC line management. There were no orders to flush the PICC or monitor the insertion site for signs of infection from 11/13/24 through 11/27/24. The resident was transferred to an acute hospital with a fever and was diagnosed with sepsis and pneumonia, with blood cultures positive for Candidiasis. The facility's failure to provide adequate training and competency checks for nursing staff on PICC line management contributed to these deficiencies. The deficiencies resulted in the identification of an Immediate Jeopardy (IJ) situation on 01/09/25, indicating a serious threat to resident health and safety. The facility's lack of proper protocols and training for central line care placed residents at risk for infection, hospitalization, and potentially more severe outcomes. The report highlights the need for consistent monitoring and adherence to professional standards in the administration of IV fluids and PICC line care.
Removal Plan
- DON completed 100% audit of current residents with central venous line - no further issues identified.
- All nurses will be in-serviced on proper dressing change and care of a central venous line by the DON and/or Designee.
- All nurses will be in-serviced on infection prevention and monitoring for infection of a central venous line by the DON and/or Designee.
- All nurses will be in-serviced on receiving and validating central venous line management care with ordering physician by the DON and/or Designee.
- All nurses/agency nurses will not be allowed to begin work until they have received the above in-services/trainings by the DON and/or Designee - staff were able to verbalize comprehension post in-servicing.
- DON in-serviced by compliance nurse - DON was able to verbalize comprehension post in-servicing.
- The medical director was notified of the immediate jeopardy situation.
- The DON / designee will view each PICC/central venous line dressing 3xwk to ensure compliance - it will be maintained on a monitoring log.
- The DON / designee will review Real time key word for any new orders for PICC/Central Venous Line 5 times a week to ensure compliance it will be maintained on a monitoring log.
- DON/Designee will validate all new orders of PICC/Central Venous Line 5 times a week to ensure compliance it will be maintained on a monitoring log.
- The QA committee will review findings and makes changes to the plan if needed.
Deficiency in Central Line Care Competency
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated the necessary competencies and skill sets to care for a resident with a central line, leading to potential risks of infection and improper medication administration. Six nurses, including the ADON, RN A, and LVNs B, C, D, and E, were involved in the care of a resident who had a PICC line inserted for intravenous medication administration. The nurses were not knowledgeable or competent in the facility's central line policy, as evidenced by the lack of proper dressing changes, flushing, and monitoring of the central line site. The resident, a female with intact cognition, was admitted with diagnoses including chronic ulcer, venous hypertension, and cellulitis, requiring intravenous medications such as Piperacillin-Tazobactam and Vancomycin. Despite the critical nature of the resident's condition, the MAR/TAR records showed that the central line site was not monitored, flushed, or had its dressing changed as per the facility's policy. The dressing was not changed from the time of insertion on December 18 until January 9, and the site was covered with tape, obscuring visibility and preventing proper assessment. Interviews with the nursing staff revealed a lack of training and competency in central line care. RN A admitted to having no prior experience with PICC lines and was uncomfortable performing dressing changes. The ADON, who performed a dressing change, did not follow sterile procedures and failed to change the caps, mistaking the central line for a peripheral IV. The DON and MD expressed expectations for proper central line maintenance, which were not met, as evidenced by the absence of specific competencies or skills checks for central lines in the proficiency audits provided for the involved nurses.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple sanitation issues observed in the kitchen. The ice machine was found to have mold on the inside door and inner upper wall, and the seal on the top of the ice machine door was cracked. The microwave had dried food debris caked on its interior top, and the meat slicer was dirty with dried food debris and had a rusty slicing blade. Additionally, trash receptacles in the kitchen were observed without lids, and ingredient bins had scoops left inside them, contrary to best practices. Food items in the kitchen were not properly labeled and dated, which could lead to the use of expired or unidentified food products. Observations revealed several bags of food in the walk-in freezer and dry storage area that were unsealed, unlabeled, and undated. This included bags of frozen hushpuppies, onion rings, chicken tenders, fish fillets, broccoli cuts, cherry pies, brown sugar, pasta, cake mix, gelatin, peanuts, pudding mix, cocoa, powdered sugar, and tortillas. The lack of proper labeling and dating could result in foodborne illnesses if expired or spoiled food is served to residents. The facility also failed to maintain proper handwashing facilities, as sinks were observed to be leaking. Hair restraint practices were not consistently followed, with staff observed wearing inadequate hair coverings, such as a ball cap with hair extending below it and a beard guard that did not fully cover facial hair. The dietary manager admitted to not maintaining daily or monthly cleaning logs and was unsure of the potential harm rust on a meat slicer blade could cause to residents. These deficiencies in sanitation and food handling practices could place residents at risk of foodborne illness.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections among residents. LVN B did not label wound care dressings for several residents, including those with chronic ulcers and pressure injuries. This omission was observed during wound care for multiple residents, where dressings lacked initials and dates, which are crucial for tracking the timing of wound care and monitoring for drainage. Additionally, LVN B did not use a barrier between a resident's wound and the bedding, increasing the risk of cross-contamination. Another significant deficiency involved LVN N, who provided catheter care to a resident without wearing the required Enhanced Barrier Precautions (EBP), such as gloves and gowns. This resident had an indwelling catheter and was supposed to be under EBP to prevent infection transmission. Despite the presence of signs and available PPE, LVN N handled the catheter without the necessary protective equipment, which could lead to infection risks for both the resident and staff. Interviews with staff, including the DON and ADM, revealed that the facility had policies in place for wound care and EBP, but these were not consistently followed. The DON and ADM acknowledged the importance of labeling wound dressings and using barriers during wound care, as well as adhering to EBP for residents with indwelling devices. The failure to comply with these infection control measures was attributed to lapses in following established protocols and ensuring staff training.
Resident's Call Light Bell Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light bell was within arm's reach, which is a reasonable accommodation of the resident's needs and preferences. The deficiency was identified for a resident who was diagnosed with cerebral infarction, hemiplegia, and hemiparesis, resulting in significant physical impairments. The resident required substantial to maximum assistance for various activities of daily living and used a wheelchair for mobility. Despite these needs, the call light bell was found on the floor, out of reach, which prevented the resident from calling for assistance when experiencing pain. During an observation and interview, the resident expressed that she did not know the location of her call light bell and felt sad about its inaccessibility. A registered nurse later entered the room, noticed the misplaced call light bell, and repositioned it within the resident's reach. The nurse instructed the resident on how to use the call light bell to request help. Interviews with facility staff, including a CNA and the DON, confirmed that the call light bell should always be within reach of residents, whether they are in bed or in a chair, to address their needs promptly. The facility lacked a specific policy on call light bell placement, but staff were trained to ensure accessibility. The facility's Resident Right Policy emphasized the right of residents to receive services with reasonable accommodation. The failure to provide the resident with access to the call light bell could lead to unmet needs and psychosocial harm, as the resident was unable to communicate her needs effectively.
Failure to Provide Timely Access to Resident Trust Funds
Penalty
Summary
The facility failed to manage the personal funds of a resident, identified as Resident #25, who was unable to access her funds in a timely manner for a dental appointment. Resident #25, a female with multiple medical conditions including dementia and major depressive disorder, had intact cognition as indicated by a BIMS score of 15. She required funds for a dental visit co-pay, which Medicaid did not cover, but was unable to receive the necessary amount from the facility's trust fund in time for her appointment. The Business Office Manager (BOM) explained that residents could immediately receive amounts up to $75, but larger amounts required a special request, which could take up to two days to process. The BOM was unavailable on the day of Resident #25's appointment, and no other staff facilitated the fund disbursement, resulting in the cancellation of her dental visit. The facility's policy stated that trust funds should be accessible during normal business hours, but the process for special requests was not clearly communicated or documented. Interviews with the BOM and other staff revealed that there were other personnel with access to the financial system who could have processed the request, but this was not done. The Administrator expressed that residents should receive their funds according to policy, acknowledging that failure to do so could negatively impact residents' ability to pay for necessary services. The deficiency highlights a lapse in the facility's management of resident trust funds, affecting Resident #25's ability to attend her scheduled dental appointment.
Facility Fails to Ensure Residents Receive Unopened Packages
Penalty
Summary
The facility failed to ensure that residents had the right to receive packages unopened, which is a violation of resident rights. This deficiency was identified during a Resident Council interview where two residents expressed concerns about receiving packages that had already been opened. The residents reported that while their mail and letters remained unopened, packages were often opened before they received them. This practice was reportedly due to safety concerns, as staff feared the presence of contraband or harmful items. Resident #14, a female with intact cognition and multiple health conditions including major depressive disorder and anxiety, expressed that packages were opened possibly due to a past incident involving another resident. She was concerned about receiving all items she ordered. Resident #253, a male with intact cognition and a history of cerebral infarction and other health issues, stated that staff opened packages due to fears of contraband. He mentioned that a small hammer he ordered was confiscated, and he felt that the practice of opening packages began with the arrival of a new administrator. Interviews with facility staff, including the Business Office Manager (BOM) and the Administrator (ADM), revealed that packages were supposed to be delivered unopened. However, any staff member who answered the facility door could receive packages, which were then left at the reception desk. The BOM and ADM acknowledged that delivering opened packages could negatively affect residents. The facility's policy on resident rights confirmed that residents have the right to receive packages delivered to the facility through means other than the postal service.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. The resident, an elderly male with multiple diagnoses including Parkinson's Disease, fractures, diabetes, heart disease, depression, and cognitive impairment, was not provided with a care plan addressing daily activities. This oversight was identified during a review of the resident's care plan, which lacked documentation regarding daily activities, despite the resident's history of social isolation and cognitive challenges. Observations and interviews revealed that the resident often stayed in bed, watching television or sleeping, and was not participating in activities or socializing. Staff interviews indicated that the resident sometimes refused care, medications, or meals, and preferred to stay in bed. Although the resident occasionally left the room to visit common areas, this was not consistent, and there was no care plan in place to address or encourage participation in daily activities. The Activity Director noted that the resident did not engage much with staff or other residents and had not been care-planned for one-on-one activities due to refusal. The facility's policy on comprehensive care planning emphasizes the need for person-centered care plans that address medical, nursing, mental, and psychosocial needs, respecting resident rights and preferences. The policy requires care plans to be developed collaboratively with the interdisciplinary team and the resident, and to be reviewed and updated regularly. However, in this case, the lack of a care plan for daily activities placed the resident at risk of social isolation and diminished quality of life, as the facility did not adequately address the resident's needs and preferences in this area.
Delayed Wheelchair Repair for Resident
Penalty
Summary
The facility failed to ensure timely repair of a custom wheelchair for a resident, which was necessary for her mobility and comfort. The resident, who had a history of hemiplegia, stroke, and other significant health issues, was using a loaner wheelchair that did not meet her specific needs. The resident's custom wheelchair had been awaiting repair since August, and despite the facility's initial contact with the repair company, no further follow-up was conducted until December. The resident's representative expressed concerns about the delay, noting that the custom wheelchair had been broken and awaiting repair for three months. The facility's staff, including the Director of Rehabilitation (DOR) and Occupational Therapist (OT), acknowledged the delay and lack of communication with the repair company. The DOR admitted that after the initial contact with the repair company, no further action was taken until prompted by the resident's representative. The facility's administration recognized the potential negative impact on the resident due to the delay in repairs. However, there was no specific policy in place to address such situations, and the facility did not have a record of a positioning/mobility equipment policy. The lack of timely follow-up and communication with the repair company contributed to the deficiency in providing appropriate care and treatment according to the resident's needs and preferences.
Facility Fails to Maintain Resident's BiPAP Machine
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care was provided with a functional BiPAP machine, consistent with professional standards of practice and the resident's care plan. The resident, who had been diagnosed with respiratory failure and sleep apnea, had a care plan that included the use of a BiPAP machine as needed. However, the resident's BiPAP machine was found to be in an unusable condition, lacking a wall outlet plug, a nasal mask, and having a discolored and dirty air intake filter. The resident expressed a desire to use the BiPAP machine despite previous non-compliance, but was unable to do so due to the machine's condition. The Director of Nursing (DON) acknowledged that the machine had been returned to the resident from storage without the necessary components, and the responsibility for the machine's upkeep was left to the resident and the supplier. However, the facility's policy indicated that it was responsible for providing ongoing therapy and maintaining the BiPAP system. Interviews with facility staff revealed that the facility was responsible for ensuring the BiPAP machine was operational and that the resident's non-compliance did not negate this responsibility. The facility's failure to maintain the BiPAP machine in a usable condition could place residents at risk of complications from respiratory distress.
Failure to Schedule Neurologist Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan. The deficiency involved a resident who required an appointment with a neurologist as ordered by their cardiologist. Despite the cardiologist's referral being faxed to the facility, the appointment was not scheduled in a timely manner, which could place the resident at risk of not receiving necessary medical care. The resident, who has a history of strokes and other medical conditions such as sleep apnea, COPD, type II diabetes, mild cognitive impairment, and PTSD, expressed difficulty in getting the facility to make the necessary neurologist appointment. The facility's social worker initially faxed the referral with incorrect diagnoses, leading to a refusal from the neurologist. Subsequent attempts to contact the neurologist were made, but no appointment was scheduled, and the social worker did not document the calls made to the neurologist's office. Interviews with facility staff, including the social worker, DON, and administrator, revealed that the facility was aware of the issue but did not take adequate steps to resolve it. The facility's policy on resident rights emphasizes the importance of planning and implementing care in accordance with the resident's preferences and goals, which was not adhered to in this case. The resident's NP acknowledged that the referral should have been followed up on sooner, indicating a lapse in the facility's processes for ensuring timely medical care for its residents.
Failure to Provide CPAP for Resident with Sleep Apnea
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident diagnosed with sleep apnea, as outlined in the resident's care plan. The resident, a male with multiple health conditions including sleep apnea, chronic obstructive pulmonary disease, and mild cognitive impairment, was not provided with a CPAP machine as required by his care plan. The care plan, updated on 10/29/24, specified the use of a CPAP/BIPAP during sleep, but the CPAP order was discontinued on 4/29/24, and there was no current order for its use. Observations revealed the absence of a CPAP machine in the resident's room, and interviews with the resident indicated that he was concerned about not having access to the CPAP machine, which was not transferred to his new room. Interviews with facility staff, including the DON and the administrator, revealed a lack of awareness regarding the resident's need for a CPAP machine and the details of his care plan. The DON, who had been working at the facility for a few months, was unaware of the resident's sleep apnea diagnosis and the care plan's requirements. The administrator also did not know why the CPAP order was discontinued and was unaware of the care plan's inclusion of the CPAP. The resident's NP was not informed of the discontinuation of the CPAP order and assumed it was being offered nightly, despite the resident's frequent refusal of treatments. The facility's policies on resident rights and comprehensive care planning emphasize the resident's right to participate in their care and the facility's responsibility to provide services as outlined in the care plan, which were not adhered to in this case.
Failure to Maintain Homelike Environment Due to Missing Countertop
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not replacing a countertop over a set of cabinets in the dining room for about a year. Observations revealed that the cabinets were partially covered with plywood, stained green tablecloths, and a bath towel, with exposed drawers containing various items and debris. Interviews with staff indicated that the countertop had been missing for a significant period, with varying accounts of when it was removed, ranging from a year to two years ago. The Maintenance Director and the Administrator mentioned that a replacement had been ordered, but there was no clear timeline for its installation. A resident expressed dissatisfaction with the appearance of the dining room, describing it as looking bad and junky. Staff members also noted that the absence of the countertop made the environment less homelike and that residents had complained about it in the past. The facility's Residents Rights policy emphasizes the importance of maintaining a safe, clean, comfortable, and homelike environment, which was not upheld in this instance. The Administrator acknowledged the issue and mentioned discussions with the Ombudsman, but no adverse effects on residents were reported other than complaints about the countertop's absence.
Failure to Notify Resident's Representative of Fracture
Penalty
Summary
The facility failed to immediately notify the resident's representative of a significant change in the resident's physical status, specifically a metacarpal fracture, for one of the residents reviewed. The resident, a female with severe cognitive impairment and a history of falls, was not reported to have a fracture until ten days after the x-ray results were received. This delay in communication was confirmed through interviews and record reviews, highlighting a lapse in the facility's protocol for notifying resident representatives of significant health changes. The resident's progress notes indicated that an x-ray was completed to assess a fracture, and a subsequent order was made for an orthopedic evaluation. However, the resident's representative was not informed of the fracture until much later, which was confirmed during a telephone interview with the representative. The Director of Nursing acknowledged that it was expected for resident representatives to be notified immediately of any changes in condition, such as fractures or falls, as part of the facility's protocol. The facility's Resident Rights Policy also mandates immediate notification of significant changes in a resident's condition.
Inappropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident who had not previously used psychotropic drugs was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. The resident, an elderly female with diagnoses including unspecified dementia, anxiety, depression, and age-related cognitive decline, was administered Zyprexa, an antipsychotic medication, without a preexisting mental illness warranting its use. The resident's quarterly MDS assessment indicated severe cognitive impairment, and her care plan noted a risk of falls related to psychoactive drug use. The facility's psychiatrist indicated that the resident's Zyprexa prescription was for aggression, which he deemed an acceptable diagnosis if the resident posed a potential danger to others. However, the Director of Nursing stated that aggression was not an appropriate diagnosis for Zyprexa, which should be prescribed for conditions like bipolar disorder, schizophrenia, or psychosis. The facility's policy on psychotropic drugs emphasized that such medications should only be administered to treat specific conditions as diagnosed and documented in the clinical record.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed in advance about the risks and benefits of proposed care, treatment alternatives, and options, specifically for one resident reviewed for consents. The deficiency involved the administration of Xanax, a psychotropic medication, to a resident without obtaining a written consent from the resident's representative. The resident, a female with diagnoses including dementia, major depressive disorder, generalized anxiety disorder, and mild cognitive impairment, was administered Xanax on multiple occasions without documented consent. The Director of Nursing (DON) acknowledged that consent for psychotropic medications must be obtained before administration to prevent chemical restraint and ensure that the resident's representative can make informed decisions regarding their care. Despite the facility's policy requiring documented consent for psychotropic drugs, the resident's electronic medical record showed no signed consent form for Xanax. The facility had conducted an in-service training to reeducate nurses on obtaining consents for psychotropic medications, but the deficiency still occurred.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner documented their rationale for extending the order in the resident's medical record. This deficiency was identified for a resident who was prescribed Xanax, a medication used to treat anxiety. The resident, a female with a history of dementia, major depressive disorder, generalized anxiety disorder, and mild cognitive impairment, was admitted to the facility and had a physician order for Xanax without a specified stop date. The medication was administered on multiple occasions over a period exceeding 14 days without documented justification for the extended use. The Director of Nursing (DON) acknowledged during an interview that PRN psychotropic medication orders should not be open-ended and must be limited to 14 days to allow for assessment of the medication's effectiveness and necessity. The facility's policy on psychotropic drugs, revised in 2017, also stipulated that PRN orders for such medications should be limited to 14 days. The lack of a stop date for the PRN Xanax order for the resident could lead to overmedication or unnecessary medication use, posing a risk of sedation or chemical restraint.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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