Regency Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Webster, Texas.
- Location
- 409 W Green, Webster, Texas 77598
- CMS Provider Number
- 675961
- Inspections on file
- 28
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Regency Village during CMS and state inspections, most recent first.
A resident with multiple medical conditions and an indwelling catheter was left in urine-soaked clothing and bedding after an LVN failed to flush or change the leaking catheter as ordered, despite the resident's requests. The resident called 911 for help and was transported to the hospital, where he was treated for a dislodged catheter and UTI. The incident was not reported to the DON until after the resident's return.
A resident with a neurogenic bladder and Foley catheter did not receive required catheter care when the device was leaking and not draining, despite physician orders to flush or change the catheter as needed. The assigned LVN did not take action, resulting in the resident being soaked in urine and requiring EMS transport to the ER, where a dislodged catheter and UTI were diagnosed. Facility policy and orders for catheter management were not followed.
A resident with behavioral and psychiatric diagnoses physically assaulted another resident in the dining room, resulting in a failure to protect the victim from abuse. The incident was witnessed by staff, and although the assaulted resident did not sustain injuries or emotional distress, the event highlighted a lapse in preventing resident-to-resident abuse despite existing care plans and staff training.
Surveyors found that the facility failed to maintain kitchen equipment cleanliness, properly label and date food items, and remove expired products from storage. Observations included dirty equipment, undated and unlabeled foods, and expired items in the walk-in cooler. Staff interviews confirmed that these practices did not meet expected standards for food safety and sanitation.
Three residents with documented falls had their incidents omitted or inaccurately recorded in their MDS assessments, despite falls being noted in care plans and facility logs. Staff interviews confirmed that these falls should have been included in the MDS, and the omission was acknowledged by facility leadership.
Three residents with complex medical needs did not have comprehensive care plans developed or implemented, as required. Their electronic medical records contained blank care plans, with no documented focus areas, goals, or interventions to guide direct care staff. Staff interviews revealed that the MDS coordinator did not enter the care plans into the EMR, and the process for care plan development was not completed, despite facility policy requiring timely and individualized care planning.
A resident's admission MDS assessment was not completed and transmitted within the required 14-day period due to staffing shortages and turnover in the MDS department. Interim coverage by the DON, Director of Reimbursement, and an MDS Consultant was in place, but the assessment was finalized late, exceeding regulatory requirements.
A resident with severe cognitive impairment and a need for extensive assistance did not receive adequate oral care, as evidenced by missed documentation, visible buildup in the mouth, and inconsistent staff understanding of oral hygiene responsibilities. This failure was confirmed through observations, interviews, and record review, and placed the resident at risk of diminished quality of life.
Two residents receiving oxygen therapy did not have their oxygen humidifier bottles properly maintained, with one resident's humidifier found empty on multiple occasions and another resident's humidifier low on water while her concentrator was beeping. Both residents had significant medical conditions requiring oxygen, and staff interviews confirmed that humidifier maintenance was not consistently performed as required by facility policy.
A resident with diabetes and peripheral vascular disease experienced a change in condition when pain and an open wound developed on his right foot. Nursing staff noted the issue but did not notify the physician or responsible party, nor did they obtain wound care orders or escalate the concern. The resident's condition deteriorated, leading to multiple toe amputations and loss of independent mobility. Documentation and interviews revealed a lack of timely physician notification, missed podiatry appointments, and absence of staff training or competency checks related to change in condition and wound care.
A resident with diabetes and peripheral vascular disease did not receive scheduled podiatry care, and staff failed to promptly notify a physician after a change in the resident's foot condition was observed. The delay in assessment and intervention led to the development of gangrene, resulting in multiple toe amputations and loss of independent mobility.
A resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors repeatedly attempted to leave the facility without effective interventions being implemented. The resident ultimately eloped and was found walking outside by staff, despite prior documentation of multiple elopement attempts and the need for supervision.
A resident with intellectual disabilities and multiple medical conditions did not receive timely habilitative therapy services (PT, OT, ST) as agreed upon in an IDT meeting, due to the facility's failure to complete and submit required PASRR documentation and therapy evaluations within the mandated timeframe. Staff turnover and incomplete records contributed to the lack of service initiation, leaving the resident without the specialized therapies needed for optimal functioning.
A facility failed to develop a comprehensive care plan within the required timeframe for a resident with multiple health issues, including dementia and recurrent Enterocolitis. The resident's care plan was not completed due to communication and staffing issues, as revealed in interviews with the DON and MDS coordinator. This oversight could risk the resident not receiving necessary care.
A facility failed to maintain an effective infection control program when an Administrator entered a resident's room, who was on droplet precautions for COVID-19, without proper PPE and hand hygiene. The resident, an elderly female with COVID-19, was on strict isolation. The Administrator did not wear a gown, gloves, or N95 mask, and failed to sanitize his hands, potentially exposing others to the virus. Interviews with the DON and ADON confirmed non-compliance with infection control policies.
Failure to Provide Timely Catheter Care and Maintain Resident Dignity
Penalty
Summary
A resident with neuromuscular dysfunction of the bladder, paraplegia, osteomyelitis, diabetes, and a right below-knee amputation, who was dependent on staff for toileting and had an indwelling catheter, experienced a failure in care when his foley catheter began leaking and was not draining properly. The resident had physician orders for the catheter to be flushed every shift and as needed, and to change the catheter if there was leakage, blockage, or sedimentation. On the day of the incident, the resident was found soaked in urine, with both his bed linen and t-shirt wet, and he requested assistance from an LVN to change his catheter. Despite the resident's request and the presence of standing orders, the LVN did not flush or change the catheter, instead telling the resident that she wanted to call the physician first. The resident, not wanting to wait and still sitting in urine, called 911 for assistance. EMS staff who arrived observed the resident covered in urine from his mid-chest down. The LVN did not provide any catheter care or hygiene assistance prior to the resident's transport to the hospital. Upon return from the hospital, the resident reported the incident to another LVN, who did not escalate the issue. The Director of Nursing confirmed that this was the first time she was made aware of the incident. The facility's policy requires staff to treat residents with kindness, respect, and dignity, and to support residents in exercising their rights. The failure to provide timely catheter care and hygiene resulted in the resident being left in a urine-soaked state and ultimately being transported to the hospital for a dislodged catheter and a urinary tract infection.
Failure to Provide Appropriate Catheter Care and Prevent UTI
Penalty
Summary
A deficiency occurred when a resident with a history of neuromuscular bladder dysfunction, paraplegia, diabetes, and a stage 4 pressure ulcer did not receive appropriate catheter care as ordered. The resident had physician orders for a Foley catheter, including instructions to flush the catheter every shift and as needed, and to change the catheter in cases of leakage, blockage, or sedimentation. On the day of the incident, the resident's catheter was leaking and not draining properly, resulting in the resident being soaked in urine and experiencing a full, tender bladder. Despite the resident's request for assistance, the assigned LVN did not flush or change the catheter as ordered, nor did she clean the resident or address the leakage. The LVN stated she intended to call the physician before taking action, even though standing orders were in place to change the catheter for leakage. She also reported not having previously changed a catheter at the facility and only working PRN. The resident, after not receiving help, called 911 and was transported to the emergency room, where it was found that the catheter was dislodged and a UTI was present. EMS personnel and another LVN confirmed the resident was covered in urine, the catheter was leaking, and the tip was improperly positioned in the urethra rather than the bladder. Facility policy required replacing the catheter and collecting system using aseptic technique in cases of leakage or system compromise, and to observe and report complications such as urinary retention or infection. The DON confirmed that the nurse should have flushed or changed the catheter per orders and policy. The incident was not documented accurately in the nursing notes, and the DON was not made aware of the situation until after the resident filed a grievance.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from abuse by another resident in the facility's dining room. One resident, with a history of dementia, schizoaffective disorder, bipolar disorder, and traumatic brain injury, physically assaulted another resident by punching him in the face. The incident was witnessed by dietary staff, and the aggressor was noted to have been upset because the other resident was looking at him while he ate. There was no verbal exchange prior to the assault, and the two residents were immediately separated by staff. The resident who was assaulted had a history of malnutrition, myocardial infarction, Type 2 diabetes, unspecified dementia, and depression, and was assessed after the incident. He did not exhibit any physical injuries or pain, and subsequent assessments showed no changes to his skin or signs of emotional distress. The facility's investigation included witness statements and post-incident monitoring, but the event itself demonstrated a failure to ensure the right of the resident to be free from abuse. Interviews with facility leadership revealed that staff were aware of the potential for resident-to-resident abuse, particularly among residents with behavioral issues. The facility had policies and care plans in place for managing behaviors, but the incident still occurred. Staff had been trained on abuse and neglect, and interventions such as monitoring and redirection were described, but these measures did not prevent the physical assault in the dining area.
Deficient Food Storage, Labeling, and Kitchen Cleanliness
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and cleanliness. The commercial can opener had a dark substance around the cutting blades and holder, and the deep fryer contained dark grease with white floating substances, with uncertainty about when the grease was last changed. In the walk-in cooler, several food items were found either expired, undated, or unlabeled, including dairy drinks, sandwich meats, coleslaw, crushed pineapple, cottage cheese, margarine, and other products. Some items were partially exposed or had unknown substances, and all undated and unlabeled items were removed by the cook during the inspection. Interviews with dietary staff and facility leadership confirmed expectations that all food items should be labeled with identification and expiration dates, and that the kitchen should be kept clean. The Dietary Manager was noted to be new to the position and facing challenges, and the Registered Dietitian stated that prepared foods should be discarded after three days if unused. Facility policy requires food storage areas to be maintained in a clean, safe, and sanitary manner, with prepared foods dated and sealed, and daily checks of refrigerator and freezer temperatures.
Failure to Accurately Document Falls in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the fall history of three residents. For one resident with diagnoses including congestive heart failure and muscle weakness, two unwitnessed falls that occurred on the same day were documented in the care plan and nurses' notes, but were not recorded in the annual MDS assessment. Interviews with the DON and Director of Reimbursement confirmed that these falls should have been included in the MDS, and that omission could impact care planning. Two additional residents with multiple falls documented in care plans and the facility's accident and incident logs also had MDS assessments that either left the fall history section blank or incorrectly coded no falls since admission or the prior assessment. These inaccuracies were confirmed through record review and staff interviews, with staff acknowledging that the MDS should have reflected the residents' fall history as documented elsewhere in their records.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable objectives and timetables for three residents, as required by regulation. For each of these residents, the electronic medical records contained blank care plans with no focus areas, goals, or interventions documented to guide direct care staff. The residents involved had complex medical histories, including conditions such as chronic obstructive pulmonary disease, hypertension, heart failure, Parkinson's disease, visual impairment, anxiety, depression, dementia, peripheral neuropathy, and osteoarthritis. Their Minimum Data Set (MDS) assessments indicated varying levels of cognitive function and assistance needs, but these assessments were not translated into individualized care plans. Interviews with facility staff, including the DON, ADON, and RDO, revealed that the MDS coordinator did not enter the care plans into the electronic medical record system, and that the process for developing care plans from MDS-triggered areas was not completed for the affected residents. Staff acknowledged that the responsibility for care plans lay with the DON and MDS nurse, and that there had been turnover in the MDS nurse position. The facility's policy required comprehensive, person-centered care plans to be developed within seven days of the required assessment and updated as resident conditions changed, but this was not followed for the residents in question.
Failure to Complete and Transmit Admission MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit an accurate and complete Minimum Data Set (MDS) assessment for a resident within the required 14-day timeframe following admission. Record review showed that the resident's admission MDS assessment was signed as completed 18 days after admission, exceeding the regulatory requirement. The delay was confirmed through interviews with facility staff, including the DON, Director of Reimbursement, and MDS Consultant, who indicated that the MDS process was being managed remotely due to staffing shortages and that the facility was in the process of hiring a new MDS nurse. The previous MDS Coordinator had recently left, and interim coverage was being provided by the Director of Reimbursement and an MDS Consultant. The deficiency was identified for one resident whose admission MDS assessment was not completed and transmitted to the CMS system within the mandated period. The facility's policy was to follow the RAI manual for MDS completion, but due to turnover and gaps in MDS staffing, the assessment was not finalized on time. Staff interviews confirmed the late completion and acknowledged the staffing challenges that contributed to the delay.
Failure to Provide Adequate Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically oral care, for a resident with severe cognitive impairment who required extensive staff support for personal hygiene. Record review showed gaps in documentation of oral care over several days, and interviews with staff revealed uncertainty about the frequency and responsibility for providing oral care. Observations confirmed the resident had dried brown crustiness on her lips and a dry brown substance coating her teeth, indicating inadequate oral hygiene. The resident's family member also reported concerns about the state of the resident's mouth and had previously requested assistance with oral care. Staff interviews indicated inconsistent understanding and training regarding oral care procedures, with some staff unsure of the required frequency and others stating oral care should be performed daily or after meals. The facility's own policies required assistance for residents unable to perform activities of daily living, including oral hygiene, but these were not consistently followed. The lack of adequate oral care placed the resident at risk of diminished quality of life or decreased self-esteem, as directly stated in the report.
Failure to Maintain Oxygen Humidifiers and Equipment for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with severe cognitive impairment and diagnoses including Alzheimer's Disease and heart failure, observations on two consecutive days revealed that the oxygen humidifier bottle attached to her concentrator was empty while she was receiving oxygen via nasal cannula. Facility records indicated that the oxygen tubing and water were to be changed weekly and as needed, and the care plan specified continuous oxygen therapy. The Director of Nursing confirmed that nurses were responsible for refilling humidifiers, which should occur on Sundays, but the humidifier was found empty during the survey. For another resident with moderate cognitive impairment and diagnoses including diabetes and heart failure, observations showed that her oxygen humidifier bottle was low on water and her oxygen concentrator was beeping on two occasions. The resident reported discomfort from a dry nose and recalled nearly running out of water in the humidifier. Staff interviews revealed that daily checks of humidifier bottles were performed, but the responsibility for refilling them was assigned to Sunday night staff. Facility policy required periodic re-checks of the water level in humidifying jars, but this was not consistently followed, resulting in inadequate respiratory care for the residents.
Failure to Notify Physician of Change in Condition Resulting in Amputation
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's physical condition. The resident, who had a history of intellectual disabilities, Down syndrome, Type II diabetes mellitus with circulatory complications, peripheral vascular disease, and acute osteomyelitis, reported pain in his right foot. Upon assessment by a nurse, a small opening and swelling were noted on the third toe of the right foot, but there was no documentation that the physician, nurse practitioner, or responsible party were notified of this change. The nurse applied topical antibiotic ointment and a bandage without obtaining an order or further escalating the issue. The resident was not seen by the scheduled podiatrist, and there was no documentation explaining the missed appointment. Over the following days, the resident's condition worsened, and it was only after the resident requested an evaluation from the nurse practitioner that a full assessment was conducted. At that time, the third toe was found to have black eschar, maceration, foul odor, and exposed bone, leading to the resident being sent to the hospital. The resident subsequently underwent amputation of the third toe, and later, the remaining toes on the right foot due to ongoing infection and complications. The resident, who had previously been independent in ambulation, became wheelchair-bound as a result. Record reviews and interviews revealed a lack of documentation regarding timely physician notification, absence of wound care orders prior to the incident, and no evidence of staff following up on the resident's change in condition. Staff interviews indicated poor recall of the incident, lack of use of change in condition forms, and no clear communication with the physician or responsible party. Additionally, there was no evidence of staff training or competency checks related to change in condition, wound care, or physician notification in personnel files. The facility's policies did not provide specific guidance on wounds, skin, or foot problems, and there was no documentation of appropriate notifications or interventions at the time of the resident's decline.
Failure to Provide Timely Podiatry Care and Physician Notification Resulting in Amputation
Penalty
Summary
A resident with a history of intellectual disabilities, Down syndrome, Type II diabetes mellitus with circulatory complications, peripheral vascular disease, and acute osteomyelitis was admitted and readmitted to the facility. The resident was care planned for risks related to fragile skin and peripheral vascular disease, with interventions including monitoring for injury, infection, and ulcers, and education on proper foot care. Despite being scheduled for podiatry services, the resident was not seen as planned, and there was no documentation or explanation for the missed appointment. Additionally, there were no wound care orders in place for the months leading up to the incident. On one occasion, the resident complained of pain in his right foot, and a nurse noted a small opening and swelling on the third toe. The nurse cleansed the area and applied a topical antibiotic and bandage but did not document notifying the physician, nurse practitioner, or responsible party, nor did they complete a change in condition form or incident report. There was no evidence of further assessment or physician notification until several days later, when the resident requested evaluation from a nurse practitioner due to ongoing pain. At that time, the toe was found to be ischemic, macerated, with foul odor and exposed bone, leading to the resident being sent to the hospital, where gangrene and diabetic foot infection were diagnosed, resulting in amputation of the third toe and, later, the remaining toes on the right foot. The resident, who had previously been independent with ambulation and activities of daily living, became wheelchair-dependent following the amputations. Interviews with staff revealed a lack of recall regarding proper notification and documentation procedures, and personnel files showed no evidence of completed training or competencies related to wound care, change in condition, or physician notification. Facility policies required timely notification of changes in resident condition, but there was no documentation that these procedures were followed in this case. The failure to provide timely podiatry care and to accurately and thoroughly report and address the resident's change in condition resulted in significant harm, including loss of all toes on the right foot and decreased mobility.
Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with a known history of exit-seeking behaviors and wandering. The resident, who had diagnoses including dementia with behavioral disturbance, depression, hypertension, psychosis, and schizoaffective disorder, was assessed as having severely impaired cognitive skills and was independent in ambulation but required supervision with activities of daily living. Despite multiple documented attempts to elope on a single day, the resident was only re-directed and re-educated each time, with no additional safety measures or interventions implemented to address the ongoing risk. The resident's baseline care plan identified him as a fall and safety risk, with instructions to re-direct him to use a walker and return to his room. However, the admission elopement assessment was not completed for safety measures, and the care plan was not updated to reflect the resident's elopement risk until after the incident. On the day of the elopement, the resident was last seen being escorted to his room, but was later found walking on the street outside the facility by a staff member, who then returned him to the facility. The resident was confused at the time and could not explain where he was going. Interviews with staff confirmed that the resident was known to wander and required frequent re-direction, but no staff reported that he had previously eloped. Observations revealed that some egress doors had added keypads and alarms, but not all doors had delayed egress hardware installed at the time of the incident. The facility's policies required staff to report and prevent resident departures, but these measures were not effectively implemented prior to the resident's elopement.
Failure to Coordinate and Initiate PASRR Habilitative Therapy Services
Penalty
Summary
The facility failed to coordinate with the Pre-Admission Screening and Resident Review (PASRR) program and did not initiate habilitative therapy services within the required timeframe for a resident with intellectual and developmental disabilities. Despite an interdisciplinary team (IDT) meeting where the need for specialized assessments and services in physical therapy (PT), occupational therapy (OT), and speech therapy (ST) was agreed upon, the facility did not complete or submit the necessary therapy evaluations and NFSS forms within 30 days as required. As a result, requests for these services were denied due to missing or late documentation, and the resident did not receive timely habilitative therapies as outlined in the PASRR service plan. The resident involved was an adult male with diagnoses including intellectual disabilities, Down syndrome, diabetes mellitus type II, peripheral vascular disease, and acute osteomyelitis of the right ankle and foot. At the time of the deficiency, he had moderate cognitive impairment and required assistance with all activities of daily living. He had undergone multiple surgeries resulting in the loss of all toes on his right foot, which left him unable to walk and reliant on a wheelchair for mobility. The resident expressed a desire to regain the ability to walk, but was not receiving the agreed-upon therapy services due to the facility's failure to complete the necessary PASRR processes. Interviews with facility staff revealed that there had been a change in facility ownership and staff turnover, resulting in incomplete records and a lack of continuity in care coordination. The current Director of Rehabilitation and MDS Coordinator were unable to account for the actions or documentation of previous staff, and there was no evidence that the required therapy assessments or service initiation had occurred within the mandated timeframe. Facility policy required that all specialized services identified by the Local Authority be added to the care plan and initiated within 25 days, but this was not followed in this case.
Incomplete Care Plan for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed within 7 days after the completion of the comprehensive assessment for a resident. The resident, an elderly male with multiple diagnoses including recurrent Enterocolitis due to Clostridium Difficile, schizoaffective disorders, and unspecified dementia, was admitted to the facility. His initial MDS assessment indicated severely impaired cognition with a BIMS score of 03, and he required partial/moderate assistance with daily activities such as eating and oral hygiene. However, a review of his electronic health record revealed that his care plan was not completed. Interviews with the Director of Nursing (DON) and the MDS coordinator highlighted a lack of communication and staffing issues as contributing factors to the incomplete care plan. The DON mentioned being on vacation and the responsibility falling on the MDS coordinator, who was unsure why the care plan was not completed. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan within seven days of the comprehensive assessment, but this was not adhered to, potentially placing the resident at risk of not receiving necessary care or services.
Inadequate Infection Control Practices by Administrator
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of the Administrator who did not adhere to proper infection control protocols. The Administrator entered the room of a resident who was on droplet precautions for COVID-19 without donning the appropriate personal protective equipment (PPE), which included a gown, gloves, and an N95 mask. Additionally, the Administrator did not sanitize his hands before entering or after exiting the resident's room, and he left the door open, which could potentially expose others to the virus. The resident involved was an elderly female with a history of lymphedema, anemia, and hypertension, who had tested positive for COVID-19 and was placed on strict isolation. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. The Administrator assisted the resident with her meal without following the necessary infection control measures, which included not sanitizing his hands or wearing the required PPE. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that the Administrator's actions were not in compliance with the facility's infection control policies. The DON stated that the Administrator's failure to wear the required PPE and sanitize his hands placed residents and staff at risk of spreading infection. The facility's infection control policy and CDC guidelines emphasize the importance of using PPE and hand hygiene to prevent the transmission of communicable diseases.
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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