River Bend Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Seguin, Texas.
- Location
- 1339 Eastwood Dr, Seguin, Texas 78155
- CMS Provider Number
- 676274
- Inspections on file
- 37
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at River Bend Healthcare during CMS and state inspections, most recent first.
A resident admitted for rehabilitation with severe cognitive impairment and requiring IV antibiotics did not have a baseline care plan developed within 48 hours that included interventions for IV access, despite documentation of the need for IV therapy in nursing notes and physician orders. This omission was not identified during team reviews, resulting in a lack of clear instructions for staff to manage the resident's IV care.
A resident was admitted with an IV access and received IV medications and fluids without a physician's order for the IV access. Nursing staff administered treatments through the IV and later established a new IV site when the original became occluded, again without obtaining or verifying a physician's order or notifying the physician. The care plan and MDS assessment did not document the IV access, and facility policy requiring timely physician orders was not followed.
A resident with Parkinson's disease and severe cognitive impairment was given an incorrect dose of Carbidopa-Levodopa when staff administered five tablets at once from an outdated blister pack, despite a recent order change to split the dose throughout the day. The error occurred because the discontinued blister pack remained on the medication cart, and staff failed to verify the current order on the MAR, resulting in the resident being hospitalized for altered mental status.
A resident with severe cognitive impairment and multiple medical conditions experienced a medication error, a change in condition, and was transferred to the hospital. Facility staff did not immediately notify the responsible party as required, with both the charge nurse and ADON assuming the other would make the notification. The responsible party was only informed the following day, contrary to facility policy.
The facility failed to maintain food safety standards, with issues such as uncovered and undated beverages, improperly sealed and dated dry foods, and unsanitary temperature-taking practices. Additionally, a staff member with facial hair was observed preparing food without a beard restraint, violating hygiene protocols. These deficiencies could lead to foodborne illnesses among residents.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing hospice services, pain management, and communication needs. A resident's care plan was deactivated and not updated for hospice services, another lacked pain management strategies despite hospital transfers for pain, and a third did not reflect full code status, ADL assistance, or Spanish-only communication needs. The DON and SW acknowledged these oversights, which are contrary to the facility's policy requiring timely care plan development.
The facility failed to revise care plans for four residents after assessments, including significant changes in condition and hospital returns. A resident's care plan was not updated quarterly, another's was not revised after a significant change, and two others were not reviewed post-assessment. The DON acknowledged these oversights, emphasizing the importance of current care plans for appropriate resident care.
The facility failed to provide properly prepared pureed diets, serving meat with an incorrect consistency during meals. The dietary manager used milk instead of gravy for pureeing, contrary to recipe instructions, and lacked training on meal texture preparation. The facility had no policy on diet textures, posing risks of choking or aspiration pneumonia.
The facility failed to ensure that 10 staff members, including CNAs, CMAs, hospitality staff, the Dietary Manager, and the Activity Director, completed their mandatory QAPI annual training. This oversight was due to the absence of the Human Resources staff responsible for training compliance, who was on vacation. The lack of training could place residents at risk due to care by insufficiently trained staff.
The facility did not ensure that 10 staff members, including CNAs, CMAs, hospitality staff, the Dietary Manager, and the Activity Director, completed their mandatory annual ethics training. The oversight was acknowledged by the Administrator and DON, who noted that the Human Resources staff responsible for tracking training was on vacation and had recently been promoted from a CNA position. This lack of training could potentially affect residents by placing them at risk of poor care or victimization.
A facility failed to accurately assess a resident's range of motion in the MDS, recording no impairment despite the resident having a left arm contracture. The resident, who was receiving physical therapy, had a known limitation in range of motion. The DON acknowledged the inaccuracy, which was attributed to a contracted MDS nurse's error.
A resident with COPD was observed receiving oxygen at rates higher than the physician-ordered 2 liters per minute. Despite the order, the resident received 2.5 and 3.5 liters per minute on different occasions. Interviews with nursing staff revealed a lack of adherence to the prescribed oxygen rate, contrary to the facility's policy.
The facility failed to remove expired medications from their storage areas, with an expired bottle of Ocular Vitamins found in the Recovery medication room and an expired antimicrobial skin and wound gel in the Recovery nursing cart. The ADON and Recovery nurse acknowledged the oversight, which contradicts the facility's policy requiring regular checks and removal of expired medications.
A resident continued to receive Melatonin 5 mg for insomnia despite a pharmacist's recommendation and physician agreement to gradually reduce and discontinue the medication. The oversight was acknowledged by the DON, who failed to implement the necessary changes, resulting in the continued administration of an unnecessary drug.
A treatment cart was found unlocked and unattended, containing medications and other items, posing a risk to residents and visitors. The wound care nurse admitted to leaving it unsecured, and the DON confirmed the importance of keeping it locked to prevent unauthorized access.
A facility failed to maintain proper documentation for a resident receiving hospice care, as there were no hospice nursing notes or records of visits available. The resident had complex medical conditions, and the lack of documentation could affect the continuity of care. Observations showed hospice staff visited the resident, but their notes were not integrated into the facility's records. Facility staff were unclear about who was responsible for ensuring hospice notes were included, and the DON did not provide the hospice documentation policy when requested.
The facility failed to maintain infection control standards, as evidenced by a resident's uncovered suction tube and improper incontinence care by a CNA. The suction tube was left uncovered, risking infection, while the CNA used improper techniques, such as using a single wipe for multiple passes and handling clean items with dirty gloves. Both incidents involved residents with severe cognitive impairments.
A resident with dementia and hemiplegia was found in a wheelchair with the call light out of reach, contrary to facility policy. Staff interviews confirmed the call light should always be accessible to prevent delays in care. The facility's policy requires call lights to be within easy reach when residents are in bed or a chair.
A facility failed to secure medications properly on one of its medication carts, leading to the disappearance of Norco tablets. An RN left the medication cart keys unattended, resulting in the loss of approximately forty tablets. The incident involved a resident with multiple diagnoses, including congestive heart failure and diabetes, who was not in pain when the medication went missing. The issue was identified as past non-compliance, as it was corrected before the survey began.
A resident's narcotic pain medication went missing from the medication cart, resulting in missed doses and unmanaged pain. The incident involved a cognitively intact resident with chronic pain and other health issues. The deficiency was identified when a nurse discovered the missing tablets during a medication pass. The facility's investigation revealed lapses in protocol, including unattended keys and improper narcotic counts, contributing to the misappropriation.
A resident's narcotic pain medication was not properly counted, and keys to the medication cart were left unsecured, resulting in the diversion of 81 tablets and missed doses. The resident, with a history of chronic pain, reported experiencing pain due to the missed medication. Observations revealed further issues with the narcotic count process, and staff interviews indicated a lack of adherence to proper procedures.
A resident with osteoporosis was taken to a hospital appointment without her wheelchair leg rests and foot pedals, resulting in a fractured femur. The Maintenance Director, unaware of the need for these assistive devices, did not report the incident immediately. Staff interviews revealed a lack of communication and awareness regarding the resident's needs.
The facility failed to develop and implement comprehensive care plans for three residents requiring wheelchair leg rests and foot pedals. Observations and interviews confirmed the omission of these critical details, posing potential risks to resident safety.
A facility failed to report an incident where a resident's leg got caught under a moving wheelchair during transport, leading to significant pain and a delay in treatment. The Maintenance Director, acting as a backup van driver, did not attach necessary leg rests and foot pedals and failed to report the incident immediately.
Failure to Develop Baseline Care Plan for IV Access Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted for rehabilitation care due to a urinary tract infection and required intravenous antibiotics. Upon admission, the resident was noted to have severe cognitive impairment and an intravenous line in place for administration of meropenem, a broad-spectrum antibiotic. However, the baseline care plan did not include any interventions or instructions to support the resident's intravenous access, despite documentation in the nursing progress notes and physician's orders indicating the need for IV therapy. Interviews with facility leadership confirmed that the omission was not identified during interdisciplinary team reviews, and the MDS nurse did not document the IV access in the care plan template. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, including all necessary information to meet the resident's immediate healthcare needs. The lack of a documented plan for IV access meant that staff did not have clear guidance on how to manage this critical aspect of the resident's care.
Failure to Obtain Physician Order for IV Access Prior to Administration
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, a resident was admitted with an intravenous (IV) access in place, but there was no physician's order for the IV access upon admission. Nursing staff documented the presence of the IV and administered medications and fluids through it without verifying or obtaining the necessary physician's order for the IV access itself. The resident was later prescribed IV antibiotics, but the order for the IV access remained missing. Further review of the resident's records showed that the care plan did not include interventions to support the need for IV access, and the MDS assessment did not document the IV access in the care plan template. When the initial IV access became occluded, a nurse discontinued it and established a new IV access in a different location, again without a physician's order or notifying the physician of the change. The nurse assumed that an order for IV antibiotics implied an order for IV access, and did not check the physician's orders or contact the physician for clarification. Interviews with facility leadership confirmed that the admission nurse was responsible for securing the order for IV access, and that the lack of an order should have been identified during the review of new admissions and when the antibiotic order was received. The facility's policy required timely physician orders for all treatments and interventions, but this was not followed in the case of the resident who received IV medications and fluids without a physician's order for the IV access.
Medication Administration Error Due to Failure to Update and Remove Discontinued Medication Blister Pack
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, dementia, diabetes, and a recent hip fracture was administered an incorrect dosage of Carbidopa-Levodopa. Upon admission, the resident had a hospital discharge order for Carbidopa-Levodopa 25-100mg, five tablets daily, but the order did not specify administration times. Facility staff entered this order into the electronic medical record (EMR) and began administering five tablets at once, as indicated by the hospital discharge summary and the resident's home medication bottle. The medication was administered from both the resident's personal supply and pharmacy blister packs, which were labeled for five tablets per dose. Multiple staff, including medication aides and nurses, followed this order and administered the medication as written, without clarifying the timing or questioning the appropriateness of the dose frequency. Subsequently, the nurse practitioner reviewed the medication regimen and changed the order to split the total daily dose into multiple administrations throughout the day. New blister packs were ordered to reflect the updated dosing schedule, and a change in direction sticker was placed on the old blister pack. However, the discontinued blister pack with the previous instructions remained on the medication cart. On the day of the incident, a medication aide administered five tablets at once from the old blister pack, not noticing the change in direction sticker or verifying the new order on the MAR. This resulted in the resident receiving a higher dose than prescribed under the new order. The error was discovered later in the day when another medication aide noticed a discrepancy between the MAR and the blister pack, and the resident exhibited altered mental status and lethargy. Interviews with staff revealed a lack of critical thinking and failure to follow the five rights of medication administration, including verifying that the medication label matched the current physician order and MAR. The medication aide who administered the incorrect dose stated she followed the blister pack instructions and did not see the change in direction sticker. Other staff members indicated that the discontinued blister pack should have been removed from the cart when the order was changed. The resident was subsequently transferred to the hospital for evaluation after the medication error was identified and a change in condition was observed.
Failure to Immediately Notify Responsible Party of Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the responsible party of a resident when there was a significant change in the resident's condition, a medication error, and a subsequent transfer to the hospital. The resident involved was an elderly female with severe cognitive impairment, Parkinson's disease, a hip fracture, type 2 diabetes, and dementia. Her care plan included medication management for Parkinson's disease. On the day of the incident, the resident experienced altered mental status and shortness of breath after a medication error, which led to her being transferred to the hospital. Documentation showed that the resident's emergency contacts were listed in her records, and facility policy required prompt notification of responsible parties following significant events such as medication errors or transfers. However, interviews with staff revealed that neither the charge nurse nor the ADON notified the responsible party at the time of the incident. The charge nurse assumed the ADON would make the notification, while the ADON believed it was the charge nurse's responsibility. Both staff members acknowledged that the responsible party was not informed until the following day, when they arrived at the facility. The responsible party confirmed during an interview that they were not notified of the medication error, change in condition, or hospital transfer until after the fact. Facility records and staff interviews consistently indicated that the required immediate notification did not occur, despite the facility's policy and the resident's need for such communication due to her cognitive impairment and medical condition.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Several issues were identified, including the improper storage and labeling of food items. Four pitchers of beverages were found in the refrigerator without covers or dates indicating when they were prepared. Additionally, a box of powdered sugar and bags of spaghetti and elbow noodles were not dated with their opening dates, which is crucial for tracking freshness and preventing contamination. The survey also revealed improper practices in taking food temperatures. A staff member was observed using a digital thermometer to measure the temperature of various food items without properly sanitizing it between uses. The thermometer was wiped with a napkin instead of an alcohol swab, which could lead to cross-contamination between food items. This practice was acknowledged by the staff as potentially hazardous, as it could result in foodborne illnesses among residents. Furthermore, the facility did not ensure that staff adhered to hygiene protocols regarding hair restraints. A staff member with facial hair was observed preparing food without wearing a beard restraint, which is required to prevent hair from contaminating food. Despite being questioned about the importance of beard nets, the staff member continued to prepare food without one until provided with a restraint by the dietary manager. The facility's policies and the U.S. Food Code emphasize the necessity of hair restraints to maintain food safety and prevent contamination.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. Resident #6's care plan did not reflect his hospice services, as it was deactivated and not updated to include his current care needs. The Director of Nursing (DON) acknowledged that the lack of an active care plan could lead to staff being unaware of how to properly care for Resident #6. Resident #22's care plan did not address his pain management needs, despite having a diagnosis of shoulder pain and receiving scheduled pain medication. The resident had been transferred to a local acute hospital due to shoulder pain, but the care plan did not reflect any pain management strategies. The DON admitted that forgetting to develop a care plan for pain management could result in inadequate pain management for the resident. Resident #62's care plan failed to address his full code status, need for assistance with activities of daily living (ADLs), and his communication needs as a Spanish-only speaker. The Social Worker (SW) and DON both recognized the importance of including these elements in the care plan to ensure staff are aware of the resident's needs and preferences. The facility's policy requires comprehensive care plans to be developed within seven days of the completion of the resident's comprehensive assessment, but this was not adhered to in these cases.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for four residents were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. Resident #4's care plan was not revised quarterly, and there was no current care plan available in the electronic health record. The Director of Nursing (DON) acknowledged the oversight and emphasized the importance of having updated care plans to ensure residents receive necessary services. Resident #25's care plan was not revised after a significant change in condition and upon return from the hospital. The care plan had a start date and target date but was not reviewed or revised for the quarter. The DON admitted that the facility was trying to catch up on care plans that were not completed before her tenure and highlighted the need for up-to-date care plans for proper resident care. Resident #30's care plan was not reviewed or revised after the quarterly Minimum Data Set (MDS) was completed. The DON was unsure why the care plan was not updated, despite the facility generally holding interdisciplinary team meetings after quarterly MDS completion. Similarly, Resident #39's care plan was not revised after returning from the hospital and experiencing a significant change in condition. The DON admitted the oversight and acknowledged the necessity of revising care plans to reflect current resident needs.
Failure to Provide Properly Prepared Pureed Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for residents on a pureed diet. During a breakfast meal, the meat served to residents on a pureed diet was observed to have a grainy, fine ground meat consistency rather than the required pudding consistency. The dietary manager (DM) attempted to correct the texture by mashing the meat with a plastic spoon and later pureeing it further, but this action was taken only after most of the meals had already been served. Additionally, during the preparation of a lunch meal, the DM used milk instead of gravy to puree chicken fried steak, contrary to the recipe instructions. Interviews revealed that the DM had not received in-service training on meal texture preparation and was unaware of the need to follow the recipe book for diet preparation. The facility did not have a policy regarding diet textures and preparation, relying instead on recipe instructions. The DM and the Director of Nursing (DON) acknowledged the risk of choking or aspiration pneumonia if residents received food that was not the correct consistency. The Administrator (ADM) confirmed that pureed diets should have a pudding consistency to prevent such risks.
Failure to Complete Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that 10 out of 19 staff members completed their mandatory Quality Assurance Performance Improvement (QAPI) annual training. The staff members who did not complete the training included CNAs, CMAs, hospitality staff, the Dietary Manager, and the Activity Director. The lack of training was identified through a record review of the annual staff training information, which revealed that these staff members had not fulfilled the QAPI training requirement. During an interview, the Administrator and Director of Nursing (DON) acknowledged that the staff had not completed their mandatory QAPI training. They attributed this oversight to the absence of the Human Resources staff, who was on vacation at the time. The responsibility for ensuring the completion of mandatory training fell to the Human Resources staff, who had recently been promoted from a CNA position. The DON suggested that the staff might be in the process of catching up on missing trainings. The report indicates that this failure could place residents at risk due to care being provided by insufficiently trained staff.
Failure to Complete Mandatory Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that compliance and ethics training was completed for 10 out of 19 employees reviewed for orientation training. These employees included CNAs, CMAs, hospitality staff, the Dietary Manager, and the Activity Director. The record review revealed that these staff members had not completed their mandatory annual ethics training. During an interview, the Administrator and DON acknowledged the oversight, noting that the Human Resources staff responsible for tracking training was on vacation and had recently been promoted from a CNA position. This lack of training could potentially affect residents by placing them at risk of poor care or victimization due to the staff's lack of knowledge on resolving issues or dealing with residents appropriately.
Inaccurate MDS Assessment of Resident's Range of Motion
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's functional limitation in range of motion, specifically for a resident with left arm impairment. The quarterly MDS assessment inaccurately recorded no impairment to the upper extremity, despite the resident having a known contracture and limitation in range of motion in the left arm. This discrepancy was identified through observations, interviews, and record reviews, which revealed that the resident had been receiving physical therapy for the impairment since admission. The Director of Rehab confirmed the resident's limitation in range of motion, and the DON acknowledged the inaccuracy in the MDS assessment, attributing it to the contracted MDS nurse's failure to code the impairment correctly. The facility's policy and the CMS MDS 3.0 Manual emphasize the importance of accurate assessments to describe residents' capabilities and identify impairments, highlighting the significance of this deficiency.
Failure to Adhere to Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD), as evidenced by discrepancies in the oxygen administration rate. The resident, a male with an intact cognitive function, had a physician's order for oxygen at 2 liters per minute via nasal cannula. However, observations revealed that the resident was receiving oxygen at higher rates of 2.5 and 3.5 liters per minute on separate occasions. This inconsistency in oxygen administration was not in line with the physician's order. Interviews with the nursing staff, including an RN and the Director of Nursing (DON), confirmed that the oxygen rate was not maintained as per the physician's order. The RN acknowledged that the oxygen rate was above the prescribed 2 liters per minute and was unsure of the reason for the increase. The DON stated that the facility's nurses should have adhered to the physician's order for the oxygen rate. The facility's policy on oxygen administration required verification of a physician's order, which was not followed in this instance.
Expired Medications Found in Facility's Medication Room and Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired medications from their storage areas. During an observation, a bottle of Ocular Vitamins, which expired in September 2024, was found in the Recovery medication room. The Assistant Director of Nursing (ADON) acknowledged the presence of the expired medication and stated that the facility's medication aides were responsible for weekly reviews of the medication room, while nurses were tasked with removing expired medications. However, the expired medication was not removed, which could lead to incorrect therapeutic effects if administered to residents. Additionally, an expired antimicrobial skin and wound gel, intended for hospital and professional use only, was found in the Recovery nursing cart. The gel had expired on August 1, 2024. The ADON confirmed that expired medications should not be present in nursing and medication aide carts, and it was the responsibility of the Recovery nurse to review and remove expired medications. The Recovery nurse, LVN-F, admitted to not knowing why the expired gel was still in the cart and confirmed that it should have been removed. The facility's policy, revised in April 2011, mandates checking expiration dates on medication labels, but this was not adhered to in these instances.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not discontinue Melatonin 5 mg for a resident with insomnia, despite the primary care physician agreeing to the pharmacist's recommendation for a gradual dose reduction and eventual discontinuation. The pharmacist had recommended this change on 08/21/2024, and the physician agreed on 09/18/2024. However, the resident continued to receive the medication as per the original order, which was not adjusted to reflect the agreed-upon changes. The resident, a male with a diagnosis of insomnia, had a BIMS score of 15, indicating intact cognitive function. The Director of Nursing (DON) acknowledged the oversight, stating that it was their responsibility to ensure adherence to pharmacist recommendations and physician orders. The facility's policy on pharmacy services emphasizes collaboration with staff and practitioners to address medication-related needs, but in this case, the necessary changes were not implemented, resulting in the continued administration of an unnecessary medication.
Unattended and Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an unlocked and unattended treatment cart on the 200 hall. During an observation, the surveyor found the treatment cart unlocked, with all drawers accessible, revealing multiple creams, scissors, and bottles of medications. This incident involved a wound care nurse, RN-G, who admitted to leaving the cart unlocked and acknowledged the importance of keeping it secured to ensure the safety of residents, visitors, and staff. The Director of Nursing (DON) confirmed that the treatment cart should not have been left unlocked, as it posed a safety risk. The DON expressed concern that an unlocked cart could allow unauthorized individuals, such as residents with dementia, to access medications and potentially ingest them. The facility's policy on administering medications, revised in April 2011, mandates that the medication cart must be kept closed and locked when out of the sight of the medication nurse or aide, highlighting a clear deviation from established procedures.
Lack of Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that hospice services met professional standards and principles for a resident receiving hospice care. Specifically, there were no hospice nursing notes, records of visits, or care documentation available for the resident at the facility. This lack of documentation could potentially place residents receiving hospice services at risk of not receiving their needed services and care, and a decreased continuity of care between facility staff and hospice staff. The resident in question had multiple complex medical conditions, including heart failure, cognitive decline, and muscle wasting, and was always incontinent of urine and bowel. Observations and interviews revealed that hospice staff visited the resident, but their documentation was not integrated into the facility's records. The hospice service binder at the nursing station contained minimal documentation, and there was confusion among facility staff about who was responsible for ensuring hospice notes were included in the resident's records. The Director of Nursing acknowledged the importance of having hospice notes available to ensure continuity of care but did not provide the facility's hospice documentation policy when requested. The hospice nurse also indicated uncertainty about how their notes were supposed to be integrated into the facility's records.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving residents. In the first incident, a suction tube Yankauer used by a resident was observed hanging on the nightstand without being covered in a plastic bag when not in use. This was confirmed by interviews with RN-E and the Director of Nursing (DON), who both acknowledged that the Yankauer should have been covered to prevent infection. The resident involved had severe cognitive impairment and required assistance with oral hygiene, making proper infection control practices crucial. In the second incident, a CNA was observed providing incontinence care to another resident using improper techniques. The CNA used a single wipe for multiple passes and touched a new, clean brief with old, dirty gloves. The CNA admitted to these actions during an interview, stating that she was nervous and forgot the proper procedure. The DON confirmed that the CNA should have used a new wipe for each pass and changed gloves before handling clean items. The resident involved had severe cognitive impairment and required assistance with personal care, highlighting the importance of adhering to infection control protocols.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach while the resident was positioned in his wheelchair. This deficiency was identified during an observation where the resident was found in his wheelchair in front of his bed, with the call light placed on the bed behind him, making it inaccessible. The resident, who has a history of dementia, hemiplegia, and muscle weakness, was unable to reach the call light to request assistance. This situation was compounded by the resident's low voice, which made it difficult for staff to hear his calls for help. Interviews with facility staff, including a CNA and an LVN, confirmed that the call light should have been within the resident's reach at all times, as per facility policy. The Director of Nursing also acknowledged that the resident's care might be delayed if the call light was not accessible. The facility's policy on answering call lights, revised in 2003, mandates that call lights be plugged in and within easy reach of residents when they are in bed or confined to a chair. The failure to adhere to this policy could result in delays in care and services for the resident.
Medication Security Lapse in LTC Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and that only authorized personnel had access to the keys for the medication cart. This deficiency was identified in one of the three medication carts reviewed for medication storage. Specifically, the non-compliance involved medication cart #2, where medications were not secured properly. The issue began when RN A left the medication cart keys unattended in her coat at the nursing station, which led to the disappearance of approximately forty Norco oral tablets (10-325 mg) and the narcotic sheet. The incident involved a resident who was not in pain at the time when his medication, Norco 10-325 mg, went missing. The resident was admitted with diagnoses including congestive heart failure, osteoarthritis, and type II diabetes. On the day of the incident, RN A reported that the medication count was accurate at the start of her shift, but later discovered the missing tablets. The Director of Nursing (DON) was notified, and the police were called to file a report. The deficiency was identified as past non-compliance, as the facility had corrected the issue before the survey began.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their narcotic pain medication, resulting in 81 tablets of Norco going missing from the medication cart. The incident involved a resident who was cognitively intact and had a history of chronic pain, alcohol-induced persisting dementia, and Type 2 diabetes with circulatory problems. The resident's scheduled Norco medication was not administered as prescribed on several occasions due to the missing tablets, which were never found. The deficiency was identified when LVN A discovered the missing narcotics during a medication pass. It was noted that LVN A did not count the narcotics with the off-going medication aide, and the keys to the medication cart were left unattended in a drawer at the nursing station. This lapse in protocol allowed for the possibility of the narcotics being taken without detection. The facility's investigation revealed that the narcotic count sheets were not properly maintained, and there was a lack of verification of medication and dosage during narcotic counts. Interviews with staff members indicated a lack of awareness of any drug diversion or misappropriation beyond the reported incident. The facility's policies on controlled substances and reporting of misappropriation were not adhered to, as evidenced by the improper handling and storage of narcotic keys and the failure to conduct narcotic counts as required. The resident expressed experiencing pain due to the missed doses, highlighting the impact of the deficiency on their quality of life.
Failure in Pharmaceutical Services Leads to Drug Diversion
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, leading to the misappropriation of narcotic pain medication. The resident, an elderly male with a history of alcohol-induced dementia, type 2 diabetes, and chronic pain, was prescribed Norco for pain management. However, the medication was not properly counted, and the keys to the medication cart were left unsecured, resulting in the diversion of 81 tablets and the resident missing four doses of his scheduled pain medication. The incident occurred when LVN A, responsible for the medication cart, did not count the narcotics with the off-going medication aide and left the keys unattended. This lapse in protocol allowed for the narcotics to be taken without detection. The resident's electronic medical records indicated that he did not receive his scheduled doses of Norco on specific dates, and although Tylenol was administered as an alternative, the resident reported experiencing pain due to the missed doses. Observations during the survey revealed further issues with the narcotic count process, as staff members were not verifying the medication or dosage during counts. Interviews with staff involved indicated a lack of adherence to proper procedures, such as counting narcotics together and securing keys. The facility's policies on controlled substances were not followed, contributing to the deficiency in pharmaceutical services.
Failure to Provide Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to ensure that Resident #1 had her leg rests and foot pedals on her wheelchair when she went to an appointment. This resulted in her unsupported right foot sliding off and getting caught under the moving wheelchair, leading to a fractured femur. The Maintenance Director, who was not the regular van driver, was unaware of the need for leg rests and foot pedals and did not report the incident immediately. Resident #1 had a history of osteoporosis and other conditions that made her bones fragile. She was cognitively intact and required moderate assistance with her activities of daily living. On the day of the incident, she was taken to a hospital appointment without her leg rests and foot pedals, which she usually had on her wheelchair for support. During the transport, her right leg slipped and got caught under the wheelchair, causing her significant pain and a fracture. Interviews with staff revealed that there was a lack of communication and awareness regarding the resident's need for leg rests and foot pedals. The Maintenance Director admitted to not knowing about the requirement and failing to report the incident promptly. The facility's policies on safety and supervision, as well as van safety, were not adequately followed, leading to the resident's injury.
Failure to Implement Comprehensive Care Plans for Wheelchair-Bound Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents who required wheelchair leg rests and foot pedals for support. Resident #1's care plan did not reflect her partial dependence on staff for wheelchair locomotion and the need for leg rests and foot pedals. Despite her cognitive intactness and moderate assistance requirement for ADLs, her care plan lacked these critical details, which were confirmed through observations and interviews with the resident and staff. Resident #2's care plan inaccurately described her as ambulatory and mobilizing in her wheelchair, failing to address her dependence on staff for mobility and the necessity of leg rests and foot pedals. Observations revealed she was in a tall wheelchair with the required supports, but her care plan did not reflect this need. Interviews with staff confirmed the oversight and the potential risks associated with it. Resident #3's care plan did not include the use of a leg rest and foot pedal for his affected leg, despite his severe cognitive impairment and dependence on a wheelchair for locomotion. Observations and interviews confirmed that he used these supports, but his care plan failed to document this requirement. The Director of Nursing acknowledged the importance of including such details in care plans to prevent accidents and ensure resident safety.
Failure to Report Incident Involving Resident's Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made. This deficiency was observed in the case of a resident who required the use of a wheelchair with leg rests and foot pedals for mobility. The Maintenance Director, who was acting as a backup van driver, did not report an incident where the resident's right foot and leg dropped down under the moving wheelchair and got caught as she was being assisted out of the van until the next morning. The resident, who had multiple diagnoses including hypertensive chronic kidney disease, rheumatoid arthritis, and osteoporosis with a current pathological fracture of the right femur, was being transported to a hospital appointment. The Maintenance Director, unaware of the need for leg rests and foot pedals, did not attach them to the resident's wheelchair. As a result, the resident's right leg slipped under the wheelchair during transport, causing her significant pain. The incident was not reported immediately, leading to a delay in assessment and treatment. Interviews with the resident, staff, and the Maintenance Director revealed that the resident experienced severe pain during her appointment and upon returning to the facility. The Maintenance Director admitted to not reporting the incident immediately due to being busy with other rides and not being informed about the resident's need for leg rests and foot pedals. The facility's policies on safety, supervision, and reporting incidents were not followed, resulting in a delay in addressing the resident's injury and pain.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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