River City Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 921 Nolan St, San Antonio, Texas 78202
- CMS Provider Number
- 675896
- Inspections on file
- 26
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at River City Care Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors found that drugs and biologicals were not properly stored or labeled, including loose unidentified pills in a medication cart, an insulin vial without an open date, a narcotic lock box in the medication fridge that was not securely affixed, and treatment cart keys stored in an unlocked container on the cart. Staff interviews confirmed these practices did not meet facility policy or professional standards.
Surveyors identified failures in kitchen sanitation and food storage, including dirty ceiling and wall vents, undated opened food items in both the refrigerator and storage room, and a dish machine that did not record sanitizer levels after cycles. These issues were confirmed by interviews and were not in accordance with facility policies for cleaning and food labeling.
A resident with an indwelling urinary catheter was observed with the catheter bag touching the floor and not placed in a dignity bag, contrary to physician orders and facility policy. Staff interviews confirmed the bag should have been kept off the floor and inside a dignity bag to prevent contamination, but this was not done at the time of observation.
Surveyors found that the facility did not provide the required 80 square feet per resident in most multi-occupancy rooms, as confirmed by direct measurements and record review. The facility had previously operated under a room size waiver, which had expired, and a new waiver request was pending at the time of the survey. No changes had been made to the number or size of the affected rooms.
A resident with moderate cognitive impairment and a history of wandering was able to leave the facility unsupervised, traveling to a distant location before being found. The care plan did not address elopement risk prior to the incident, and staff interviews revealed inconsistent understanding and application of elopement risk assessments and supervision protocols, resulting in a failure to prevent the resident's unsupervised departure.
The facility failed to store, prepare, distribute, and serve food according to professional standards, with issues including improper labeling, expired food, and unsanitary practices by staff. Observations revealed unlabeled and expired food items, open containers, and staff not adhering to sanitary practices, such as keeping personal drinks on food prep tables and licking fingers while handling dietary preference sheets.
The facility failed to respect resident dignity and privacy, as staff entered rooms without knocking and stood while feeding residents due to a lack of chairs. This affected multiple residents, including one who expressed dislike for staff entering without knocking.
The facility failed to update care plans to include enhanced barrier precautions for residents with indwelling urinary catheters, feeding tubes, and other conditions requiring such precautions. Observations revealed a lack of precautionary signs and PPE storage in residents' rooms, and staff interviews confirmed the oversight.
A resident with Parkinson's disease and other conditions did not receive scheduled doses of Methadone due to the facility running out of the medication. Despite notifying the DON and ADON, the medication was not refilled in time, leading to missed doses and potential withdrawal symptoms.
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies. Staff did not utilize enhanced barrier precautions for residents with indwelling catheters and feeding tubes, and proper hand hygiene was not followed. Observations and interviews revealed a lack of understanding and training among staff regarding infection control protocols.
The facility failed to ensure a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was properly completed and valid. The OOH DNR was not signed by a witness, a second physician, or a notary public, rendering it invalid. Despite the resident being identified as DNR status, the incomplete form could lead to the resident's end-of-life wishes not being honored.
A facility failed to ensure accurate PASRR Screening for a resident with bipolar disorder. The resident's diagnosis was not reflected in the initial PASRR Level 1 Screening, and the DON admitted that a new Level 1 should have been resubmitted after the diagnosis was added. This oversight could result in the resident missing out on necessary PASRR services.
The facility failed to ensure that two residents with indwelling urinary catheters received appropriate care, as their catheter drainage bags were observed touching the floor, contrary to care plan instructions and facility policy.
A facility failed to ensure a resident with a feeding tube received appropriate care, as RN F did not elevate the head of the bed to at least 30 degrees during medication administration. The resident, who had severe cognitive impairment and multiple diagnoses, was observed lying flat, contrary to care plan and physician orders. The DON confirmed the expectation to elevate the head of the bed to prevent aspiration.
A facility failed to provide appropriate respiratory care for a resident with COPD, heart disease, and cognitive decline. The resident's oxygen concentrator was set below the physician's order and had a dirty filter. Staff were unaware of the need to check and clean the filters, leading to potential risks for the resident.
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease. The resident's care plan was not consistently followed, and pre-dialysis vitals were not documented, despite the resident's refusal. The DON confirmed the lack of documentation and the absence of a dialysis policy.
The facility had a medication error rate of 7.14%, involving two residents who received incorrect dosages of Vitamin D due to Med Aide D following incorrect information on the medication bottle cap instead of the label or orders. The DON confirmed that staff are expected to check medication orders and labels for accuracy.
The facility failed to ensure proper storage and administration of medications. An LVN left a medication cart unlocked and unattended, and a resident was found with medications left at the bedside. Both incidents were confirmed by staff interviews, highlighting a breach in medication safety protocols.
The facility failed to maintain accurate medical records for a resident requiring Methadone for pain management. Med Aide Q documented administering doses that were not given, and the resident reported not receiving scheduled doses. The DON acknowledged discrepancies between the narcotic log and the MAR.
The facility failed to provide mandatory behavioral health training for the DON, whose personnel record showed no evidence of such training. The DON was unsure why the training was not completed and how it could affect residents. A policy for training was requested but not provided.
The facility failed to ensure that 46 out of 49 multiple occupancy resident rooms provided a minimum of 80 square feet per resident. The Administrator acknowledged the issue and expressed a desire to continue with the room waiver for all non-compliant rooms. The facility had a census of 42 residents at the time of the survey.
The facility failed to ensure a resident's care plan accurately reflected her current status, documenting her as ambulatory and able to propel her wheelchair despite being totally dependent on staff for mobility and other ADLs. This discrepancy was confirmed through interviews and observations, highlighting a significant risk of inadequate care.
The facility failed to ensure that a treatment cart was locked when left unattended, which could result in unauthorized access to medications and potential harm. A nurse admitted to not locking the cart after use, and the DON emphasized the importance of this safety measure.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
Surveyors observed multiple failures in the storage and labeling of drugs and biologicals. On the west medication cart, two loose white pills and two loose pink pills were found in the top drawer, and an insulin vial for a resident did not have an open date. The LVN present was unable to identify the loose pills and confirmed that such pills should be discarded, not administered. The DON confirmed that loose pills should not be present in medication carts and that both insulin vials and their boxes should be labeled with the open date to prevent confusion if separated. In the west hall medication storage room, the refrigerator used for resident medications contained a plastic narcotic lock box that was not permanently affixed, as the padlock was not fully closed and the screws securing the bracket were loose and easily removed. The box contained vials of liquid lorazepam, a controlled substance. The DON demonstrated that the lock was not fully engaged and acknowledged the box was not securely attached. Additionally, the nurse treatment cart was found to have its keys stored in an unlocked container attached to the cart, which an LVN accessed openly. The DON stated that it was acceptable for the keys to be stored in this manner, as they were not in the line of sight and residents were not aware of their location.
Deficiencies in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations, including unclean conditions and improper food storage practices. Specifically, a ceiling vent and a side wall air vent in the kitchen were found covered with dirt and dust particles. Additionally, an opened jar of mayonnaise in the refrigerator and two bags of cookie pieces in the storage room were not dated, contrary to facility policy. The dish machine was also found to be malfunctioning, as it did not record the sanitizer concentrate level after a wash cycle, raising concerns about the effectiveness of dishware sanitation. Interviews with the Food Service Director confirmed that the vents had not been cleaned and that food items were not properly labeled with dates as required. The Food Service Director was unaware of the dish machine sanitizer issue, which was not functioning at the time of observation. The Maintenance Director stated he had not received a work order to clean the vents. Review of facility policies indicated that regular cleaning schedules and proper labeling and dating of food items were required, but these procedures were not followed, resulting in the cited deficiencies.
Failure to Maintain Catheter Bag Off Floor as Required by Infection Control Policy
Penalty
Summary
A deficiency was identified when a resident with a history of sepsis due to streptococcus pneumoniae, recurrent urinary tract infections, vesicoureteral reflux, dementia, and Parkinson's disease was observed with an indwelling urinary catheter bag that was not properly maintained according to facility policy and physician orders. The resident's care plan and physician orders specified that the catheter bag should be kept in a privacy (dignity) bag and off the floor at all times. However, during observation, the catheter bag was found visible from the doorway, not in a dignity bag, and touching the floor while the resident was in bed. Interviews with staff confirmed that the catheter bag should have been inside a dignity bag and placed in a basin to prevent contamination from the floor. The CNA interviewed was unsure who had corrected the issue after it was observed, and the DON acknowledged that the catheter bag should not be on the floor due to infection risk. Review of the facility's catheter care policy also confirmed the requirement to keep catheter tubing and drainage bags off the floor. These findings demonstrate a failure to follow established infection prevention and control protocols for catheter care.
Failure to Meet Minimum Room Size Requirements for Residents
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms, as determined by interviews and record review. Specifically, 45 out of 46 resident rooms reviewed did not meet the required space, with measurements for each room showing less than 80 square feet per resident. The rooms in question were all measured by a Life Safety Inspector, and the findings were based on these direct measurements. The deficiency was further substantiated by the review of facility records, which confirmed the room sizes and the number of beds in each room. Additionally, the facility's Provider History Profile indicated that there was an existing room size waiver, which had expired prior to the current survey. The Administrator confirmed that a new waiver request had been submitted, but there had been no changes to the number or size of the affected rooms since the previous waiver. The deficiency was identified through both interviews and documentation, with no evidence of compliance with the required room size standards at the time of the survey.
Resident Elopement Due to Inadequate Supervision and Elopement Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of dementia, mood disturbance, and wandering behaviors was able to leave the facility's front porch without staff knowledge. The resident, who required supervision or touch assistance with mobility and had a BIMS score indicating moderate cognitive impairment, was not identified on the care plan as being at risk for wandering or elopement prior to the incident. Despite staff concerns about the resident's safety on the front porch, the resident was allowed to sit outside unsupervised, leading to the resident leaving the premises, traveling to a grocery store 1.7 miles away, and ultimately being found at a homeless shelter where he had previously lived. Interviews with staff revealed inconsistent understanding and implementation of elopement risk assessments and supervision protocols. Some staff relied on a list at the nurses' station to identify residents at risk for elopement, while others based decisions on their own judgment or the resident's cognitive status at the time. Several staff members indicated that they would ask a nurse before allowing a resident outside, but there was no clear, consistently applied process for assessing and supervising residents with cognitive impairment or wandering behaviors. The resident's care plan did not address wandering or elopement risk until after the incident occurred. The facility's failure to ensure the environment was free from accident hazards and to provide adequate supervision resulted in the resident's unsupervised departure. The lack of a comprehensive and consistently implemented elopement risk assessment and supervision protocol contributed to the incident, as staff did not have clear guidance or documentation regarding which residents required supervision when outside. This deficiency was identified through observation, interviews, and record review, and was determined to have placed residents at risk for accidents that could result in serious harm.
Removal Plan
- Assess all residents in facility for any active exit seeking behaviors or any active wandering behaviors by DON or designee.
- Complete elopement assessments for all residents in facility by DON or Designee; ensure any resident at risk for elopement has interventions in place to include risk for elopement on residents Kardex and care plan.
- Review all resident current BIMS assessments to determine cognitive status by MDS nurse.
- Notify Medical Director of Immediate Jeopardy Situation.
- Complete ADHOC QA with IDT team regarding Immediate Jeopardy Situation.
- Initiate in-services for all staff on elopement policy, elopement prevention, how to identify a resident at risk for elopement in PCC via POC task (non-licensed nursing staff), how to identify a resident BIMS score in PCC via POC task, and instruct all other non-licensed staff to inquire with licensed nurses for questions regarding resident BIMS score.
- Provide in-service for licensed nurses on how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, and how to identify resident BIMS assessment score located in special instructions tab in residents' chart in PCC.
- Require all non-licensed staff to notify licensed nurses prior to letting any resident go outside of facility.
- Ensure residents identified as cognitively impaired via BIMS assessment score (0-7 severe or 8-12 moderate cognitive impairment) utilize the back courtyard to sit outside upon their request or staff supervision.
- Complete in-service with DON/ADON and MDS nurse regarding entering BIMS score in special instruction tab in PCC by RCN.
- Ensure BIMS assessment score is located in the special instructions tab in each patient's chart (licensed nurses).
- Ensure facility patio/back courtyard is located on facility premises within a secure gate not considered leaving facility property.
- Review all elopement assessments to ensure any residents at risk for elopement have proper interventions in place (includes new admissions).
- Review all residents BIMS assessments to ensure residents identified with cognitive impairment have interventions in place (special instructions in place in PCC) (includes new admissions).
- Update special instructions tab in PCC if a change in BIMS score is identified.
- Notify staff if any BIMS score change is noted upon review of assessments and on an as needed basis via communication board in PCC.
- Ask 4 non-licensed nursing staff situational questions related to elopement (how to identify a resident at risk for elopement in PCC, what to do if a resident elopes).
- Ask 4 licensed nurses situational questions regarding elopement and cognition (how to identify a resident at risk for elopement in PCC, how to identify a resident with a cognitive deficit in PCC).
- Monitor to ensure there is no evidence of facility staff or visitors allowing residents to go outside without notifying nurse.
- Review all findings in monthly QA and make changes to the plan if needed.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that food items in the walk-in fridge/freezer were not properly labeled or dated, including strawberries, leafy greens, mixed frozen vegetables, and croissant dough. Additionally, expired food products such as hummus were not discarded, and food with freezer burn was not removed. In the dry food storage area, a bag of spaghetti was found open and spilled on the shelf, and a container of sugar was left open. These lapses in food storage and labeling were acknowledged by the Dietary Manager (DM) and other staff members during interviews, who admitted that the items should have been properly labeled, dated, and discarded if expired or compromised in quality. Further observations indicated that staff did not adhere to sanitary practices. Personal drinks were found on food prep tables, and a dietary aide was seen licking her fingers while placing dietary preference sheets on resident food trays. This unsanitary behavior was confirmed by the dietary aide, who acknowledged that it was not appropriate and could potentially make residents sick. The Activity Director also admitted to not following proper procedures for labeling and dating food items used for residents. The facility's policy on sanitation and food handling, which mandates proper handwashing, clean work surfaces, and securely covered and labeled food items, was not followed, leading to these deficiencies.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by multiple observations and interviews. LVN A entered Resident #22's room without knocking, despite the resident expressing that staff frequently entered without knocking, which he disliked. LVN A admitted to not knocking because she had been in the room several times that day and assumed the resident was expecting her. CNA R was observed standing while feeding Resident #40 during dinner, citing the lack of available chairs as the reason. CNA R acknowledged that she should have been at the resident's eye level for comfort. Similarly, LVN A was seen standing while feeding two unidentified residents, also due to the unavailability of chairs, and admitted that sitting down would have been more comfortable for the residents. RN F entered Resident #39's room without knocking during a medication pass. Although RN F announced herself, she recognized the importance of knocking to respect the resident's space. The Director of Nursing (DON) confirmed that staff are expected to knock and announce themselves before entering a resident's room and to sit while feeding residents to maintain their dignity.
Failure to Implement Enhanced Barrier Precautions in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the medical and nursing needs of eight residents. Specifically, the facility did not update the care plans to address the need for enhanced barrier precautions for residents with indwelling urinary catheters, feeding tubes, and other conditions requiring such precautions. This deficiency was observed in multiple residents, including those with acute kidney failure, chronic kidney disease, dementia, and neuromuscular dysfunction of the bladder, among other diagnoses. For instance, Resident #14, who had an indwelling urinary catheter due to neuromuscular dysfunction of the bladder, did not have enhanced barrier precautions included in her care plan. Observations revealed that there were no signs or indications of enhanced barrier precautions in her room, and no PPE storage with gowns was noted. Similar deficiencies were noted for Resident #19, who had a supra pubic catheter, and Resident #21, who had an indwelling urinary catheter and a wound, both of whom also lacked updated care plans and appropriate precautionary measures. Additionally, Resident #23, who had a feeding tube, and Resident #31, who had an indwelling urinary catheter, were also found to be without enhanced barrier precaution signs or PPE storage in their rooms. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the oversight, indicating that the nurse managers were responsible for updating the care plans but had not done so. The lack of adherence to enhanced barrier precautions was further confirmed through staff interviews and observations, highlighting a systemic issue in the facility's infection control practices.
Failure to Administer Methadone as Ordered
Penalty
Summary
The facility failed to ensure that a resident was administered Methadone as ordered by the physician. The resident, who had diagnoses including Parkinson's disease, blindness in one eye, and anxiety disorder, was admitted to the facility and required medication for pain management. The resident's comprehensive care plan included interventions to monitor and respond to pain, and the Methadone was to be administered twice a day. However, the Methadone narcotic log revealed that the resident received the last dose on the morning of 4/30/24, and subsequent doses were not administered as scheduled due to the facility running out of the medication. Interviews with the resident and Med Aide Q confirmed that the resident did not receive the scheduled doses of Methadone on 5/1/24. The resident reported being informed by an unidentified nurse that the medication needed to be refilled for three days. Med Aide Q indicated that the DON and ADON were notified about the shortage, and the DON confirmed that the NP had been informed and was waiting for the MD to sign the prescription. The DON acknowledged that the resident could suffer withdrawals if the Methadone was not administered as scheduled. The facility's policy and procedure for medication administration required that any deviation from the scheduled medication be documented in the nursing notes. However, there were discrepancies between the narcotic log and the nursing progress notes. The DON stated that the documentation on the narcotic log should match the MAR, indicating a failure in the facility's medication administration process and documentation practices.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies in infection control practices. Specifically, the facility did not utilize enhanced barrier precautions for several residents with indwelling urinary catheters and feeding tubes. Observations revealed that there were no enhanced barrier precaution signs or PPE storage in or around the rooms of these residents. Staff members, including CNAs and LVNs, were observed not wearing gowns as required by enhanced barrier precautions while providing care to these residents. Interviews with staff indicated a lack of understanding and training regarding enhanced barrier precautions, with some staff members unaware of the requirements and others incorrectly believing that enhanced barrier precautions were related only to the use of barrier cream or isolation for infections. Additionally, the facility failed to ensure proper hand hygiene and infection control principles were followed by staff. LVN A did not perform hand hygiene between glove changes and did not sanitize the site before obtaining a blood sample for an accu check on a resident. LVN C and Med Aide D were observed using the same paper towel to dry their hands and turn off the water faucet, which is considered cross-contamination. Interviews with the staff confirmed their awareness of the correct procedures but revealed lapses in following them. The deficiencies in infection control practices were further highlighted by the lack of proper training and implementation of enhanced barrier precautions. The DON and ADON acknowledged the issues and stated that training was provided through the facility's computer training program. However, the observations and interviews indicated that the training was not effectively implemented, putting residents at risk for infection. The facility's failure to adhere to infection control protocols and adequately train staff on enhanced barrier precautions contributed to the identified deficiencies.
Failure to Ensure Valid Out-of-Hospital Do Not Resuscitate (OOH DNR) Order
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was properly completed and valid. Specifically, the OOH DNR for a resident with severe cognitive impairment and multiple serious health conditions, including acute respiratory failure, acute kidney failure, and cardiomyopathy, was not signed by a witness, a second physician, or a notary public, rendering the document invalid. Despite the resident being identified as DNR status in their face sheet, comprehensive care plan, and order summary report, the incomplete OOH DNR form could lead to the resident's end-of-life wishes not being honored. During an interview, the Director of Nursing (DON) confirmed that the DNR document had been deleted from the electronic medical record to be corrected and that they were waiting for hospice to fix the DNR. The DON acknowledged that while the facility considered the DNR valid, external medical personnel would not honor it, potentially resulting in CPR being performed against the resident's wishes. The facility's policy on DNR orders was reviewed, which outlined the requirements for a valid OOH DNR, but the resident's document did not meet these requirements.
Failure to Ensure Accurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening. Specifically, a resident with a diagnosis of bipolar disorder did not have this condition accurately reflected in their PASRR Level 1 Screening. The resident's face sheet and quarterly MDS assessment indicated a diagnosis of bipolar disorder, and the resident was taking Depakote daily for this condition. However, the PASRR Level 1 Screening completed earlier did not indicate any evidence of mental illness. The Director of Nursing (DON) acknowledged that the bipolar diagnosis was added after the initial PASRR Level 1 was completed and admitted that a new Level 1 should have been resubmitted to reflect the updated diagnosis. This oversight could result in the resident missing out on necessary PASRR services.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure that two residents with indwelling urinary catheters received appropriate care to prevent urinary tract infections. Resident #21, a severely cognitively impaired female with chronic kidney disease and dementia, was observed with her catheter drainage bag touching the floor despite care plan interventions to keep it off the floor and in a dignity bag. Similarly, Resident #35, a male with diabetes and asthma, was seen in his wheelchair with his catheter bag touching the floor, contrary to his care plan instructions. Both residents had orders for catheter care every shift and to ensure the catheter bags were in privacy bags and off the floor, but these orders were not followed. Interviews with staff revealed that the catheter bags should not be touching the floor due to the risk of contamination and potential damage. The Director of Nursing (DON) confirmed that the facility had basins available to prevent catheter bags from touching the floor, but these were not utilized. The facility's policy on catheter care also emphasized keeping tubing and drainage bags off the floor, which was not adhered to in these cases.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, RN F did not elevate the head of the bed to at least 30 degrees while administering medications via the feeding tube to a resident with severe cognitive impairment and multiple diagnoses, including dysphagia, gastro-esophageal reflux disease, and protein-calorie malnutrition. The resident's care plan and physician orders explicitly required the head of the bed to be elevated during feedings and medication administration to prevent complications such as regurgitation and aspiration. During an observation, RN F was seen administering medications to the resident while the resident was lying flat on the bed, with two pillows on either side of the resident's head. RN F acknowledged that the head of the bed might not have been elevated to the required 30 degrees, which could lead to regurgitation. The Director of Nursing (DON) confirmed that it was the facility's expectation for nursing staff to ensure the head of the bed was elevated during feedings and medication administration for residents with feeding tubes to prevent aspiration.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Resident #15, who had chronic obstructive pulmonary disease, heart disease, and age-related cognitive decline, was observed with an oxygen concentrator set at 3 liters per minute, contrary to the physician's order of 4 liters per minute. Additionally, the oxygen concentrator's filter was covered in a thick white substance, indicating it had not been cleaned as required by the physician's orders. The Licensed Vocational Nurse (LVN) admitted to not knowing the location of the filters and stated that she had never checked them, believing it was the responsibility of the hospice service providing the equipment. The Director of Nursing (DON) confirmed that the facility's nursing staff were responsible for maintaining the oxygen concentrator filters and acknowledged the discrepancy in the oxygen setting. The observations and interviews revealed that the facility staff were not adhering to the physician's orders for oxygen therapy and were not maintaining the oxygen concentrator equipment properly. This failure to follow professional standards of practice and the resident's care plan could lead to inadequate oxygen delivery, potentially causing labored breathing and confusion in the resident. The DON confirmed that the oxygen concentrator should have been set at 4 liters per minute and that the nursing staff were responsible for ensuring the cleanliness of the oxygen filters, which were visibly dirty and covered in a white substance.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that residents who required dialysis received services consistent with professional standards of practice. Specifically, the facility did not maintain proper communication, coordination, and collaboration with the dialysis facility for a resident with end-stage renal disease. The resident's comprehensive care plan included interventions to monitor and report signs of infection, renal insufficiency, and other complications, but these were not consistently followed. The resident's dialysis communication record showed no pre-assessment vitals were taken by the nursing facility nurse from early March to late April, despite the resident's statement that staff used to take his blood pressure before dialysis. During an interview, the Director of Nursing (DON) confirmed that the resident refused his vitals before dialysis and acknowledged that staff should document such refusals. The DON also noted that without pre-dialysis vitals, staff would not be able to notice any changes in the resident's condition from the time he left the facility to when he arrived at the dialysis center. Additionally, the facility was unable to provide a dialysis policy when requested, further indicating a lack of proper protocol and documentation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that it was free of a medication error rate of 5 percent or greater, resulting in a medication error rate of 7.14%. This involved two residents who did not receive the correct dosage of Vitamin D. Specifically, Med Aide D administered 20 mcg (800 Unit) of Vitamin D to Resident #18 instead of the prescribed 50 mcg (2000 Unit), and 10 mcg (400 Unit) to Resident #28 instead of the prescribed 1000 Unit. The errors were due to Med Aide D using a Vitamin D bottle labeled 10 mcg (400 Unit) and following the incorrect dosage written on the cap rather than the label on the bottle or the residents' medication orders. Resident #18, a [AGE] year-old female with diagnoses including type 2 diabetes, personal history of infectious and parasitic diseases, and morbid obesity, and Resident #28, a [AGE] year-old female with diagnoses including protein-calorie malnutrition, type 2 diabetes, and dementia, were both affected by this error. During an interview, Med Aide D acknowledged the mistake and the DON confirmed that the expectation was for staff to check the medication order and label for accuracy. The facility's policy on medication administration procedures emphasizes adherence to the 10 rights of medication, including the right dose.
Failure to Properly Store and Administer Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. During a medication pass, an LVN left the West Wing medication cart unlocked and unattended in the main hall between the units and the dining room area. The LVN admitted to leaving the cart unlocked because she was nervous, acknowledging that the cart should never be left unlocked and unattended due to the risk of theft and overdose by residents known to wander the unit. This incident was observed and confirmed during an interview with the LVN, who further stated that there were true addicts in the facility who could potentially misuse the medications if accessed improperly. Additionally, the facility failed to ensure medications were not left at the bedside for a resident diagnosed with Parkinson's disease, blindness in one eye, and anxiety disorder. The resident was found with a medication cup containing two pink oval tablets identified as Benadryl on the bedside table. The resident admitted to receiving the medications from a Med Aide earlier that morning but had forgotten to take them. The Med Aide confirmed that medications should not be left in the resident's room and that she was taught to watch residents take their medications. The DON also confirmed that no residents in the facility were allowed to self-medicate and that medications should not be left at the bedside to prevent adverse reactions or overdoses.
Failure to Maintain Accurate Medical Records for Pain Management
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident reviewed for accuracy of medical records. Specifically, Med Aide Q documented that she administered Resident #11's afternoon dose of Methadone on two occasions after the resident had already received his last dose of Methadone during the scheduled morning dose. This discrepancy was identified through record reviews and interviews, revealing that the resident did not receive the scheduled morning dose of Methadone on one of the days in question and that the facility had run out of the medication. Resident #11, a male with diagnoses including Parkinson's disease, blindness in one eye, and anxiety disorder, was admitted to the facility and required Methadone for pain management. Despite the resident's comprehensive care plan indicating the need for pain medication therapy, the Methadone narcotic log and Medication Administration Record (MAR) showed inconsistencies. Interviews with the resident and Med Aide Q confirmed that the resident did not receive the scheduled doses as documented, and the Director of Nursing acknowledged the discrepancies between the narcotic log and the MAR.
Failure to Provide Behavioral Health Training to DON
Penalty
Summary
The facility failed to provide mandatory effective behavioral health training for the Director of Nursing (DON). The DON's personnel record, with a hire date of 10/19/23, showed no evidence of behavioral health training. During a record review and interview on 5/3/24, the BOM/HR Personnel confirmed that the DON did not have the required training. In an interview on the same day, the DON stated she had completed the training assigned to her but was unsure why she had not done the behavioral health training. She mentioned having received similar training at other workplaces but was uncertain about how the lack of this training could affect the residents. A policy for training was requested but not provided.
Facility Fails to Provide Minimum Required Square Footage in Resident Rooms
Penalty
Summary
The facility failed to ensure that 46 out of 49 multiple occupancy resident rooms provided a minimum of 80 square feet per resident. This deficiency was identified through observation, interview, and record review. The measurements of the rooms were found to be below the required square footage, with most rooms providing only around 73 square feet per resident. This issue was acknowledged by the Administrator during an interview, where he expressed a desire to continue with the room waiver for all resident rooms that did not meet the required square footage. The specific measurements of the rooms were detailed in the report, showing that none of the rooms met the 80 square feet requirement. The facility had a census of 42 residents at the time of the survey. This deficiency could affect all residents in need of at least 80 square feet of living space and could pose problems in their activities of daily living. The report did not mention any corrective actions or follow-up actions taken to address the deficiency after the incident.
Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to ensure the care plan accurately reflected the resident's status for one of the residents reviewed. Specifically, the care plan for a resident admitted with diagnoses including pulmonary embolism, stage 3 chronic kidney disease, dementia, and protein-calorie malnutrition, was not updated to reflect her current condition. The resident, who had stopped walking in December 2022, was documented in the care plan as needing appropriate footwear for ambulation and being able to propel her wheelchair, despite being totally dependent on staff for mobility and other activities of daily living (ADLs). This discrepancy was noted during an interview with the resident's Power of Attorney (POA) and the Director of Nursing (DON), who confirmed the resident's total dependence on staff for repositioning, feeding, ADLs, and transfers. Observations and interviews revealed that the resident was in a contracted fetal position in bed and was not ambulatory or able to propel her wheelchair. The facility's policy on comprehensive care planning mandates that care plans be developed and implemented based on the resident's clinical condition, cognitive and functional status, and use of services as identified in the comprehensive assessment. The failure to update the care plan accurately could place residents at risk of inadequate care, as the care plan provides essential information for staff to deliver appropriate care.
Failure to Lock Treatment Cart
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the treatment cart. During an observation and interview, it was noted that the nurse treatment cart was left unlocked and unattended. The Administrator had to lock the cart upon noticing it was left unsecured. This incident could result in harm due to unauthorized access to medications, misappropriation, and drug diversion. Nurse A admitted to not locking the treatment cart after completing wound care for a resident. She acknowledged the importance of locking the cart to prevent harm from medications and scissors stored in it. The Director of Nursing (DON) also emphasized the necessity of keeping the cart locked for safety reasons. The facility's policy mandates that medication carts must be locked when not in use or under direct supervision.
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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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