River Hills Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kerrville, Texas.
- Location
- 2091 Bandera Hwy, Kerrville, Texas 78028
- CMS Provider Number
- 676114
- Inspections on file
- 38
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at River Hills Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, anxiety, severe cognitive impairment, and documented behavioral symptoms including physical aggression, rejection of care, and wandering exhibited escalating agitation and violent behaviors toward staff and a roommate, leading to an emergent transfer to an acute care hospital for higher-level evaluation and care. Nursing and physician notes described multiple aggressive incidents and a determination that the resident could not safely return until after psychiatric evaluation and stabilization. The DON later acknowledged that no written discharge notice was provided to the resident or representative, and the LSW confirmed she was unaware of the admission and discharge and did not issue any notice, despite facility policy requiring written notice to the resident, representative, and LTC Ombudsman as soon as practicable in such safety-related transfers.
A resident with dementia and anxiety had a discharge MDS that did not accurately code the presence and frequency of aggressive and wandering behaviors. Facility progress notes documented repeated attempts to elope, daily verbal and physical aggression toward staff and others, refusal of medications, and dangerous actions such as attempting to smother a roommate and overturning furniture, requiring 1:1 supervision. However, the MDS coded physical behaviors as occurring only 1–3 days, verbal behaviors as not exhibited, and wandering as occurring 4–6 days but less than daily. The MDS coordinator later acknowledged that Section E did not accurately reflect the resident’s behaviors, while an LVN and the DON reported that these behaviors occurred multiple times daily and necessitated constant observation, meeting the facility’s own definition of a significant assessment error.
The facility did not ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control. The DON, listed as the IP, had an expired certification and could not provide proof of current training, while an LVN acting as IP in training had not started any specialized training. This was not in accordance with facility policy requiring the IP to be qualified by education, training, experience, or certification.
Two residents with a history of falls and care plans requiring fall mats were found in bed without these safety devices in place. Staff interviews revealed confusion and lack of awareness regarding the need for fall mats, and the DON confirmed the failure to implement required fall prevention interventions as outlined in the residents' care plans.
Surveyors identified that the facility did not maintain accurate and comprehensive care plans for multiple residents. Deficiencies included missing interventions for hearing loss, incorrect code status, inaccurate oxygen settings, and the wrong tube feeding formula. These issues were confirmed through record review, observation, and staff interviews, revealing inconsistencies between care plans and current physician orders or resident needs.
A resident who was fully dependent on staff for bathing and had significant medical conditions did not receive 7 out of 9 scheduled showers over a three-week period. Documentation was lacking, and staff were unable to provide records of completed showers, despite facility policy and expectations for regular hygiene care.
A resident with a neurogenic bladder and severe cognitive impairment did not receive physician-ordered indwelling urinary catheter flushes for ten days because the order was incorrectly documented in the electronic record, preventing it from appearing on the treatment administration record used by nursing staff. As a result, the prescribed treatment was not administered or recorded, contrary to facility policy.
The facility did not provide RN coverage for at least 8 consecutive hours on two days, despite a census of 101 residents. The ADON, responsible for scheduling, was unable to secure an RN and instead filled the shift with an agency LVN without notifying supervisors until after the fact. The DON and Administrator were unaware of the lapse until it was reported in a subsequent meeting.
Medication carts and a medication room were found unattended and unlocked on several occasions, with nurses admitting to leaving them unsecured while providing care elsewhere. The facility's policy requires all medications to be locked and supervised, but staff interviews confirmed that this was not consistently followed, resulting in unsecured access to drugs, including narcotics and alcoholic substances.
Surveyors found that a refrigerator used for resident snacks contained an unlabeled, undated sandwich and expired milk, and a dry storage bin of breading had a scoop left inside. Staff interviews confirmed these practices did not follow facility policy or professional standards for food safety.
A medication aide left a computer displaying a resident's medication list unlocked and unattended for 10 minutes, exposing the resident's private medical information. The aide was unaware that minimizing the screen did not secure the data, and the DON confirmed that staff are expected to lock screens to protect resident privacy.
A community shower chair was found with a brown substance on the seat, and both a shower room and a resident room had structural deficiencies, including a missing tile and a missing bathroom door frame. Staff confirmed these issues had not been reported or addressed, contrary to facility policy requiring a clean and homelike environment.
A resident with a history of hearing impairment did not receive proper assessment or replacement of lost hearing aids, as required by facility policy. The resident's care plan did not reflect their hearing needs, and staff were unaware of the last hearing assessment, resulting in unmet needs for hearing support.
A resident with severe cognitive impairment, hemiplegia, and a history of falls did not have a required fall mat in place at bedside after a COTA moved it and failed to return it, despite the care plan and staff interviews confirming its necessity for fall prevention.
A nurse administered an IV antibiotic to a resident with chronic kidney disease and osteomyelitis at twice the prescribed infusion rate, completing the dose in 30 minutes instead of the required 60 minutes. The nurse did not follow the pharmacy label instructions, resulting in a significant medication error.
A resident's personal refrigerator contained a container of mole and fideo that was observed to be unlabeled and undated on two separate occasions. An LVN and the DON confirmed the presence of the food items, and the DON stated that night shift nursing assistants were responsible for labeling and dating perishable foods, but this was not being monitored. Facility policy requires all food to be dated for proper rotation.
A nurse administered IV antibiotics to a resident with a PICC line and a wound under Enhanced Barrier Precautions by bringing the entire medication cart into the room and then removing it without sanitization, intending to use it for other residents. This action was not in compliance with facility policy and CDC guidelines, as confirmed by the DON, and involved a resident with multiple serious health conditions.
A resident with anxiety, depression, and hypertension was prescribed Xanax 0.5 mg every 6 hours PRN on an indefinite basis, in violation of regulations requiring PRN psychotropic medication orders to be limited to 14 days unless properly justified and documented by a physician. The DON confirmed the order should not have been indefinite, and the nursing supervisor attributed the oversight to random monitoring practices.
Three residents with significant cognitive and physical impairments did not have access to their call lights, as required by their care plans and facility policy. In each case, the call light was placed out of reach—either in a basket, attached behind a bed, or inside a closed drawer—despite staff training and policy requiring accessibility. Staff and administration confirmed the deficiency during interviews.
A resident with dementia and osteoporosis experienced two falls during an MDS assessment period, but only one fall was documented on the MDS, despite facility records confirming both incidents. The omission was confirmed by staff interviews and review of care plans and incident reports, resulting in an inaccurate assessment of the resident's status.
A resident with Type II Diabetes Mellitus did not receive prescribed insulin glargine for six days due to the facility's failure to transcribe hospital discharge orders. The resident informed a family member about the missed medication, but the facility staff were not notified until later. This oversight put the resident at risk for hyperglycemia.
A resident with Type II Diabetes did not receive prescribed insulin for six days due to a failure in transcribing hospital discharge orders into the facility's medication administration record. This oversight led to elevated blood glucose levels and was identified as an Immediate Jeopardy situation.
A resident with Type II Diabetes Mellitus did not receive prescribed Insulin Glargine for six days due to a failure in transcribing hospital discharge orders into the facility's MAR. The oversight was discovered after the resident's family notified staff, leading to elevated blood glucose levels. The facility's policies on medication reconciliation and administration were not followed, resulting in a significant medication error.
A facility failed to obtain a UA C&S for a resident as ordered by a physician, leading to a delay in diagnosing a UTI. The resident, with a history of cognitive impairment, was confused and agitated, prompting the order. However, the order was not entered into the system, and the urine sample was not collected. The resident was later diagnosed with a UTI during a hospital admission for a different issue.
A resident with multiple medical conditions and cognitive impairments experienced seven falls in a month due to inadequate supervision and ineffective interventions. Despite being a high fall risk, the resident's care plan was not properly updated or communicated among staff, leading to repeated falls and a serious injury requiring hospitalization.
The facility failed to provide RN coverage for at least eight consecutive hours per day, seven days a week, on four specific dates. Staffing records showed only one RN was scheduled for six hours during the day shift, with no RN for the night shift. The facility did not have a waiver for this requirement, and key staff were unaware of the need for RN coverage beyond the DON.
The facility failed to implement baseline care plans within 48 hours for two residents with complex medical conditions, including skin cancer and myocardial infarction. Staff interviews revealed confusion over responsibility for completing these plans, with the ADONs responsible for ensuring timely completion. The facility lacked a DON during the investigation.
The facility failed to develop comprehensive care plans for two residents, omitting key areas such as ADL needs, cognitive deficits, and dietary needs. One resident had multiple medical conditions requiring various levels of assistance, while another had severe cognitive impairment and required substantial assistance. Staff interviews revealed a lack of coordination in updating care plans, with misunderstandings about responsibilities. The facility's policy for timely and regular care plan reviews was not followed, resulting in incomplete and inaccurate care plans.
A resident with multiple health conditions experienced several falls, but the facility failed to update the care plan after each incident. Despite the facility's policy requiring updates for significant changes, the MDS coordinator did not ensure the care plan reflected the falls. Staff interviews revealed confusion about responsibilities, and the absence of a DON may have contributed to the oversight.
The facility failed to implement its abuse prevention policies, leading to unreported incidents involving two residents and a staff member. One resident suffered a severe neck fracture from a fall, which was not reported due to assumptions about the cause. Another resident alleged mishandling during a transfer, but the facility attributed it to cognitive impairment and did not report it. Additionally, the facility did not conduct timely background checks for a staff member.
A facility failed to report two incidents involving residents to the State Survey Agency. One resident with Alzheimer's fell from a wheelchair, resulting in a neck fracture, but the facility did not report it, believing the fall was not suspicious. Another resident alleged mishandling by a staff member, but the facility's investigation found the claims unsubstantiated, attributing them to a change in the resident's cognitive condition. The facility's leadership decided not to report these incidents, failing to meet reporting requirements.
A resident with systemic lupus erythematosus did not receive her morning medications on time due to the late arrival of a medication aide. The medications, crucial for managing her condition, were administered several hours past the scheduled time. The facility's policy requires medications to be given within a specific time window, which was not adhered to, potentially affecting the resident's therapeutic outcomes.
A facility failed to ensure an LVN was properly licensed according to state laws. The LVN, who moved from Colorado to Texas, was working with an inactive Texas license and an expired Colorado multistate license. Despite being aware of the situation, facility management allowed the LVN to continue working, contrary to the Nurse Licensure Compact requirements.
The facility failed to adhere to professional standards for food service safety, including issues with labeling and dating food, non-functional dish machine test strips, and unsanitary conditions in the kitchen. These deficiencies were confirmed by the Dietary Manager and Administrator, highlighting the importance of these practices for food safety and sanitation.
The facility failed to ensure residents' personal privacy and the confidentiality of their medical records. A nurse did not close the window curtain while providing wound care to a resident, and shower sheets with medical details of eight residents were left in a public hallway. Both the nurse and the DON confirmed that privacy should have been maintained.
The facility failed to employ a certified dietary manager, placing residents at risk of foodborne illness and inadequate nutrition. The Dietary Manager, hired without the required certification, and both the Human Resources Director and Administrator were unaware of this requirement.
The facility failed to designate an interdisciplinary team member responsible for collaborating and communicating with hospice representatives. Interviews with various staff members, including the Social Worker, Medical Records Director, ADON, and MDS Coordinator, revealed that none of them were aware of who was designated as the hospice liaison. The DON and ADON confirmed that no specific staff member had been designated for this role.
Two CNAs failed to follow proper hand hygiene protocols while providing incontinent care to a resident, leading to a deficiency in the facility's infection prevention and control program. Despite receiving infection control training, the CNAs did not change gloves or sanitize their hands after touching dirty items before starting care.
The facility failed to provide a safe environment by leaving two containers of hazardous cleaning fluids in an unlocked shower room on the 200 hallway, within reach of residents. Interviews confirmed that these materials should not be accessible to residents.
A resident's Quarterly MDS assessment was inaccurately documented as not receiving an antidepressant, despite physician orders indicating otherwise. Both the MDS Coordinator and DON confirmed the error, acknowledging that it could negatively impact the resident's care.
The facility failed to update a resident's care plan to address a significant weight loss of 13 pounds over four months, despite the resident's complex medical conditions. Interviews with staff revealed lapses in updating the care plan, leading to potential inconsistencies in care.
A resident was prescribed Lorazepam for anxiety without a documented diagnosis of anxiety in the clinical record. The DON and ADON confirmed the oversight, which was against the facility's policy requiring specific conditions for psychotropic medication use.
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. A CMA administered medications without verifying the correct dosage, and the resident involved had severe cognitive impairment. The Charge Nurse and DON confirmed that the medications should not have been administered without a clear dosage listed on the EMAR.
The facility failed to ensure safe and sanitary storage of food items in two residents' personal refrigerators, which contained unlabeled and undated perishable foods. This was confirmed by a CNA and the DON, who acknowledged that perishable foods should be labeled and dated to prevent spoilage.
Failure to Provide Required Written Discharge Notice After Emergent Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of discharge to a resident and the resident’s representative after an emergent, unplanned discharge. The resident was an elderly male with unspecified dementia and anxiety, admitted in early February and discharged in January to an acute care hospital. His admission MDS showed a BIMS score of 06, indicating severely impaired cognition, and documented behavioral symptoms including physical aggression toward others, rejection of care, and wandering. The MDS also reflected that his overall goal was discharge to the community and that discharge planning was not actively occurring at the time of submission. On the day of discharge, progress notes documented escalating behavioral issues. Nursing notes described the resident becoming increasingly agitated despite staff attempts at redirection and reassurance, physically assaulting a caregiver by punching them in the face, and later being found in bed with his roommate with a pillow and lying on top of the roommate. The resident was then removed to a common area where he flipped a coffee table, attempted to throw a lamp through a window, and began banging on the window. He was sent to a local hospital emergency department via ambulance and police involvement. A physician progress note documented severe agitation, refusal of medications, attempts to leave the facility, and aggressive behaviors such as hitting, biting, kicking, and attempting to head-butt staff, leading the physician to order transfer to the ER and later to state that the facility was unable to accept the resident back until psychiatric evaluation and a period of stability. Interviews with the DON and the LSW confirmed that no written notice of discharge was provided to the resident or his representative following this unplanned discharge. The DON stated that due to the nature of the behaviors, she instructed staff to transfer the resident to the emergency department and to inform the hospital that the resident could not return for safety reasons, and acknowledged that the resident had likely not been given written notice of discharge because the LSW was out of town and the situation was unusual. The LSW stated she was out of town during the resident’s entire admission, was unaware of his admission and discharge, and confirmed that the resident had not been given written notice of discharge. The facility’s transfer and discharge policy required that, in exceptional cases where health or safety is endangered, notice must be provided to the resident, the resident’s representative if appropriate, and the LTC Ombudsman as soon as practicable before transfer or discharge, which did not occur in this case.
Inaccurate Discharge MDS Coding of Aggressive and Wandering Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge Minimum Data Set (MDS) accurately reflected the presence and frequency of physically aggressive and wandering behaviors during the assessment look-back period. The resident was an elderly male with diagnoses of unspecified dementia and anxiety who was admitted and later discharged to an acute care hospital. His Discharge – Return Not Anticipated MDS coded physical behavioral symptoms toward others as occurring 1–3 days, verbal behavioral symptoms as not exhibited, rejection of care as occurring 1–3 days, and wandering as occurring 4–6 days but less than daily. The Brief Interview for Mental Status (BIMS) was not assessed on this discharge MDS. Progress notes for the days immediately preceding discharge documented frequent and severe behaviors that were inconsistent with the limited frequency captured on the MDS. Nursing and physician notes described the resident as repeatedly attempting to elope, being verbally and physically aggressive (hitting, kicking, biting, head-butting staff, attempting to throw his wheelchair), refusing medications, and engaging in dangerous behaviors such as attempting to smother his roommate with a pillow, flipping a coffee table, attempting to throw a lamp through a window, and banging on windows. Notes also documented that the resident required 1:1 oversight due to behaviors and elopement attempts, with multiple entries indicating ongoing agitation, aggression, and repeated attempts to leave the facility. In interviews, the MDS coordinator stated she was responsible for completing the admission and discharge MDS assessments and that she obtained Section E information from nursing progress and behavior notes. After reviewing the discharge MDS, she acknowledged that Section E did not accurately reflect the behaviors exhibited by the resident during the assessment period and agreed that an inaccurate MDS could affect proper care and provide an inaccurate reflection of residents’ status. An LVN and the DON both reported that the resident exhibited physically and verbally aggressive behaviors multiple times a day, continuously attempted to elope, required constant 1:1 observation, and was a danger to himself, other residents, and staff. The facility’s Comprehensive Assessments policy defined a significant error as one in which the resident’s overall clinical status is not accurately represented on the assessment and has not been corrected by a more recent assessment, aligning with the surveyors’ finding that the discharge MDS did not accurately represent the resident’s behavioral status.
Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that the individual designated as the Infection Preventionist (IP) had completed specialized training in infection prevention and control. Record review showed that the Director of Nursing (DON) was listed as the facility's IP, but during interviews, it was revealed that an LVN was acting as the IP in training and had not started or completed any specialized training. The LVN was only in the process of identifying a training program and had not registered for or completed any portion of the required training. The DON, who was responsible for oversight of the infection prevention program, stated she believed the LVN had already completed the necessary training, but learned during the interview that this was not the case. The DON also stated that her own infection prevention certification had expired and she was unable to provide proof of current training. Facility policy requires that the IP be qualified by education, training, experience, or certification, and remain current with infection prevention and control issues. The policy also specifies that the IP must physically work onsite and cannot be an off-site consultant. Despite these requirements, neither the DON nor the LVN designated as the IP had completed the necessary specialized training at the time of the survey, resulting in a deficiency related to the facility's infection prevention and control program.
Failure to Implement Care Planned Fall Mats for At-Risk Residents
Penalty
Summary
The facility failed to ensure that fall prevention interventions, specifically fall mats, were in place for two residents identified as being at risk for falls. Both residents had documented histories of falls and were care planned for fall prevention measures, including the use of fall mats while in bed. On the date of observation, both residents were found in bed without their fall mats in place; instead, the mats were folded and leaning against furniture in their rooms. Staff interviews revealed a lack of awareness and communication regarding the implementation of fall mats. One healthcare aide was unaware that a fall mat was required for a resident and was unsure to whom the mat belonged. Another CNA acknowledged that fall mats were part of the care plan but was not aware that the mat was not in place after the resident returned from physical therapy. The LVN confirmed that both residents required fall mats and was unaware that the mats were not implemented at the time of observation, despite routine rounding to check fall prevention measures. The Director of Nursing confirmed that both residents had care plans requiring fall mats and acknowledged the failure to implement these interventions. The facility's policy required individualized, person-centered interventions, including assistive devices and adequate supervision, to reduce risks related to environmental hazards. The lack of implementation of care planned fall mats for these residents constituted a failure to provide adequate supervision and assistance devices to prevent accidents.
Failure to Maintain Accurate and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as identified through observation, interview, and record review. For one resident with chronic obstructive pulmonary disease and pneumonia, the care plan did not address the resident's severe hearing loss, despite documentation in the medical record and the resident's own report of difficulty hearing and lack of hearing aids. Another resident with acute kidney failure and schizophrenia had a documented DNR (do not resuscitate) order in the medical record, but the care plan incorrectly listed the resident as Full Code. Staff interviews confirmed confusion regarding responsibility for updating code status in care plans. A third resident with heart failure and acute kidney failure had a physician's order for oxygen at 2 liters per minute, but the care plan listed the oxygen setting as 3 liters per minute. Observations confirmed the resident was receiving 2 liters per minute, and staff interviews revealed a lack of communication regarding updates to care plans following order changes. For a fourth resident with seizures and cognitive deficits, the care plan listed the wrong tube feeding formula, documenting Glucerna 1.2 instead of the ordered Jevity 1.5 or equivalent. These deficiencies were identified through direct observation, resident and staff interviews, and review of medical records and care plans. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but the care plans reviewed did not consistently reflect current physician orders or the residents' assessed needs.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all bathing and showering needs due to moderate cognitive impairment and multiple medical conditions including osteomyelitis, chronic kidney disease, and congestive heart failure, did not receive the necessary assistance with personal hygiene. The resident's care plan required extensive assistance from one to two staff members for bathing or showering three times per week. However, documentation in the electronic health record showed that the resident received only two out of nine scheduled showers over a three-week period. Observations included a sign in the resident's room from family expressing concern about the lack of showers, and interviews with staff revealed uncertainty about the location of shower documentation sheets. The CNA assigned to the resident's hallway was unable to provide the requested shower documentation, and the DON confirmed that residents are expected to receive showers on a rotating schedule. Facility policy stated that residents unable to perform activities of daily living independently should receive necessary services to maintain personal hygiene.
Failure to Provide Physician-Ordered Catheter Flushes Due to Documentation Error
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a neurogenic bladder, requiring an indwelling urinary catheter, did not receive physician-ordered catheter flushes for a period of ten consecutive days. The physician had ordered the catheter to be flushed twice daily, but this order was not properly documented in the electronic medical record system. Specifically, the order was entered as 'other orders (no documentation required),' which prevented it from appearing on the treatment administration record used by floor nurses to guide daily care. As a result of this documentation error, nursing staff were unaware of the flush order and did not perform or record the prescribed catheter flushes. Multiple interviews with nursing staff and facility leadership confirmed that the order was not visible to those responsible for the resident's care, and there was no evidence in the medical record that the flushes had been administered during the specified period. The issue was identified during a review of the resident's care and confirmed through interviews and record reviews. The resident involved had a history of neuromuscular dysfunction of the bladder, urinary tract infection, and Parkinson's disease, and was admitted for long-term care due to neurogenic bladder. The failure to provide the ordered catheter flushes was not detected during daily interdisciplinary team meetings, as the review process did not identify the improperly documented order. The facility's own Charting and Documentation policy requires that all procedures and treatments be documented in detail, but this was not followed in this instance.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by federal and state regulations. Specifically, there was no RN coverage for two consecutive days, despite a daily census of 101 residents. Review of staffing records confirmed the absence of RN services on these dates, and the facility's policy requires an RN to be present for at least 8 consecutive hours every 24 hours. The Assistant Director of Nursing (ADON) was responsible for the nursing schedule and, upon realizing no regular RN was available for the weekend, attempted to fill the shift with agency staff. When no RN accepted the shift, the ADON filled it with an agency LVN instead, without notifying supervisors until after the fact. Interviews with the ADON, DON, and Administrator revealed that the DON and Administrator were unaware of the lack of RN coverage until after the weekend. The ADON did not escalate the issue prior to the shift, and the change from RN to LVN coverage was only reported to the interdisciplinary team after the weekend had passed. The DON stated that, had she been informed, she could have intervened to provide RN coverage herself. The facility's policy and the statements from leadership confirm that the required RN coverage was not maintained during the identified period.
Unattended and Unlocked Medication Storage Areas
Penalty
Summary
Surveyors observed that medication carts and a medication room were left unattended, unsupervised, and unlocked on multiple occasions. Specifically, medication carts assigned to LVN L and LVN Q on the 100-hall were found unlocked and unattended, with no nurse present to supervise them. Additionally, the medication room on the 100-200-hall was found with its door propped open by a cardboard box, unsupervised and unlocked, containing various drugs, including narcotics stored in a single locked compartment, as well as alcoholic liquors and wines. Staff interviews confirmed that the carts and medication room were left unsecured while nurses were providing care elsewhere and could not see or supervise the medication storage areas during that time. The facility's policy requires all drugs and biologicals to be stored in locked compartments under proper temperature controls, with access limited to authorized personnel. The policy also specifies that medications must be under the direct observation of the person administering them or locked in the storage area or cart during medication passes. Despite this, staff admitted to leaving medication carts and the medication room unlocked and unattended, contrary to facility policy. The Director of Nursing acknowledged receiving reports of these lapses and confirmed that all medications should be secured and locked when not in direct attendance.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed that a refrigerator used for resident snacks contained an unlabeled and undated sandwich, as well as a gallon of milk that was past its best-by date. A medication aide stated that she regularly checked the refrigerator and disposed of items two days after their labeled date, but was unsure why the sandwich was not labeled and acknowledged that the milk should have been discarded on or shortly after its best-by date. These findings indicate that food items were not consistently labeled, dated, or discarded in accordance with professional standards and facility policy. Additionally, in the kitchen's dry storage area, a large bin of breading was found with a scoop left inside the container. Both the food service manager and the dietician confirmed during interviews that the scoop should not have been left in the bin, and the dietician noted that this practice could risk bacteria growth. Facility policies reviewed stated that all food should be appropriately dated and stored to maintain safety and integrity, but these procedures were not followed in the instances observed.
Failure to Secure Electronic Medical Records
Penalty
Summary
A medication aide (MA) failed to ensure the privacy and confidentiality of a resident's personal and medical records by leaving a computer screen displaying the resident's morning medication list unattended and unlocked for 10 minutes. The computer was left facing the wall, but the screen was not locked, and the MA was unaware that simply minimizing the screen did not secure the information. This incident was observed during a medication pass for a female resident with severe cognitive impairment, as indicated by a BIMS score of 04, and diagnoses including anxiety disorder, Alzheimer's disease, and dysphagia. During interviews, the MA admitted to not knowing how to lock the computer screen and acknowledged that the resident's private medical information could have been exposed. The Director of Nursing (DON) was unaware of the incident prior to being informed and stated that the expectation was for all nursing staff to lock computer screens when unattended to comply with HIPAA regulations and protect resident information. The facility's policy requires adherence to privacy standards, but this was not followed in this instance.
Failure to Maintain Clean and Homelike Environment in Shower and Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by several deficiencies observed in both a community shower room and a resident room. During an observation, a shower chair in the 400-hall community shower was found to have a brown substance on the bottom of the seat. Certified Nursing Assistants (CNAs) confirmed that the chair should be cleaned after each use and stated that the hospice CNA was the last to use the shower room. The Licensed Vocational Nurse (LVN) and Assistant Director of Nursing (ADON) acknowledged the presence of the substance and indicated that the expectation was for shower chairs to be cleaned and disinfected after each use. The ADON also stated that such conditions could pose infection control risks. Additionally, the 400-hall shower room was found to be missing a tile, and a resident room was missing a door frame on one side of the bathroom entrance. Staff interviews revealed that these issues had not been reported to the Maintenance Director, and the Housekeeping Manager was unaware of the missing tile and door frame. The facility's policy requires a clean, sanitary, and orderly environment, but these deficiencies were not addressed or reported as required, resulting in a failure to uphold the residents' right to a safe and homelike environment.
Failure to Provide Hearing Assessment and Assistive Devices
Penalty
Summary
The facility failed to ensure that a resident with a history of hearing impairment received proper assessment and assistive devices to maintain hearing abilities. Record review showed that the resident was documented as having moderate to severe hearing difficulty, with a BIMS score indicating moderate difficulty and a provider note stating the resident was severely hard of hearing. Despite this, the resident's comprehensive care plan did not reflect any hearing impairment, and there was no evidence that appropriate services were provided to assess or address the resident's hearing needs. During observation and interview, the resident reported being unable to hear the surveyor and stated that previously issued hearing aids had been lost, with uncertainty about whether they would be replaced. The social worker was aware of an upcoming appointment but did not know when the last hearing assessment occurred and indicated that information might be available from the VA. Facility policy required staff to assist residents in obtaining needed hearing services and replacing lost or damaged devices, but this was not followed for the resident in question.
Failure to Maintain Fall Prevention Intervention for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a fall mat, an intervention identified in the care plan, was consistently in place for a resident with a history of falls, hemiplegia, hemiparesis, cognitive impairment, and other significant medical conditions. The resident's care plan specifically required a fall mat at bedside due to her poor balance, unsteady gait, and history of falls. On the day of observation, the fall mat was initially in place, but a Certified Occupational Therapy Assistant (COTA) moved it to access the resident and did not return it to its proper position before leaving the room. Subsequent observation confirmed the fall mat was not in place, and the COTA acknowledged forgetting to replace it. Interviews with staff, including a CNA, the DON, MDS nurses, and the ADON, confirmed that the fall mat was a required intervention for this resident and that failure to have it in place could result in injury. The resident had previously experienced a fall resulting in a laceration and emergency room visit. Facility policy required that interventions to reduce accident risks, such as fall mats, be implemented as documented in the care plan. The failure to ensure the fall mat was in place represented a lapse in following the resident's individualized safety interventions.
Significant Medication Error: IV Antibiotic Administered at Incorrect Rate
Penalty
Summary
A deficiency occurred when a nurse administered an intravenous antibiotic, meropenem, to a resident at an incorrect infusion rate. The resident, who had a history of osteomyelitis in the left ankle, chronic kidney disease stage 4, and diabetes mellitus, was prescribed 1 gram of meropenem to be infused intravenously every 12 hours over 60 minutes. The pharmacy label on the medication also specified that the 100ml dose should be infused over 60 minutes. During medication administration, the nurse set the intravenous flow regulator to 200ml per hour, resulting in the medication being infused over 30 minutes instead of the prescribed 60 minutes. The nurse stated that the physician's order did not specify a flow rate, so she used her previous practice of setting the rate at 200ml per hour and set an alarm to return in 45 minutes, expecting the infusion to be completed. The nurse did not follow the pharmacy label instructions, which clearly indicated the correct infusion rate. Facility policy required nursing staff to review the physician's order, including the rate, and to administer medications according to the prescribed rate. The Director of Nursing confirmed that the flow regulator should have been set to the pharmacy's recommended rate of 100ml per hour. The failure to administer the medication at the correct rate constituted a significant medication error, as it did not comply with the prescribed method of administration.
Unlabeled and Undated Food in Resident Refrigerator
Penalty
Summary
Surveyors observed that a personal refrigerator in a resident's room contained a container of mole and fideo that was unlabeled and undated on two consecutive days. Interviews with an LVN and the DON confirmed the presence of the unlabeled and undated food items in the resident's refrigerator. The DON acknowledged that perishable food and drinks in residents' personal refrigerators should be labeled and dated, and stated that night shift nursing assistants were responsible for this task, but it was not being monitored. Review of the facility's policy indicated that all food should be appropriately dated to ensure proper rotation by expiration date.
Failure to Follow Enhanced Barrier Precautions During IV Medication Administration
Penalty
Summary
A deficiency was identified when a nurse (LVN) administered intravenous antibiotics to a resident with a PICC line and a left foot wound under Enhanced Barrier Precautions (EBP). The nurse brought the entire medication cart into the resident's room, which was clearly marked with EBP signage instructing staff to clean their hands before entering and leaving, and to wear gloves and gowns for high-contact care activities. After administering the medication, the nurse removed the cart from the room without sanitizing it and intended to continue using it for medication administration to other residents. The resident involved had a history of osteomyelitis in the left ankle and foot, chronic kidney disease stage 4, and diabetes mellitus, and was admitted for long-term care due to a bone infection. The resident was assessed with mild cognitive impairment and had a PICC line for intravenous medication. The resident confirmed that staff wore PPE during care and that he received medications via his PICC line. Facility policy and CDC guidelines require that equipment not be taken into EBP rooms unless sanitized after use, and that reusable items potentially contaminated with infectious materials be handled according to strict protocols. The Director of Nursing confirmed that the nurse's actions were not in compliance with these requirements, specifically noting that the medication cart should not have been taken into the EBP room and that failure to sanitize the cart posed a risk of cross-contamination.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
A deficiency was identified when a resident with diagnoses including anxiety, depression, and hypertension was prescribed the antianxiety medication Xanax on a PRN (as needed) basis without a specified duration, contrary to regulatory requirements that limit PRN orders for psychotropic drugs to 14 days unless a physician documents the rationale and duration for extension. The resident's order for Xanax 0.5 mg every 6 hours PRN was written as indefinite, and medication administration records showed the resident received the medication on multiple occasions within a week. During an interview, the DON acknowledged that the PRN order should have been limited to 14 days and was unable to explain why the order was written for an indefinite period. The nursing supervisor, responsible for daily oversight of such orders, confirmed that monitoring was done at random, which contributed to the oversight. Facility policy requires that all medication decisions include appropriate elements of the care process, but this was not followed in this instance.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had access to their call lights, as required by their care plans and facility policy. For one resident with Parkinsonism and a high fall risk, the call light was found wrapped up in a basket on the nightstand, approximately four feet away and out of reach. The resident confirmed he could not reach the call light, though he stated staff usually kept it within reach. A medication aide verified the call light was not accessible and acknowledged the importance of keeping it within reach. Another resident, who had diagnoses including dementia, Parkinsonism, and hemiplegia, was observed with his call light attached to the bed behind him, making it inaccessible while he was in his wheelchair. The resident was unaware of the call light's location and could not reach it. Later, the call light was observed draped over a roommate's nightstand and another call light was found on the floor, both out of reach. The administrator confirmed the call light should have been within the resident's reach. A third resident, with a traumatic brain injury and severe cognitive and communication deficits, was observed twice with his call light tucked inside a closed nightstand drawer, out of reach. Staff interviews confirmed the call light was not accessible and that all staff are responsible for ensuring call lights are within reach. Facility policy and recent in-service training emphasized the requirement for call lights to be accessible to residents at all times.
Inaccurate MDS Assessment Coding of Resident Falls
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status, specifically for one resident who experienced two falls during the assessment period. The discharge MDS assessment only documented one fall with a major injury, omitting a second fall that occurred without injury. Documentation in the resident's care plan and incident reports confirmed two separate falls: one from a wheelchair without injury and another resulting in a hip fracture. The MDS Coordinator confirmed that both falls should have been recorded in Section J of the MDS, but only one was captured. Interviews with facility staff revealed that MDS Coordinators are responsible for compiling information from various sources, including the electronic medical record, progress notes, and incident reports, to ensure accurate MDS coding. The MDS Coordinator who completed the inaccurate assessment was no longer employed at the facility. The facility's policy requires comprehensive assessments to be used in developing and revising person-centered care plans, and these assessments are to be maintained in the resident's active record. The failure to accurately code both falls on the MDS assessment resulted in an incomplete representation of the resident's care needs.
Failure to Administer Insulin as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not transcribe the hospital discharge order for insulin glargine for a resident upon admission, resulting in the resident not receiving the medication for six days. This oversight was identified during a review of the resident's medical records and interviews with staff and the resident. The resident, a female with a history of Type II Diabetes Mellitus, was admitted to the facility following a hospitalization for a urinary tract infection and congestive heart failure exacerbation. The hospital discharge instructions included an order for 17 units of insulin glargine to be administered once daily. However, the facility did not transcribe this order into the resident's medication administration record until several days after admission, leading to missed doses of the medication. Interviews with the resident and facility staff revealed that the resident had informed a family member about not receiving her insulin, but this information was not communicated to the facility staff until later. The Director of Nursing confirmed that the resident had not received insulin for six days, which put the resident at risk for hyperglycemia. The facility's failure to administer the prescribed medication was acknowledged by the Administrator, who stated that nursing staff are expected to follow physicians' orders.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to provide pharmacological services to meet the needs of a resident, specifically in the administration of insulin. The deficiency involved a failure to acquire, receive, dispense, and administer the prescribed 17 units of Insulin Glargine daily for a resident over a period of six days. This lapse occurred from the time of the resident's admission following a hospital discharge, during which the admitting nurse did not transcribe the insulin order into the medication administration record (MAR). The resident, a female with a history of Type II Diabetes Mellitus, was admitted to the facility after a recent hospitalization for a urinary tract infection and congestive heart failure exacerbation. Despite having hospital discharge instructions that included a daily insulin regimen, the facility did not administer the insulin as ordered until six days after admission. The resident's blood glucose levels were not monitored until the insulin order was finally transcribed, resulting in elevated blood sugar levels during the period of non-administration. Interviews with facility staff revealed that the oversight was identified when a family member of the resident notified a nurse about the missing insulin administration. The Director of Nursing (DON) confirmed the lapse and acknowledged the risk of hyperglycemia due to the missed doses. The facility's policies on medication reconciliation and administration were not followed, leading to this deficiency, which was identified as an Immediate Jeopardy situation.
Failure to Administer Insulin Leads to Significant Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Insulin Glargine. The resident, a female with a history of Type II Diabetes Mellitus, was admitted with hospital discharge instructions that included a daily dose of 17 units of Insulin Glargine. However, the facility did not transcribe this order into the Medication Administration Record (MAR) until several days after admission, resulting in the resident not receiving her prescribed insulin for six consecutive days. During this period, the resident's blood glucose levels were not monitored until the fifth day, revealing elevated levels that posed a risk for hyperglycemia and potential complications such as diabetic ketoacidosis. The oversight was discovered when a family member informed a Licensed Vocational Nurse (LVN) that the resident had not been receiving her insulin. The LVN confirmed the omission and notified the Director of Nursing (DON) and the resident's physician, who then provided orders to administer the insulin. Interviews with the resident and medical staff revealed that the resident was accustomed to self-administering insulin at home and did not initially report the missed doses to facility staff. The facility's policies on medication reconciliation and administration were not followed, leading to this significant medication error. The Director of Nursing acknowledged the failure to transcribe the insulin order and the associated risks to the resident's health.
Removal Plan
- The Medical Director was notified by the Administrator of the Immediate Jeopardy.
- The DON completed a chart audit on all residents receiving insulin.
- An insulin tracker was implemented for an audit to assure insulin is administered correctly and in a timely manner.
- The DON completed an insulin audit to confirm insulin orders were in place and transcribed correctly.
- An in-service was conducted with DON and ADONs by the VP of Clinical regarding the insulin order audit and educating staff on administration competency and glucometer use check off.
- One on one education to clinical staff regarding physician's orders for insulin administration are to be followed accurately and on time.
- Blood glucose monitoring orders are to be followed accurately and on time.
- DON will educate nursing staff before their next shift and new hire nurses before they begin working.
- IDT Team members were educated on the importance of timely insulin administration.
- DON or designee will verify daily insulin tracker in clinical meeting on new admissions and insulin dependent residents by reviewing the MAR daily.
- Staff that were not physically present in the facility were contacted via phone and education reviewed with them by the DON and ADONs.
- The order listing will be reviewed daily in the morning clinical meeting by the IDT Team.
- The order listing will be reviewed by the DON or designee and tracked on the insulin log.
- Interventions will be implemented with the insulin tracker log in the clinical meeting with the IDT Members and monitored by the DON or designee.
- Insulin tracker will be monitored by the DON and Administrator for completion.
- The insulin monitoring tracker will be presented at the monthly QAPI meeting for a minimum of three months.
- Insulin/glucose administration competencies were observed and conducted by the DON and ADONs.
- Insulin/glucose competencies will be completed for new hire nurses during onboarding with DON or designee.
- An Ad Hoc QAPI committee meeting was completed.
Failure to Obtain Ordered Laboratory Test for Resident
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, as they did not obtain a UA C&S as ordered by the physician. The resident, who had a history of Raynaud's syndrome, hypertension, depression, and cognitive communication deficit, was noted to be confused and agitated, prompting the physician to order a UA C&S. However, the order was not entered into the system, and the urine sample was not collected, leading to a delay in diagnosing a urinary tract infection (UTI). Interviews revealed that the Assistant Director of Nursing (ADON) was unaware of the missed order, and the Registered Nurse (RN) responsible for the resident's care did not follow up on the urine sample collection. The resident was later admitted to the hospital for a different reason, where a UTI was diagnosed and treated. The facility's policy required verbal orders to be documented and followed up, but this was not adhered to, resulting in the oversight.
Inadequate Supervision and Fall Prevention for Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident, who experienced seven falls within a month. The resident, who had a history of falls and multiple medical conditions including cognitive impairments, was not provided with effective interventions to mitigate the risk of falls. Despite being identified as a high fall risk, the resident's care plan lacked appropriate and timely updates to address the recurring falls. The resident's medical history included conditions such as malignant melanoma, osteoporosis, muscle weakness, gait and mobility abnormalities, cognitive communication deficits, and memory deficits, among others. The resident required assistance with various activities of daily living and was dependent on staff for mobility. Despite these needs, the facility's interventions, such as reminders to use the call light and the placement of fall mats, were either not implemented or ineffective in preventing falls. Interviews with staff revealed a lack of communication and understanding of the resident's care plan and interventions. Staff members were unaware of the specific interventions in place and did not consistently monitor or update the care plan following each fall. The resident's cognitive impairments and forgetfulness were not adequately addressed, leading to repeated falls and ultimately resulting in a serious injury that required hospitalization.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to utilize the services of a registered nurse (RN) for at least eight consecutive hours per day, seven days per week on four specific dates. The facility's Staffing Disclosure Sheets and employee timesheets revealed that on these dates, there was only one RN scheduled for the day shift for six hours, and no RN was scheduled for the night shift. Interviews with the Administrator and LVN E confirmed that the facility did not have an RN during weekdays, other than the Director of Nursing (DON), until the DON left approximately three weeks prior to the investigation. The facility did not have a waiver for the requirement to provide RN services for more than 40 hours a week. The facility's policy, titled Staffing, Sufficient and Competent Nursing, requires a registered nurse to provide services at least eight consecutive hours every 24 hours, seven days a week. However, the facility did not adhere to this policy, as evidenced by the lack of RN coverage on the specified dates. The Administrator, LVN E, and the CVP were not aware of the requirement to utilize the services of an RN, other than the DON, for the specified hours. This deficiency could place residents at risk of not receiving adequate care.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for two residents within 48 hours of their admission, as required by their policy. Resident #1 was initially admitted with multiple diagnoses, including malignant melanoma, osteoporosis, and type 2 diabetes, among others. The baseline care plan for this resident was completed four days after admission. Similarly, Resident #4, who was admitted with conditions such as myocardial infarction and dementia, had their baseline care plan completed four days post-admission. Interviews with facility staff revealed a lack of clarity regarding responsibility for completing baseline care plans. LVN H, the MDS Nurse, was unaware of why the plans were not completed on time, indicating it was the admitting nurse's responsibility. LVN M, the ADON, stated that floor nurses were responsible for the assessment part of the care plans, and the IDT reviewed them during morning meetings. The ADONs were tasked with ensuring completion within the required timeframe. The facility was operating without a DON during the investigation, which may have contributed to the oversight.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which did not include measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. For one resident, the care plan did not address activities of daily living (ADL) needs, risk for falls, cognitive deficits, dietary needs, therapy, and discharge planning. This resident had a history of multiple medical conditions, including malignant melanoma, osteoporosis, diabetes, and cognitive deficits, and required various levels of assistance with daily activities. The care plan was not updated to reflect these needs, despite the comprehensive assessment indicating several care area triggers. Another resident's care plan was also incomplete, failing to address ADL needs, cognitive deficits, dietary needs, hospice care, medication side effects, and treatments. This resident had severe cognitive impairment and required substantial assistance with daily activities. The comprehensive assessment highlighted several care area triggers, including cognitive loss, communication, and risk for pressure ulcers, but these were not adequately reflected in the care plan. Interviews with facility staff revealed a lack of coordination and responsibility in updating care plans. The MDS nurse was responsible for ensuring care plans were complete, but there was a misunderstanding about who should update the care plans based on the MDS assessments. The facility's policy required care plans to be completed within seven days of the admission MDS assessment and reviewed regularly, but this was not adhered to, leading to incomplete and inaccurate care plans for the residents.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident after each assessment, specifically following multiple falls. The resident, who had a history of malignant melanoma, osteoporosis, muscle weakness, and other conditions, experienced several falls within a short period. Despite these incidents, the care plan was not updated to reflect the falls and implement new interventions. The care plan was initially revised on 12/6/24, but it did not account for subsequent falls on 12/11/24 and 12/13/24. Interviews with staff revealed a lack of clarity and responsibility regarding the updating of care plans, with some staff unaware of the need for immediate updates following each fall. The facility's policy required care plans to be reviewed and updated when there was a significant change in the resident's condition or when desired outcomes were not met. However, the MDS coordinator, who was responsible for ensuring care plans were updated, acknowledged that the necessary updates were not made. The absence of a Director of Nursing during the investigation may have contributed to the oversight. The failure to update the care plan could potentially affect the resident's care and delay treatment, as noted in the report.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to report, prohibit, and prevent abuse for two residents and one staff member. The facility did not develop and implement abuse policies for reporting abuse to the State Reporting Agency and failed to review an employee's EMR and criminal history at least once every 12 months. These failures could place residents at risk of abuse, neglect, and misappropriation of property. In the case of the first resident, the facility did not report an incident where the resident fell from a wheelchair, resulting in a severe neck fracture. The resident, who had severe cognitive impairment, was found on the floor with a laceration and hematoma on her forehead. Despite the severity of the injury, the facility's leadership team decided not to report the incident to the State Survey Agency, as they did not consider it an injury of unknown origin. The decision was based on the assumption that the resident fell while reaching for her doll, which was found on the floor with her. For the second resident, the facility did not report an allegation of abuse made by the resident, who had severe cognitive impairment. The resident reported being mishandled during a transfer, resulting in a shoulder injury. The facility's investigation concluded that the resident's cognitive impairment and change of condition explained the incident, and thus it was not reported. Additionally, the facility failed to conduct annual criminal background checks and EMR checks for a staff member, which were overdue by several months.
Failure to Report Incidents of Resident Injury and Alleged Abuse
Penalty
Summary
The facility failed to report two significant incidents involving residents to the State Survey Agency within the required timeframe. The first incident involved a resident with Alzheimer's disease who experienced an unwitnessed fall from her wheelchair, resulting in a severe neck fracture. Despite the resident's inability to communicate due to severe cognitive impairment, the facility did not classify the injury as one of unknown origin and did not report it, as they believed the fall was not suspicious. The decision not to report was made after internal discussions among the facility's leadership, including the Administrator and Operations Manager. The second incident involved another resident with dementia who alleged being mishandled by a staff member during a transfer, resulting in her hitting her head on the wall. The resident described the staff member, but the facility's investigation, which included interviews with the resident and staff, concluded that the allegations were unsubstantiated. The facility attributed the resident's claims to a change in her cognitive condition, which was addressed medically. The decision not to report this incident was also made by the facility's leadership, who did not consider the incident to meet the criteria for reporting. Both incidents highlight the facility's failure to adhere to the reporting requirements for suspected abuse, neglect, or injuries of unknown origin. The facility's policy did not adequately address the reporting of such incidents, and the leadership's interpretation of the guidelines led to a lack of timely reporting to the appropriate authorities. This failure could potentially delay the identification and prevention of further harm to residents.
Late Medication Administration for Resident with Lupus
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #3, as observed through the late administration of morning medications. Resident #3, who has systemic lupus erythematosus and requires timely medication for pain management, did not receive her medications within the facility's policy window. The medications, including Amlodipine Besylate, Esomeprazole Magnesium, Cholecalciferol, Prednisone, Tylenol, Tramadol, and Hydrocodone-Acetaminophen, were scheduled for administration at 8:00 am and 9:00 am but were not given until after 12:00 pm. The delay in medication administration was attributed to the late arrival of Medication Aide (MA) F, who was supposed to start work at 6:00 am but arrived at 8:30 am. MA F did not inform anyone upon arrival that she was late, nor did she request assistance to ensure timely medication administration. The charge nurse, LVN G, was aware of MA F's habitual tardiness but did not take action to address the late medication administration. The Director of Nursing (DON) was informed of MA F's late arrival but was not aware of the late medication administration. The facility's policy requires medications to be administered within one hour of their scheduled time, with time-critical medications needing to be given within 30 minutes of the scheduled time. The failure to adhere to this policy could affect the therapeutic effectiveness of the medications, particularly for conditions like lupus that require precise timing for pain management. The DON acknowledged the importance of timely medication administration for patient safety and the need for staff to communicate any delays before the medication administration window expires.
Failure to Ensure Proper Licensing of Nursing Staff
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN A) was properly licensed in accordance with state laws. LVN A, who had moved from Colorado to Texas, was observed working in the facility with an inactive Texas nursing license and an expired Colorado multistate license. Despite having established residency in Texas, LVN A did not transfer her nursing license to Texas within the required 60 days. This oversight was acknowledged by LVN A, who stated that she was unaware of the need for a Texas license and had been informed by the facility's management that her Colorado license was sufficient. Interviews with the facility's HR Director, Operations Manager, and Administrator revealed that they were aware of LVN A's licensing situation. The HR Director confirmed that the former Director of Nursing (DON) and Administrator were informed of the expired Texas license but allowed LVN A to continue working based on her active Colorado license. The current management also decided to permit LVN A to work under the same conditions. This decision was made despite the requirements outlined in the Nurse Licensure Compact, which mandates that a nurse must apply for licensure in the new home state within 60 days of changing their primary state of residence.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, it was observed that an overhead light in the kitchen storage room was not working, and several food items in the refrigerator, including a bag of hard-boiled eggs, shredded cheese, and ham slices, were not labeled or dated. Additionally, the temperature test strips for the dish machine were wet and unusable, and there were signs of mold around the edges of a ceiling vent across from the dish machine. The grill vent above the dish machine hood cover was also covered with dirt and grease. These observations were confirmed by the Dietary Manager, who acknowledged the importance of these issues for food safety and sanitation. Interviews with the Dietary Manager and the Administrator highlighted the significance of labeling and dating food to monitor expiration dates and the necessity of functional dish machine test strips to ensure proper cleaning. The facility's policies for food storage and kitchen safety, as well as the U.S. Public Health Service Food Code, were reviewed and found to support the need for these practices. The failure to adhere to these standards could place residents at risk for foodborne illness due to improper infection control, lack of food label date monitoring, and inadequate equipment maintenance and sanitation in the kitchen area.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure residents' personal privacy during nursing care and the confidentiality of their medical records. Specifically, a treatment nurse did not close the window curtain while providing wound care for a resident, whose bed was visible from the parking lot. The resident had multiple diagnoses, including depression, sarcoidosis, type 2 diabetes mellitus, hypertension, and chronic kidney disease, and was mildly impaired with a BIMS score of 11. The nurse confirmed that the window curtain should have been closed to provide privacy during the care. The Director of Nursing (DON) also confirmed that privacy must be provided during nursing care and that the window curtains should have been closed completely. Additionally, shower sheets containing the names and medical details of eight residents were found on a side table in a hallway accessible to residents, staff, and visitors. The sheets included information about the residents' ability to bathe or shower themselves. A Certified Nursing Assistant (CNA) noticed the sheets and confirmed that they contained protected medical information that should not have been left in a public area. The DON and Assistant Director of Nursing (ADON) confirmed that protected medical information should be kept private, in accordance with the facility's policy on dignity.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a certified dietary manager as required, which could place residents at increased risk of foodborne illness and inadequate nutrition. The Dietary Manager, hired on 04/17/2023, had not taken a Dietary Manager Certification course and was unaware of the requirement. His previous experience was limited to working as a cook, and this was his first position as a Dietary Manager. During an interview, the Dietary Director admitted to not having completed the necessary certification course. The Human Resources Director and the Administrator were also unaware of the certification requirement for the Dietary Manager position. The Human Resources Director stated that she, along with the Administrator, would have been responsible for ensuring department heads met their certification requirements. The facility's employee handbook indicated that employees in positions requiring professional licensure, registration, or certification were responsible for maintaining current, active credentials at their own expense. However, this policy was not enforced in this case, leading to the deficiency.
Failure to Designate Hospice Liaison
Penalty
Summary
The facility failed to designate an interdisciplinary team member responsible for collaborating and communicating with hospice representatives. This deficiency was identified during interviews with various staff members, including the Social Worker, Medical Records Director, ADON, and MDS Coordinator, all of whom stated they were not the hospice liaison and did not know who was designated as such. The DON and ADON confirmed that no specific staff member had been designated as the hospice liaison. A review of the facility's policy on residents with hospice services revealed that the facility is required to coordinate services with hospice personnel, but this was not being followed.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care for a resident. CNA B and CNA C did not follow proper hand hygiene protocols; CNA B touched the resident's trash can with gloved hands and then proceeded to provide care without changing gloves or sanitizing her hands. Similarly, CNA C touched the trash can and privacy curtain before putting on gloves and starting care without washing or sanitizing his hands. Both CNAs acknowledged that the trash can and privacy curtain were considered dirty and that they should have changed gloves and washed their hands to prevent cross-contamination. Despite having received infection control training within the year, they failed to adhere to the facility's hand hygiene policy, which mandates hand hygiene after touching the resident's environment. The resident involved had multiple diagnoses, including Parkinson's, hypothyroidism, hyperlipidemia, hypertension, Raynaud's syndrome, and chronic kidney disease. The resident's care plan indicated that they were always incontinent of bowel and bladder and required assistance to remain clean, dry, and odor-free. The Director of Nursing confirmed that the CNAs should have changed their gloves and sanitized their hands after touching the trash can and curtain to prevent cross-contamination. The facility's policy on hand hygiene, dated October 2023, clearly stated that hand hygiene is required after touching the resident's environment. Despite passing their annual skills check for infection control, both CNAs failed to follow the established protocols during the observed incident.
Hazardous Materials Found in Unlocked Shower Room
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, staff, and visitors. Two containers of cleaning fluids with hazardous material warning labels were found within the shower room of the facility's 200 hallway. The shower room was observed to be unlocked and not in use, with the hazardous materials within reach of residents. Interviews with the AIT, DON, and ADON confirmed the presence of these hazardous materials and acknowledged that they should not be stored within resident reach. The facility's policy on maintaining a safe physical environment was not adhered to, as evidenced by the presence of these hazardous materials in an accessible area.
Inaccurate MDS Assessment for Antidepressant Use
Penalty
Summary
The facility failed to ensure the assessment accurately reflected the resident's status for one resident. Specifically, Resident #13's Quarterly MDS assessment incorrectly documented the resident as not receiving an antidepressant. This discrepancy was identified during a review of Resident #13's face sheet and physician orders, which indicated that the resident had been prescribed Sertraline HCl for depression since October 2023. The MDS Coordinator confirmed that the Quarterly MDS was inaccurately coded, despite having access to the Resident Assessment Instrument (RAI) for reference. During interviews, both the MDS Coordinator and the Director of Nursing (DON) acknowledged the error. The MDS Coordinator admitted to completing the MDS and confirmed the resident was indeed receiving an antidepressant. The DON also confirmed the resident's antidepressant use and acknowledged that the inaccuracy in the MDS assessment could negatively impact the care received by the resident. The report highlights that the facility did not adhere to the guidelines outlined in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, which requires accurate documentation of medications taken by residents during the 7-day look-back period.
Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #73, who experienced a significant weight loss of 13 pounds over a period of four months. Despite the resident's diagnoses of acute kidney failure, schizoaffective disorder, and bipolar disorder, the care plan did not include specific interventions to address the weight loss. This oversight was identified through record reviews and interviews with the MDS nurse and the Director of Nursing (DON), who acknowledged the lapse in updating the care plan. The MDS nurse admitted to not knowing why the weight loss was not included in the care plan, and the DON confirmed that it was her expectation for care plans to be updated to ensure all team members are informed and coordinated in providing care. The deficiency was further highlighted by the facility's policy on comprehensive person-centered care plans, which mandates ongoing assessments and revisions of care plans as residents' conditions change. The failure to update Resident #73's care plan with specific interventions for weight loss could lead to inconsistent care and potentially adverse outcomes. The DON mentioned that nurse managers are responsible for ensuring care plans are completed and that she monitors this intermittently, which contributed to the oversight in this case.
Failure to Document Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Resident #102 was prescribed Lorazepam for anxiety without a documented diagnosis of anxiety in the clinical record. The resident's facesheet, care plan, and order summary did not include a diagnosis of anxiety, despite the prescription for Lorazepam. The resident had a BIMS score indicating moderate cognitive decline, but no documentation supported the need for the psychotropic medication for anxiety. During an interview, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the resident had been prescribed a psychotropic drug without a documented diagnosis of anxiety. They acknowledged that the diagnosis should have been listed in the resident's record and attributed the oversight to nursing staff. The facility's Antipsychotic Medication Use Policy states that such medication should only be used to treat a specific condition for which it is indicated and effective, highlighting the deficiency in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below 5%, resulting in an 8% error rate. This was based on 2 errors out of 25 opportunities, involving a resident and a Certified Medication Aide (CMA). The CMA administered medications without verifying the correct dosage as per the physician's orders. Specifically, the CMA administered one tablet each of Lactase and Probiotic to a resident without confirming the dosage, stating she would administer whatever was on the bottle. The Charge Nurse and Director of Nursing (DON) confirmed that the medications should not have been administered without a clear dosage listed on the Electronic Medication Administration Record (EMAR). The resident involved was an elderly female with severe cognitive impairment, diagnosed with anxiety, dysphagia, and Alzheimer's disease. The resident's medication orders for Lactase and Probiotic did not have a dosage listed on the EMAR. The Charge Nurse and DON acknowledged that the orders might need to be clarified with the physician to ensure the correct dose was administered. The DON admitted that the oversight occurred due to only conducting spot checks rather than thorough daily monitoring of physician orders by Nurse Managers.
Failure to Ensure Safe and Sanitary Storage of Residents' Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of residents' food items in two personal refrigerators. Observations revealed that the personal refrigerator in one resident's room contained an unlabeled and undated sandwich, which remained there for at least two days. Similarly, another resident's personal refrigerator contained a thawed, unlabeled, and undated frozen meal, which also remained for at least two days. These observations were confirmed by a CNA during interviews on the same days the observations were made. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), it was confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The facility's policy, revised in October 2017, states that perishable foods should be discarded on or before the use-by date. The failure to adhere to this policy could place residents at risk of foodborne illness due to consuming spoiled foods.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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