Riverside Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 6801 E Riverside Dr, Austin, Texas 78741
- CMS Provider Number
- 676246
- Inspections on file
- 50
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Riverside Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with significant cognitive and neurologic impairments were in a dining area when one resident, a male with vascular dementia, intermittent explosive disorder, and expressive aphasia, became frustrated that a female stroke survivor in a wheelchair was not moving quickly enough. Staff reported that he pushed her wheelchair and then hit her right arm while she cried out for him to stop and began crying. The female resident, who had right‑sided weakness, spasms, and moderately impaired cognition, later described being shocked and scared, stated she did not feel safe, and identified the male resident as the person who hit her. Staff assessments documented her emotional distress and existing bruising on both arms, while the facility’s abuse policy affirmed residents’ rights to be free from abuse and required oversight and monitoring to prevent such incidents.
A resident with dysphagia and moderate cognitive impairment was given non-crushed acetaminophen tablets by an RN who failed to review the resident's chart and special instructions, resulting in the resident coughing uncontrollably and experiencing fear and discomfort. The resident's care plan and physician orders required all medications to be crushed due to swallowing difficulties, but these were not followed during the medication administration.
A resident with hemiplegia, hemiparesis, and moderate cognitive impairment was unable to access the call light, which was left dangling near the floor and not placed on her usable side, despite staff entering and exiting the room and care plan instructions to ensure accessibility. Staff interviews confirmed the expectation for call lights to be within reach, but this was not followed, leaving the resident without a means to call for assistance.
A resident with significant cognitive and physical impairments exited the facility unsupervised by following a contract worker out the front door, which was held open by another resident. The resident self-propelled down the driveway, crossed the street, and fell from her wheelchair at the median before staff could intervene. The receptionist responsible for monitoring the exit was not attentive, and the resident was not previously identified as high elopement risk in the facility's records.
The facility failed to maintain food safety and sanitation standards in the kitchen. Food items in the refrigerator and freezer were not labeled or dated, and some were not properly sealed. The kitchen was found to be unclean, with grease, food splatters, and residues on various appliances, and the floors were dirty. Additionally, there were no paper towels at the handwashing station, compromising hand hygiene. The Dietary Manager and Assistant Dietary Manager acknowledged these issues, emphasizing the importance of labeling, sealing, and maintaining a clean environment.
The facility failed to maintain proper infection control in the laundry area. A staff member handled soiled linen without proper hand hygiene, using hand sanitizer on wet hands due to an empty paper towel dispenser. Additionally, lint traps in dryers were not cleaned or logged, contrary to facility policy. Interviews with staff confirmed these practices did not meet facility expectations.
Two residents experienced issues with missing clothing and belongings due to the facility's failure to provide a safe, clean, and homelike environment. A resident with severe cognitive impairment and another with intact cognition both reported missing items, with no inventory lists in their medical records. Staff interviews revealed systemic issues with labeling and returning clothing, leading to numerous grievances. The facility's administration acknowledged the problem, but the lack of a consistent inventory system resulted in diminished quality of life for the residents.
A resident with schizoaffective disorder and mild cognitive impairment reported missing personal items due to the facility's inconsistent inventory management. Staff interviews revealed a lack of clear responsibility for inventorying and labeling residents' clothing. Additionally, the facility failed to maintain cleanliness in the smoking area, with numerous cigarette butts observed on the ground, indicating inadequate supervision and maintenance.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to a lack of engagement in activities and potential diminished quality of life. The care plans did not include specific interests or preferences, and there was a lack of documentation and understanding among staff on personalizing care plans.
The facility failed to provide a resident-centered activity program, as evidenced by three residents who were not engaged in activities according to their preferences and care plans. A resident with dementia and sensory impairments was left without music or television, another with severe cognitive impairment had no documented activities, and a third with intact cognition was not invited to participate in activities. The Activity Director was unaware of specific resident needs, and there was no documentation of activities being provided.
A resident with essential tremor and intact cognition did not receive meals according to her preferences and needs, as her meal ticket instructions to cut all meats and avoid certain disliked foods were not followed by the facility staff. This oversight occurred over multiple meals, leading to dissatisfaction and potential risk to the resident's quality of life.
The facility failed to maintain effective infection control practices, as staff did not consistently follow hand hygiene and equipment sanitation protocols. CNAs did not wash or sanitize hands during peri care, and a CNA and MA failed to sanitize hands and equipment between resident interactions. These lapses occurred despite the facility's policies and training, potentially increasing the risk of infection transmission among residents with various medical conditions.
The facility's pest control program was ineffective, leading to the presence of flies and cockroaches. A resident reported discomfort with bugs, while another noted persistent fly issues despite complaints. A CNA observed flies but did not report them. The facility's pest control policy required reporting pest sightings, but the administration was unaware of the ongoing issues.
The facility failed to maintain privacy and dignity for two residents during personal care. An LVN provided wound care without closing the door or curtain, exposing a resident to the hallway. A CNA provided peri care without closing the privacy curtain, leaving another resident visible to anyone entering the room. Both staff members acknowledged the oversight, and the facility's policy emphasizes the importance of maintaining resident privacy.
A resident's bottom dentures broke, and the facility failed to assist in obtaining timely dental services. Despite the dentures being sent for repair, they were lost upon return, and staff were unable to locate them. The resident, who had multiple health conditions and was dependent on staff for daily activities, experienced discomfort and difficulty chewing. Interviews with staff revealed a lack of effective communication and follow-up, contributing to the deficiency.
A resident's right to receive visitors was violated when the facility banned a family member without documented evidence or proper communication. The administration alleged the family member brought substances into the facility, but staff interviews revealed inconsistencies and lack of awareness about the ban. The deficiency also impacted another resident related to the banned family member.
The facility failed to ensure call lights were within reach and air mattresses were functioning for several residents. Observations revealed inaccessible call lights and deflated air mattresses due to being unplugged. Staff interviews indicated inconsistent checks on these essential items, despite expectations from the DON and ADM.
A resident with moderate cognitive impairment and multiple health issues was identified as a high fall risk, but the facility failed to include fall prevention interventions in the care plan. The resident subsequently fell from bed, highlighting the deficiency in care planning. The DON acknowledged the oversight, which contradicted the facility's policy requiring comprehensive care plans.
The facility failed to provide a private place for telephone communications for three residents, forcing them to use a phone at the nurses' station where conversations could be overheard. This issue was acknowledged by staff and administration, but no immediate action was taken to resolve it.
Failure to Prevent Resident‑to‑Resident Physical Abuse in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse during a resident‑to‑resident altercation. On the date of the incident, a female resident with a history of CVA with hemiparesis, vascular dementia, bipolar disorder, major depressive disorder, chronic kidney disease, and other comorbidities was in the dining room waiting in line to see a speech therapist. Her MDS showed moderately impaired cognition (BIMS 9) and dependence on staff for toileting and lower body dressing. Staff reported that she had pre‑existing bruises on both arms from a prior hospitalization, and her care plan included an ADL self‑care performance deficit related to CVA with hemiparesis and an intervention for staff to observe her skin for bruising. At the time of the incident, a male resident with severe cognitive impairment (BIMS 0), vascular dementia with mood disturbance, intermittent explosive disorder, expressive aphasia, and a history of striking another resident was also in the dining room. His care plan, last revised shortly after the incident, documented that he had previously struck another resident on an earlier date and again on the date of this event, with identified interventions such as analyzing triggers, increasing monitoring, psych medication review, and redirection when stressed. On the day of the altercation, staff observed that he became frustrated because the female resident, who had right‑sided weakness and moved slowly, was in his way and could not move quickly enough. According to staff interviews, the male resident pushed the female resident’s wheelchair and then raised his hand and hit her on the right arm while she yelled “stop” and cried. A CNA reported hearing the female resident cry out “he hit me,” and a nurse stated that by the time she got up from the nurses’ station, the male resident was already hitting the female resident on her right arm, which was known to be painful due to spasms. Staff separated the residents. Subsequent assessments documented that the female resident was crying and tearful after the incident, described being shocked and scared, and reported fear of the male resident, stating she did not feel safe and would avoid him or seek staff if she saw him. Physical assessment documented intact skin with no new skin issues at that time, though bruising was present on both arms, with some bruising attributed to a prior hospitalization. The facility’s abuse prevention policy stated that each resident has the right to be free from abuse, including willful infliction of injury causing physical harm, pain, or mental anguish, and that the facility would provide oversight and monitoring to ensure residents are free from abuse, neglect, and mistreatment.
Failure to Administer Crushed Medication as Ordered for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, and dysphagia following a stroke was not administered her prescribed medication in accordance with physician orders and care plan instructions. The resident was assessed as having moderate cognitive impairment and was dependent on staff for all activities of daily living. Her care plan and physician orders clearly indicated that all medications were to be crushed due to her swallowing difficulties, as confirmed by a swallow study and special instructions in her medical record. On the date of the incident, an RN who was not regularly assigned to the building administered two non-crushed acetaminophen tablets to the resident, despite the clear instructions to crush all medications. The RN did not review the resident's chart or special instructions prior to administration and was unaware of the requirement to crush medications. Upon administration, the resident began coughing uncontrollably, refused additional water, and expressed fear and discomfort as a result of the incident. The RN later acknowledged that the medication should have been crushed and that failure to do so could result in choking. Interviews with facility staff, including the DON, speech therapist, and social worker, confirmed that the expectation was for staff to review special instructions and physician orders before administering medications. The DON and other staff reiterated that the special instructions are prominently displayed in the electronic medical record. The resident herself reported feeling scared and terrible after the incident, and staff noted that her cognitive status made it unlikely she could reliably communicate her medication needs, emphasizing the importance of staff following documented instructions.
Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with significant physical and cognitive impairments by not providing a working communication system within easy reach. The resident, who had hemiplegia and hemiparesis following a stroke, as well as moderate cognitive impairment, was observed lying in bed unable to access the call light, which was wrapped around the right bed rail and dangling near the floor. Despite care plan interventions specifying that the call light should be within reach and on the resident's usable side, both a CNA and an RN entered and exited the room without ensuring the call light was accessible to the resident, who could only use her left side due to right-sided weakness and a sling. Interviews with staff, including the RN, CNA, DON, and ADM, confirmed the expectation that call lights should be placed within reach and on the resident's functional side. The facility's policy also required providing residents with a means of communicating with nursing staff. However, these expectations were not met, as evidenced by direct observations and staff admissions, resulting in the resident being unable to call for assistance when needed.
Resident Elopement and Fall Due to Inadequate Supervision at Exit
Penalty
Summary
A deficiency occurred when a resident with profound intellectual disabilities, dementia, muscle wasting, and cognitive communication deficit was able to elope from the facility without staff knowledge. The resident, who utilized a wheelchair for mobility and was assessed as low risk for elopement on a recent evaluation, exited the facility by following a contract worker out the front door. The front door was held open by another resident, allowing the resident in question to leave the building unsupervised. Once outside, the resident self-propelled her wheelchair down the driveway, across the street, and into a median, where she bumped into the curb and fell out of her wheelchair. Staff members observed the incident and attempted to intervene, but were unable to reach her before she fell. The resident was assessed for injuries and sent to the hospital for further evaluation, where no significant injuries were found. She returned to the facility later that night at her baseline condition. Interviews and record reviews revealed that the receptionist, who was responsible for monitoring the front door and ensuring residents did not exit inappropriately, was not attentive to the residents exiting at the time of the incident. The facility's elopement binder did not previously include the resident, and staff were not consistently verifying the intentions of residents leaving the building. The deficiency was identified as Immediate Jeopardy due to the failure to provide adequate supervision and maintain a safe environment, resulting in the resident's unsupervised exit and subsequent fall.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed that food items in the walk-in refrigerator and freezer were not labeled or dated, which is a violation of food safety regulations. Specifically, containers of vegetable soup, chicken and pasta, tuna salad, breaded chicken filets, raw chicken, raw beef burger patties, ground meat, pie crust, and taquitos were found without labels or dates. Additionally, some items were not properly sealed, exposing them to potential contamination. The kitchen's cleanliness was also found to be substandard. The fryer was coated with dark grease, the microwave was soiled with dried food splatters, and the blender had a yellow-green residue. The toaster oven was covered in oil residue and crumbs, and the ice machine had a slimy residue and unknown substances inside. The kitchen floors were dirty, with puddles of juice and other fluids, and food debris scattered in various areas. Furthermore, the facility failed to maintain proper hand hygiene supplies, as there were no paper towels available at the handwashing station. This was observed when a dietary staff member offered a used rag to dry hands, which was declined. The Dietary Manager and Assistant Dietary Manager acknowledged these issues, stating that they expected food items to be labeled, dated, and sealed, and for the kitchen environment to be clean to prevent cross-contamination and foodborne illnesses.
Inadequate Infection Control in Laundry Area
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in the laundry area, which was observed during a survey. Specifically, a staff member, LS A, was seen handling soiled linen without proper hand hygiene. After working with soiled linen, LS A rinsed her hands without using soap and moved to the clean linen area with wet hands, using hand sanitizer instead of drying them properly. The paper towel dispenser was empty, preventing proper hand drying. Additionally, the lint traps in the commercial-sized dryers were found with thick layers of lint, and there was no documentation of them being cleaned in January 2025. Interviews with the HS and ADM revealed that the facility's expectations were not being met. The HS stated that lint traps should be cleaned after each dryer use and logged accordingly, which LS A was unaware of. The ADM confirmed that handwashing with soap and water was expected before handling clean linen and that the handwash station should be stocked with necessary supplies. The facility's policies on laundry services and infection prevention emphasized the importance of these practices to prevent infection control issues.
Failure to Protect Residents' Personal Belongings
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not adequately protecting the personal belongings of two residents from loss or theft. Resident #1, a male with severe cognitive impairment due to Alzheimer's disease, and Resident #2, a female with intact cognition, both experienced issues with missing clothing and belongings. Resident #1's family reported missing polo shirts and personal blankets, while Resident #2 expressed frustration over missing clothes and receiving items that did not belong to her. Both residents' medical records lacked an inventory list of their belongings. Interviews with the residents and staff revealed systemic issues in the facility's handling of residents' clothing. Resident #1 was unsure if an inventory was taken upon his arrival, and Resident #2 reported frequent issues with the laundry service, including receiving incorrect items. The housekeeping staff acknowledged that clothing often arrived at the laundry room without names, and efforts to return items to their rightful owners were inconsistent and ineffective. The facility had implemented a weekly audit system to address these issues, but it had not yet resolved the problem. The facility's administration acknowledged the expectation for nursing and laundry staff to manage and label residents' clothing properly. However, the lack of a consistent inventory and labeling system led to numerous grievances from residents about missing clothing. The facility's Resident Rights policy emphasizes the right to retain personal possessions and maintain a homelike environment, which was not upheld in this case, resulting in diminished quality of life for the affected residents.
Deficiencies in Personal Belongings Management and Smoking Area Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, specifically in protecting personal belongings from loss or theft and maintaining cleanliness in designated smoking areas. Resident #76, a [AGE] year-old man with schizoaffective disorder, bipolar type, paranoid schizophrenia, and mild neurocognitive disorder, reported missing several personal items, including shirts and shoes. The facility lacked a consistent process for inventorying and labeling residents' clothing, leading to frequent grievances about missing items. Interviews with staff revealed inconsistencies in the responsibility and execution of inventory management, with no clear policy or in-service training on handling missing items or maintaining inventory sheets. Additionally, the facility failed to maintain cleanliness in the smoking area, where numerous cigarette butts were observed scattered on the ground despite the presence of ashtrays. The designated smoking area, located in a pavilion in the facility's parking lot, was not adequately supervised or maintained, as evidenced by the accumulation of cigarette butts. Interviews with staff, including the DSD and ADM, indicated a lack of clarity regarding who was responsible for cleaning the area and ensuring residents disposed of cigarette butts properly. These deficiencies were observed during a survey, highlighting the facility's failure to uphold residents' rights to a safe and comfortable environment. The lack of a structured process for managing residents' personal belongings and maintaining cleanliness in common areas contributed to a diminished quality of life for the residents.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which did not include measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #100, a male with severe cognitive impairment and multiple medical conditions, had no care planning related to recreational activities despite his expressed interests in various activities. There were no activity progress notes or documented tasks for him from admission to the end of the review period, and observations showed him consistently unengaged in activities. Resident #70, a female with moderate cognitive impairment and several medical diagnoses, had a care plan that lacked completion of the Activity Preferences section. Her care plan was generic and did not reflect her specific interests or preferences. There were no activity progress notes or documented tasks for her, and observations confirmed she was not engaged in any activities. Resident #104, a female with intact cognition and multiple medical issues, had a care plan that did not describe her specific activity interests. Like the other residents, there were no activity progress notes or documented tasks for her, and she was observed not participating in any activities. Interviews with staff revealed a lack of understanding and training on personalizing care plans, contributing to the deficiency. The facility's policy required comprehensive person-centered care plans, but this was not adhered to, placing residents at risk of diminished quality of life.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the preferences and needs of residents, as evidenced by the cases of three residents. Resident #27, a woman with multiple diagnoses including dementia and sensory impairments, was observed repeatedly lying in bed without music or television, despite her care plan indicating a preference for music and television. The Activity Director (AD) was unaware of her sensory impairments and did not ensure that her preferences were met, leading to a lack of engagement in activities. Resident #100, a male with severe cognitive impairment and multiple health issues, expressed a preference for reading materials, music, and outdoor activities. However, there was no care plan related to his recreational activities, and no activity tasks were documented for him. Observations revealed that he spent his time in bed without any engagement in activities, and he reported not being invited to participate in any facility activities. Resident #104, a female with intact cognition and various health conditions, also had no documented activity tasks or progress notes. Her care plan lacked specific activity interests, and she reported not being invited to activities. Observations showed her lying in bed without engagement in activities. The AD admitted to not being familiar with the residents' specific needs and preferences, and there was no documentation of activities being provided. The Director of Nursing (DON) and the Administrator acknowledged the inadequacy of the activity program, noting that one-to-one activities once a month were insufficient.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodated the allergies, intolerances, or preferences of a resident, specifically Resident #24, who was reviewed for meal preferences. The resident's meal ticket indicated that all meats should be cut at all meals and listed dislikes including squash. However, during lunch on 10/28/24, dinner on 10/29/24, and lunch on 10/30/24, the facility did not cut the resident's meat as required, and on one occasion, served squash, which was listed as a disliked food. Resident #24, a [AGE] year-old female with essential tremor, lack of coordination, and muscle weakness, required assistance with personal care and had intact cognition as indicated by a BIMS score of 15. Despite her capability to cut her own meat, the resident found it difficult due to her tremors and expressed feeling unimportant because her meal preferences were not being followed. The facility's staff, including aides and the ADOR, failed to adhere to the meal ticket instructions, and the dietary manager acknowledged a three-fold failure in the process of preparing and serving meals. Interviews with the dietary manager, DON, and ADM revealed a lack of clarity and responsibility among staff regarding who should ensure meal tickets are followed. The dietary manager stated that aides, cooks, and nurses were supposed to follow meal tickets, but there was a failure in the process. The DON and ADM both indicated that the staff serving the meals were responsible for following the meal ticket instructions, but there was no recent training on this topic. This deficiency placed residents at risk of weight loss and diminished quality of life.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with hand hygiene and equipment sanitation protocols. During observations, it was noted that CNAs did not wash or sanitize their hands before and after providing peri care to residents. Specifically, CNA G and CNA F handled wet wipe packets with soiled gloves and failed to discard contaminated materials properly, potentially leading to cross-contamination. These actions were observed during care for residents with various medical conditions, including cognitive impairments and chemotherapy treatment, which increased their vulnerability to infections. Additionally, the facility's staff did not adhere to proper hand hygiene practices during meal service and medication administration. CNA J was observed failing to sanitize her hands between handling dirty and clean meal trays, while MA I did not sanitize her hands or medical equipment, such as a blood pressure cuff, between resident interactions. This lack of adherence to infection control protocols was observed during medication administration to residents with conditions such as dementia, hypertension, and diabetes, further increasing the risk of disease transmission. Interviews with staff, including the DON and MA I, revealed a lack of consistent understanding and implementation of the facility's infection control policies. Despite receiving training, staff members admitted to lapses in following hand hygiene and equipment sanitation procedures, acknowledging the potential for spreading infections. The facility's policies clearly outlined the need for hand cleansing before and after resident contact and equipment decontamination, yet these were not consistently followed, leading to the identified deficiencies.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and cockroaches within the environment. Observations were made of a cockroach in a resident's room and multiple flies in another resident's room, as well as in the dining area. One resident expressed discomfort with the presence of bugs, while another resident reported that flies had been a persistent issue since their admission, despite having complained to staff multiple times. A CNA acknowledged the presence of flies but did not report it, understanding the potential for disease spread. The facility's pest control program, which involved bi-monthly treatments by a pest control agency, was found to be ineffective as insect activity continued. The facility's policy on pest control emphasized the use of pesticides only after other control measures were exhausted and required immediate reporting of pest sightings. However, the administration was unaware of the ongoing pest issues, indicating a breakdown in communication and reporting within the facility.
Failure to Ensure Resident Privacy and Dignity During Care
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents during personal care. In the first instance, a Licensed Vocational Nurse (LVN) provided wound care to a resident without closing the door or drawing the privacy curtain, leaving the resident exposed to the hallway. The resident, who had multiple diagnoses including COPD, heart failure, and dementia, did not notice the lack of privacy but acknowledged that he would be visible to others. The LVN admitted that the privacy and dignity of the resident were compromised and acknowledged awareness of the resident's rights to privacy, dignity, and respect. In the second instance, a Certified Nursing Assistant (CNA) provided peri care to another resident without closing the privacy curtain, although the door was closed. This resident, who had diagnoses including sepsis, COPD, and diabetes, was in a shared room and his bed was visible to anyone entering the room. The resident expressed that exposure would be embarrassing, and the CNA admitted to forgetting to close the curtain, acknowledging the lapse in respecting the resident's privacy and dignity. The Director of Nursing (DON) and the Administrator confirmed that privacy and dignity should be maintained during care, as per the facility's policy.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident #15, in obtaining timely dental services after her bottom dentures broke sometime after May 2024. Despite the resident's need for dental care, the facility did not ensure the repair or replacement of the dentures, which were sent to a lab for repair but were subsequently lost. The resident's dental progress notes indicated that the dentures were delivered back to the facility, but staff were unable to locate them, leading to a delay in the resident receiving necessary dental care. Resident #15, a female with multiple diagnoses including chronic obstructive pulmonary disease, dysphagia, and major depressive disorder, was dependent on staff for various activities of daily living. Her quarterly assessments showed no cognitive impairment, and she was on a regular diet. However, the absence of her bottom dentures made it uncomfortable for her to chew food, as observed during an interview where she expressed her discomfort and lack of communication from the staff regarding the status of her dentures. Interviews with facility staff, including the Administrator (ADM), Director of Nursing (DON), and the social worker (BSW), revealed a lack of effective communication and follow-up regarding the missing dentures. The facility's policy required prompt action within three business days for dental services, but this was not adhered to, resulting in the resident's prolonged discomfort and potential risk due to the inability to chew properly. The facility's failure to follow its dental services policy and effectively manage the situation contributed to the deficiency noted in the report.
Failure to Honor Resident Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of his choosing, leading to a deficiency in resident rights. A male resident, who was cognitively intact with a BIMS score of 15, was not allowed to visit with a family member. The facility's administration claimed the family member was banned due to allegations of bringing drugs and alcohol into the facility and sleeping in the resident's bed. However, there was no documentation or evidence provided to support these claims, and the resident was not informed in writing about the visitation ban. Interviews with staff, including LVNs, CNAs, and the DON, revealed inconsistencies in the facility's handling of the situation. Some staff members were unaware of the ban, and others had not observed any disruptive behavior from the family member. The ADM stated that the family member was banned for safety reasons, but there was no documentation of any incidents or law enforcement involvement. The facility's policies on visitation rights were not followed, as the resident was not given written notice or an opportunity for supervised visitation. The deficiency also affected another resident related to the banned family member, as the family member was not allowed to visit them either. The facility's failure to document the ban and communicate it effectively to staff and residents led to a violation of resident rights. The lack of evidence and documentation regarding the alleged disruptive behavior and the facility's failure to follow its own policies contributed to the deficiency.
Failure to Ensure Call Light Accessibility and Air Mattress Functionality
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility did not ensure that the call lights were within reach for three residents, and there was no order to check the functioning of air mattresses for two residents. On the day of observation, the call lights for three residents were not accessible, with one resident's call light found under a fall mat and another's on the floor. Additionally, the air mattress for one resident was found deflated because it was not plugged in, and there were no orders for monitoring the air mattresses for two residents. Resident #1, a woman with cerebral palsy, autism, and congenital brain malformation, was observed with her call light under a fall mat and her air mattress deflated due to being unplugged. Her care plan indicated she was at risk for pressure injuries and required a pressure-reducing device. Resident #2, with dementia and muscle weakness, had her call light cord wrapped around the bed, leaving the button on the floor and out of reach. Resident #3, with Parkinsonism and severe cognitive impairment, had his call light cord wrapped around the bed rail, making it inaccessible. Resident #4, who was cognitively intact, reported his air mattress deflated every two hours, and the settings were not appropriate for his weight. Interviews with staff revealed a lack of consistent checks on call light placement and air mattress functionality. CNAs and LVNs acknowledged the importance of ensuring call lights were within reach and air mattresses were plugged in and set correctly. However, there was no facility policy regarding air mattresses, and staff were not consistently following procedures to ensure residents' needs were met. The Director of Nursing and Administrator both stated expectations that staff ensure residents have needed items within reach and that devices are functioning, but these expectations were not met in practice.
Failure to Address High Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included addressing the resident's high fall risk. The resident, a male with moderate cognitive impairment and multiple diagnoses including type II diabetes and generalized muscle weakness, was admitted and readmitted to the facility. Despite being identified as a high fall risk in the Fall Risk Assessment, the resident's care plan did not include any interventions to prevent falls. The deficiency was highlighted when the resident was found on the floor after falling from his bed. The Director of Nursing (DON) acknowledged that the care plan should have included interventions such as keeping the bed in a low position and ensuring the call light was within reach. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes, which was not adhered to in this case.
Lack of Private Telephone Communication for Residents
Penalty
Summary
The facility failed to ensure all residents had a private place for telephone communications without being overheard. This deficiency was observed for three confidential residents (CR #1, CR #2, and CR #3) out of five reviewed for private communications. The facility only provided a phone at the nurses' station for residents to use, which did not allow for private conversations. CR #1 expressed frustration and distress over the lack of privacy during a phone call, and staff confirmed that the only phone available for residents was at the nurses' station. The facility's administration was made aware of the issue but did not take immediate action to address it. During interviews, CR #2 and CR #3 also reported discomfort and the inability to have confidential phone conversations due to the lack of a private phone area. Staff members, including an LVN and the MDSC, acknowledged the importance of resident rights to private communications and recognized that the current setup did not meet these rights. The facility's Resident Rights Policy did not specifically address the right to private phone conversations, and the administration admitted to being unaware of the non-functional cordless phones that could have provided a solution.
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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