Riverview Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Boerne, Texas.
- Location
- 1102 River Rd, Boerne, Texas 78006
- CMS Provider Number
- 675371
- Inspections on file
- 37
- Latest survey
- March 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Riverview Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to update comprehensive care plans within the required timeframe for four residents, following MDS assessments. This deficiency involved residents with various medical conditions, including cognitive impairments and mobility issues. Interviews revealed that care plan conferences were missed, potentially impacting the delivery of necessary care.
The facility's kitchen operations were found deficient in food safety standards. Observations revealed open food containers, a rat trap near food storage, and staff not adhering to hygiene protocols, such as wearing hairnets and gloves. These practices contradict the facility's policies on safe food handling.
The facility failed to maintain essential equipment in safe operating condition, with non-operational dryers, washers, and HVAC in the laundry, and an improperly supported deep fryer in the kitchen. The Maintenance Director and Administrator were aware of these issues, which violated the facility's sanitation policy.
The facility failed to maintain a safe and comfortable environment in the A and B wings. In the A Wing, window blinds were broken, and in the B Wing, mold was found on the shower tile and curtain. An LVN noted the blinds issue for maintenance, while a CMA/CNA and housekeeper confirmed the mold presence, with the latter unaware of it despite recent cleaning. The facility's cleaning policy was reviewed, but the maintenance policy was not provided.
The facility failed to report a smoke incident in the women's memory care unit's pantry closet to the appropriate authorities within the required timeframe. Staff engaged the fire alarm system, alerted the fire department, and used a fire extinguisher to address the smoke. Despite these actions, the incident was not reported to the state agency as required by the facility's policy and state law, as it was deemed not to involve flames or result in serious bodily injury.
The facility failed to report a smoke incident involving an exhaust fan in the women's Memory Care Unit to the State Survey Agency. The incident, which triggered the fire alarm and involved the local fire department, was not reported due to the absence of flames. Fourteen residents were evacuated and assessed for safety, but the facility's leadership decided the incident did not meet the criteria for reporting.
A facility failed to monitor a resident for edema as ordered by the physician, despite the resident's multiple health conditions. The LVN did not document edema checks, and the order was incorrectly entered into the EMR system. The DON acknowledged the potential health risks of not monitoring edema.
The facility failed to provide food at a safe and appetizing temperature, as a test tray was found lukewarm and the food temperature log was blank. Two residents reported their food was not hot. Dietary staff admitted to not properly recording food temperatures, contrary to facility policy.
A facility failed to ensure the safe and sanitary storage of food in a resident's personal refrigerator, where 3-4 Styrofoam cups with mold were found. The resident was asleep and had just returned from the hospital. Interviews with the DON and ADM confirmed the issue, and the cups were discarded. The facility's policy requires nursing staff to discard perishable foods by their use-by date and potentially hazardous foods left unrefrigerated for over two hours, indicating a lapse in policy adherence.
Two residents in a facility did not receive proper infection control care due to staff failing to adhere to Enhanced Barrier Precautions (EBP). One CNA provided catheter care without full PPE, while another CNA provided incontinent care without a gown, both unaware of the residents' EBP status. The lack of proper signage and staff awareness led to these deficiencies, risking cross-contamination.
The facility failed to properly dispose of garbage and refuse, as the left side door of the dumpster was found open. The Maintenance Director confirmed the issue and stated that staff were regularly instructed to keep the doors closed to prevent pest attraction. The Administrator was unaware of the open door, which could lead to pest and rodent issues. Facility policy and the U.S. Public Health Service Food Code require that refuse containers be covered with tight-fitting lids or doors.
The facility failed to provide proper pharmaceutical services, resulting in incorrect medication administration for a resident and expired medications in use. A resident received the wrong medication due to a misunderstanding by a medication aide, while two residents had insulin pens that were not discarded after the recommended 28-day period. Additionally, an expired sore throat spray was found in the medication room, indicating lapses in medication management and storage.
The facility failed to store food according to professional standards, as observed in the kitchen's dry goods pantry. An open and expired salsa container was found at room temperature, despite instructions to refrigerate after opening. The Dietary Manager confirmed the error and disposed of the salsa. Facility policy mandates refrigerated foods be stored below 41°F.
The facility failed to maintain a homelike environment in A Hall, a male secured wing, due to a persistent strong urine odor observed over several days. Despite regular cleaning and acknowledgment by the administrator, the odor remained, contradicting the facility's policy to minimize institutional odors.
A resident with severe cognitive impairment and multiple health issues had their call light inaccessible on two occasions, once behind a drawer chest and once on the floor. Staff acknowledged the oversight, and the facility's policy requires call lights to be within easy reach.
A facility failed to provide a safe environment and adequate supervision for a resident, resulting in a deficiency. A used disposable razor was found in a resident's bathroom, posing a risk of infection or injury. The resident required assistance with personal hygiene due to limited mobility. Staff interviews revealed that the razor should have been discarded in a sharps container after use, as per facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not receive proper incontinent care, as a CNA used multiple passes with a single wipe to clean the genital area, contrary to facility policy. This improper technique, acknowledged by the CNA and the DON, could lead to urinary tract infections.
A resident receiving hospice care for a terminal condition was not provided with appropriate respiratory care, as their oxygen tubing and nasal cannula were left uncovered when not in use. This was against the facility's policy, which required the equipment to be covered to prevent infection. The oversight was acknowledged by both the LVN and the DON, highlighting a lapse in following professional standards of practice.
A resident in a facility obtained a lighter and started a fire in his room while on oxygen, despite being readmitted as a non-smoker. The facility lacked processes to check for smoking materials upon readmission and failed to maintain a designated smoking area with proper signage and equipment. Staff supervision during smoke breaks was inadequate, and there was inconsistent enforcement of the smoking policy.
The facility required all residents in the memory care units to use plastic utensils during meals due to safety concerns, while residents in the general population used metal silverware. This practice was inconsistently documented in care plans and affected residents' dignity and quality of life.
The facility failed to maintain a safe, clean, comfortable, and homelike environment in the Men's Secure Unit. Observations revealed missing room numbers, lack of personalization, disrepair of furniture, and dirty floors. The administration acknowledged these issues but could not provide documentation of efforts to address them prior to the survey exit.
The facility failed to adhere to food safety standards, including improper use of beard restraints, wearing jewelry while preparing food, and improper storage of dented cans. These actions could potentially lead to foodborne illnesses among residents.
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for two residents receiving hospice services. The hospice binders lacked required forms and documentation, which are essential to ensure residents receive adequate end-of-life care. An interview revealed that the social worker was unaware of the required forms, and the administrator was informed of the missing documentation during the survey.
The facility failed to ensure valid OOH-DNR forms for two residents. Both forms were missing the attending physician's date signed, license number, and printed name, rendering them invalid. The Social Worker and Administrator acknowledged the issue and agreed on the need for immediate correction.
The facility failed to maintain an effective pest control program in the Men's Secure Unit. A surveyor found a dead roach in a handrail and a live roach in a resident's bathroom. The LVN was unsure if the unit was included in recent pest control measures, and the Administrator was aware of general pest issues but not specific to the unit. Pest control records showed monthly visits, with the last on April 1, 2024.
The facility failed to protect residents from verbal and physical abuse by a CNA, who pinched, pulled, and verbally abused several residents. Despite complaints from residents and staff, the administration did not take immediate action, leading to multiple incidents of abuse.
The facility failed to report allegations of abuse involving two residents within the required time frame. Both residents reported verbally abusive behavior by a CNA, but the facility did not notify the State Survey Agency as required. Staff interviews revealed known issues with the CNA's behavior, but these were not properly documented or addressed.
Failure to Update Care Plans Timely for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed, reviewed, and revised within the required timeframe for four residents. Specifically, the care plans were not updated within seven days following the completion of the Minimum Data Set (MDS) assessments. This deficiency was identified for four residents, each with various medical conditions, including cognitive impairments, mobility issues, and chronic diseases. The lack of timely care plan updates could result in residents not receiving necessary care. For Resident #28, the care plan was not reviewed or revised after the MDS assessment conducted on February 17, 2025. The resident, who has multiple diagnoses including HIV, respiratory disease, and dementia, reported not being invited to a care plan conference recently. Similarly, Resident #35's care plan was not updated following a significant change MDS assessment on February 25, 2025, despite having conditions such as cerebral infarction and chronic pain. The resident also noted the absence of regular care plan conferences. Resident #33's care plan was not reviewed or revised throughout 2023, despite having conditions like Parkinson's disease and schizoaffective disorder. Additionally, Resident #20's care plan was not updated after several MDS assessments in 2024 and early 2025, despite severe cognitive impairment and multiple health issues. Interviews with facility staff revealed awareness of the missed care plan conferences, but no immediate corrective actions were documented in the report.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. In the storage room, a rice container was found with its lid open and a smaller container inside, while the flour container's lid was not tightly closed. Additionally, a rat trap box was located under the shelf where the flour container was stored. These conditions were confirmed by DM R, who acknowledged the need for containers to be closed to prevent pest contamination and expressed uncertainty about the presence of the rat trap box. Further observations revealed that DM Q was not wearing a hairnet while in the kitchen to take food temperatures, which was confirmed during an interview. Additionally, Dietary aide L was observed handling chicken patties without wearing gloves, a practice that contradicts the facility's policy on food handling. The facility's policies, dated November 2022 and November 2002, respectively, emphasize the importance of safe food handling practices, including the use of hair restraints and gloves to prevent foodborne illness.
Failure to Maintain Essential Equipment in Safe Condition
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as observed in the laundry and kitchen areas. In the laundry department, two out of three commercial dryers and one out of two commercial washers were not operational. Additionally, the HVAC system for the laundry facility was not functioning. The laundry aide reported that the equipment had been malfunctioning for over four to five months, and the Maintenance Director confirmed the issues, citing excessive coolant gas leaks in the HVAC system. The Administrator was aware of the malfunctioning equipment but had not been able to replace it. In the kitchen, the deep fryer was missing a leg and was propped up by a piece of wood, which was not a suitable conductor and posed a fire risk. The stove and deep fryer were not properly restrained, which could lead to accidents. The Maintenance Director acknowledged placing the wood under the fryer and admitted it was a fire hazard. The Administrator was unaware of the wood under the fryer leg. The facility's sanitation policy required all equipment to be maintained in good repair, but a specific policy for maintenance and operation of essential equipment was not provided upon request.
Facility Environment Deficiencies in A and B Wings
Penalty
Summary
The facility failed to maintain a safe, functioning, and comfortable environment for residents, staff, and the public in both the A and B wings. In the A Wing common room, three windows were observed to have missing, broken, or bent window blind slats. This issue was noted during observation rounds, and a Licensed Vocational Nurse (LVN) mentioned that the concern would be logged for maintenance. The facility administrator acknowledged the frequent need to replace window blinds due to damage by residents in the male unit. In the B wing, the shower area was found to have mold on the tile floor and mold spots on the shower curtain. A Certified Medication Aide/Certified Nursing Assistant (CMA/CNA) confirmed the presence of a black substance, identified as mold, in multiple areas. The housekeeper, who was unaware of the mold, stated that the shower had been cleaned the previous day and acknowledged that mold could cause illness to residents. The facility's policy on cleaning and disinfecting environmental surfaces, dated August 2019, was reviewed, but the facility maintenance policy was not provided at the time of the survey exit.
Failure to Report Smoke Incident in Memory Care Unit
Penalty
Summary
The facility failed to report an incident involving smoke from an exhaust fan in the women's memory care unit's pantry closet to the appropriate authorities within the required timeframe. On January 21, 2025, the exhaust fan began to produce large amounts of smoke, prompting staff to engage the fire alarm system, alert the fire department, and use a fire extinguisher to address the smoke. Despite these actions, the incident was not reported to the state agency as required by the facility's policy and state law, as it was deemed not to involve flames or result in serious bodily injury. Interviews with staff members, including CNAs and an LVN, confirmed the occurrence of the smoke incident and the subsequent evacuation of residents to a safe area. The staff took appropriate immediate actions to ensure resident safety, including evacuating residents to the courtyard and later to the lobby due to cold weather. The fire department responded, cleared the building for safety, and inspected the exhaust fan. However, the facility's leadership, including the Administrator, DON, and RDO, decided not to report the incident to the state agency, citing the absence of flames as the reason. A review of the facility's policy on reporting abuse, neglect, exploitation, or misappropriation revealed that all such incidents should be reported to local, state, and federal agencies as required by regulations. The policy specifies that incidents not involving abuse or resulting in serious bodily injury should be reported within 24 hours. Despite this policy, the facility did not report the smoke incident, which could place residents at risk for not reporting allegations of abuse, neglect, or exploitation.
Failure to Report Smoke Incident to State Agency
Penalty
Summary
The facility failed to report the results of an investigation regarding an alleged fire incident to the State Survey Agency within the required 5 working days. On January 21, 2025, an exhaust fan in the women's Memory Care Unit (MCU) produced a large amount of smoke, triggering the fire alarm and prompting a response from the local fire department. Despite the activation of the fire alarm and the involvement of the fire department, the facility did not report the incident to the state agency, as the facility's leadership determined that the absence of flames did not warrant such a report. The incident involved 14 residents in the women's MCU, who were evacuated to a secured courtyard and later to the facility's lobby due to cold weather. Staff, including CNA A and LVN D, were involved in the evacuation and subsequent safety assessments of the residents. The facility conducted an ad hoc Quality Assurance Improvement Plan meeting on the same day, which included various staff members and contractors to address the incident. However, the decision not to report the incident was made by the Regional Director of Operations and the Director of Nursing, based on their assessment that the lack of flames did not constitute a reportable event. The facility's policy on reporting abuse, neglect, exploitation, or misappropriation requires immediate reporting of such incidents to the administrator and relevant authorities. However, the decision by the facility's leadership not to report the smoke incident to the state agency was based on their interpretation of the policy, which did not consider the smoke incident as meeting the criteria for reporting. This decision was made despite the facility's policy stating that all reports of resident abuse, neglect, exploitation, or injuries of unknown origin must be reported to local, state, and federal agencies as required by current regulations.
Failure to Monitor Edema as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not follow the physician's orders to monitor for edema in a resident with multiple health conditions, including Diabetes Type 2, COPD, and heart disease. The resident's care plan included monitoring for complications related to COPD, but the physician's order to check for edema every shift and report any abnormalities was not followed. Observations of the resident on multiple occasions revealed no noted edema, but the monitoring was not documented in the Medication Administration Record (MAR). Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) responsible for the resident's care had not documented edema checks in the MAR or progress notes, despite acknowledging the importance of monitoring for sudden increases in edema. The Assistant Director of Nursing (ADON) indicated that the order was incorrectly entered into the Electronic Medical Record (EMR) system and was not linked to the appropriate medication order. The Director of Nursing (DON) acknowledged that failure to monitor edema could lead to serious health consequences for the resident. The facility's policy and procedures for following physician's orders were requested but not provided.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at a safe and appetizing temperature, as evidenced by a test tray observation and resident interviews. During a lunch observation, a test tray containing a chicken patty melt was found to be lukewarm rather than hot. This issue was corroborated by interviews with two residents who reported that their food was not hot. Additionally, the food temperature log for the lunch meal was found to be blank, indicating a lack of proper documentation. Interviews with dietary staff revealed that the food temperatures were taken but not properly recorded. Dietary Aide L admitted to taking the temperatures and writing them on a piece of paper, which was subsequently misplaced. The Dietician consultant acknowledged the need for staff education on maintaining a food temperature log for every meal. The facility's policy on food preparation and service emphasizes compliance with safe food handling practices, including monitoring food temperatures throughout meal service, which was not adhered to in this instance.
Failure to Ensure Safe Storage of Resident's Food
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of foods brought to residents by family and other visitors, as evidenced by the condition of a resident's personal refrigerator. During an observation, it was noted that the refrigerator contained 3-4 Styrofoam empty cups with mold in them. The resident was asleep at the time of the observation and had recently returned from the hospital. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed the presence of the moldy cups, and the ADM stated that the cups were subsequently discarded. A review of the facility's policy on foods brought by family and visitors indicated that nursing staff are responsible for discarding perishable foods on or before their use-by date and potentially hazardous foods left unrefrigerated for more than two hours. However, the presence of moldy cups suggests a lapse in adherence to this policy.
Inadequate Infection Control Practices in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of adherence to Enhanced Barrier Precautions (EBP) for two residents. The first incident involved a CNA providing catheter care to a resident with an indwelling urinary catheter without donning the appropriate Personal Protective Equipment (PPE). The CNA only wore gloves and was unaware of the resident's EBP status, believing that gloves alone were sufficient for infection control. This oversight occurred despite the resident's care plan indicating the need for EBP due to the risk of infection related to the urinary catheter. In the second incident, another CNA provided incontinent care to a resident with a colostomy without wearing a gown, which is part of the required PPE under EBP. The CNA was confused about the resident's EBP status due to the absence of signage on the resident's door, which led to the improper use of PPE. The resident's care plan also indicated the need for EBP to reduce the risk of spreading infections due to the colostomy status. The Director of Nursing (DON) confirmed that the expectation was for staff to use gowns and gloves for residents with indwelling medical devices or colostomy bags under EBP. The facility's failure to ensure proper PPE use during high-contact resident care activities, as outlined by the Centers for Disease Control and Prevention (CDC), placed residents at risk for cross-contamination and the spread of communicable diseases.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed on March 6, 2025, when the left side door of the dumpster was found open. This deficiency was noted during an observation at 10:50 AM. The Maintenance Director confirmed the door was open and stated that he regularly instructed staff to keep the dumpster doors closed, emphasizing that open doors could attract pests. The Administrator was unaware of the open dumpster door and acknowledged the potential for pest and rodent issues. A review of the facility's policy from November 2022 indicated that garbage and refuse containers should be in good condition, without leaks, and properly contained with lids. Additionally, the U.S. Public Health Service Food Code requires that receptacles for refuse be kept covered with tight-fitting lids or doors if located outside the food establishment.
Pharmaceutical Service Deficiencies in Medication Administration and Storage
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for three residents and in one medication room. Resident #4 was administered milk of magnesia instead of the prescribed Geri-Lanta for gastro-esophageal reflux disease. The medication aide mistakenly believed the two medications were the same, leading to the incorrect administration. The Director of Nursing (DON) confirmed that the two medications serve different purposes and emphasized that the aide should have consulted a charge nurse if there was any confusion. For Resident #42, an insulin flex pen (Aspart) was found in the nursing cart beyond its 28-day usage period after being opened. The Assistant Director of Nursing (ADON) acknowledged that the insulin should have been discarded after 28 days, as per standard care practices. Similarly, Resident #38's insulin flex pen (Lantus) was also found in the nursing cart past its 28-day usage period. The DON confirmed that both insulin pens should have been discarded according to the standard care guidelines. Additionally, an expired Cherry Flavor Sore Throat Spray was found in the medication room. The Licensed Vocational Nurse (LVN) acknowledged the presence of the expired medication and stated that nurses are responsible for checking and discarding expired medications as per facility policy. The failure to remove expired medications could lead to their use, potentially resulting in ineffective treatment.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service in the kitchen. During an observation of the kitchen's dry goods pantry, an open container of salsa was found stored at room temperature, despite being labeled with instructions to refrigerate after opening. The salsa container was also expired. This was confirmed during an interview with the Dietary Manager, who acknowledged the error and disposed of the salsa. The facility's policy on food storage requires refrigerated foods to be stored below 41 degrees Fahrenheit unless otherwise specified by law.
Persistent Urine Odor in A Hall
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment in A Hall, a male secured wing, as evidenced by a strong urine odor observed on multiple occasions. On 10/15/24, a strong urine odor was noted in the hallway, which persisted during observations on 10/17/24 and 10/18/24. The facility's administrator acknowledged the issue and mentioned that a deep clean would be conducted. Despite some improvement noted on 10/16/24, a pungent smell remained. Interviews with staff, including a housekeeper, confirmed regular cleaning practices, but the odor persisted. The facility's policy on maintaining a homelike environment emphasizes minimizing institutional odors, which was not achieved in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for resident needs. On two separate occasions, the call light for a resident with severe cognitive impairment and multiple health issues, including cerebral infarction and heart failure, was not accessible. On the first occasion, the call light was found behind a drawer chest, and on the second occasion, it was on the floor, two feet away from the resident's bed. This oversight was observed by staff members, including a CNA and an MA, who acknowledged that the call light was not within reach and that the resident sometimes used it for help. Interviews with staff, including a CNA, an MA, an LVN, and the DON, confirmed that the call light should have been within reach at all times. The facility's policy on answering call lights, revised in 2010, also states that the call light should be within easy reach of the resident when they are in bed or confined to a chair. Despite the resident's general tendency not to use the call light, staff recognized the importance of having it accessible for when the resident might need assistance.
Failure to Ensure Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to a deficiency in accident prevention. During an observation, a used disposable razor was found on the sink faucet in the bathroom of a resident who had limited mobility and required assistance with personal hygiene. The resident, who had a history of intracranial injury, hemiplegia, anxiety disorder, dementia, and muscle wasting, was cognitively intact but needed supervision for daily activities. The presence of the razor posed a risk of infection or physical injury to the resident and others. Interviews with staff revealed that the resident could not use the razor independently, and it was the staff's responsibility to dispose of used razors in a sharps container after use. The LVN acknowledged seeing the razor and stated that staff might have used it to shave the resident's beard but failed to discard it properly. The DON confirmed that staff should have discarded the razor to prevent infection and injury, aligning with the facility's policy to maintain a safe environment free from accident hazards.
Improper Incontinent Care Technique
Penalty
Summary
The facility failed to provide appropriate incontinent care to a resident, which could lead to urinary tract infections. During an observation, two CNAs were providing urinary incontinence care to a resident. One of the CNAs cleaned the resident's genital area using multiple passes with a single wipe, contrary to the facility's policy that requires using a new wipe for each stroke. This improper technique was acknowledged by the CNA during an interview, who admitted that the correct procedure should involve a single pass with one wipe to prevent possible urinary tract infections. The resident involved was an elderly male with severe cognitive impairment and multiple medical conditions, including cellulitis, cerebral infarction, dysphagia, type 2 diabetes mellitus, muscle wasting, and hyperlipidemia. The resident required substantial assistance for toilet hygiene and was frequently incontinent of bowel and bladder. The facility's care plan for the resident included checking for incontinence every 2 to 3 hours and ensuring proper cleaning to prevent urinary tract infections. However, the observed care did not adhere to these guidelines, as confirmed by the Director of Nursing, who acknowledged the potential risk of infection due to the improper cleaning technique.
Failure to Properly Store Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as observed during a survey. The resident, who was cognitively intact and receiving hospice care due to a terminal condition related to cerebral infarction, had an order for medical oxygen to be administered as needed for dyspnea. However, during an observation, it was noted that the resident's oxygen tubing and nasal cannula, connected to an oxygen concentrator, were not covered in a plastic bag when not in use. This oversight was acknowledged by the LVN, who confirmed that the equipment should have been covered to prevent potential infection. Further interviews with the Director of Nursing corroborated that the facility's policy required the oxygen tubing and nasal cannula to be covered when not in use to prevent respiratory infections. The facility's policy on oxygen administration, revised in 2010, was reviewed and indicated that used supplies should be discarded into designated containers. The failure to adhere to these guidelines could lead to infections, as the equipment was not maintained according to professional standards of practice.
Failure to Prevent Smoking Hazards and Ensure Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, particularly concerning smoking materials. A resident, who had been assessed as a safe smoker, managed to obtain a lighter and set a piece of paper on fire in his room while his oxygen concentrator was on. This incident occurred despite the resident being readmitted as a non-smoker with a nicotine patch. The staff did not have a process in place to check for smoking paraphernalia upon the resident's return from the hospital, and the resident was not asked if he had any smoking materials in his possession. The facility also failed to maintain a designated smoking area with appropriate signage and metal ashtrays. Observations revealed that residents were disposing of cigarette butts on the ground, and there were no signs indicating the smoking area. Staff supervision during smoke breaks was inadequate, as residents were left unsupervised at times, and there was a lack of proper equipment to safely dispose of smoking materials. Interviews with staff and residents highlighted a lack of consistent enforcement and understanding of the facility's smoking policy. Staff were not routinely asking residents or their families about smoking paraphernalia upon readmission or return from outings. Additionally, there was no clear process for ensuring that residents did not have access to smoking materials, which contributed to the incident involving the resident starting a fire in his room.
Use of Plastic Utensils in Memory Care Units
Penalty
Summary
The facility failed to treat each resident with respect and dignity by requiring all residents in the male and female memory care units to use plastic utensils during meals, while residents in the general population were allowed to use metal silverware. This decision was made due to safety concerns, as residents had previously used metal utensils as tools to attempt elopement. During a dining observation, residents were seen eating with plastic utensils, and staff confirmed that this practice was care planned for all residents in the memory care units. However, the care plans for some residents did not include this focus, indicating inconsistency in documentation. Resident #44, who was cognitively intact with a BIMS score of 13, had a care plan that included the use of plastic utensils due to the potential for using metal utensils as tools for elopement. Other residents, such as Resident #65 and Resident #53, had severe cognitive impairments or other significant medical conditions but did not have care plans reflecting the use of plastic utensils. The facility's actions placed residents at risk for diminished quality of life, loss of dignity, and self-worth, as they were not treated with the same respect and dignity as other residents in the general population.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in the Men's Secure Unit. Observations from 4/23/24 through 4/26/24 revealed that most of the room numbers were missing, and none of the 15 rooms were personalized with pictures or decorations. Additionally, the furniture in the resident rooms was in disrepair, with examples including drawers off track and knobs missing. The floors appeared dirty, with specific instances of sticky substances observed on the floor in some rooms. These conditions were confirmed through interviews with the facility's administration, who acknowledged the issues but could not provide documentation of efforts to secure additional furniture or decorations prior to the survey exit. During an interview, the administrator stated that the facility was in the process of replacing beds and furniture and acknowledged that many nightstands were off track. The administrator also mentioned plans to strip and wax the floors. However, the administrator admitted that attempts to decorate the rooms had been unsuccessful as residents tended to tear down the decorations. The administrator could not provide any documentation of efforts to address these issues before the survey exit, indicating a lack of proactive measures to ensure a safe and homelike environment for the residents.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed that the Dietary Manager, Cook, and Dietary Aid were not wearing beard restraints while working in the kitchen. Additionally, the Visiting Dietary Manager was observed wearing jewelry while preparing food. These actions are against the professional standards for food safety and could potentially lead to foodborne illnesses among residents. Further observations in the kitchen's dry storage area revealed a dented can of tomatoes, which had been received several months prior, stored alongside other usable canned goods. The facility did not have a written policy for handling dented cans, and staff were unsure of the proper procedures for dealing with them. This lack of policy and improper storage practices could lead to the use of compromised food products. Interviews with the kitchen staff confirmed that they were aware of the requirements for hair and beard restraints and the prohibition of jewelry while preparing food. However, these standards were not consistently enforced. The facility also lacked specific policies for the storage and disposal of dented cans, further contributing to the deficiencies observed during the survey.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. Specifically, the facility did not maintain the required hospice forms and documentation in the current hospice binders, which are essential to ensure residents receive adequate end-of-life care. This deficiency was identified for two residents, one with diagnoses including Methicillin Resistant Staphylococcus Aureus infection, acute and chronic respiratory failure, unspecified dementia, anorexia, generalized anxiety disorder, and chronic systolic heart failure, and another with diagnoses including unspecified cirrhosis of the liver, senile degeneration of the brain, myelodysplastic syndrome, and Hodgkin lymphoma. Both residents had care plans documenting death and dying issues related to their terminal conditions and were receiving hospice services. During the survey, it was found that the hospice binders for these residents lacked required forms such as the hospice election form and certification of terminal illness by the physician, as well as evidence of coordination of care plans between the hospices and the facility. An interview with the social worker revealed that she was unaware of the required forms from hospice, and the administrator was informed of the missing documentation during the interview. The required forms and documentation were provided to the surveyor before the exit of the survey, but the initial failure to maintain these documents could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.
Invalid OOH-DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that residents had the right to formulate an advance directive, specifically an Out of Hospital Do Not Resuscitate (OOH-DNR) form, for two residents. Resident #44's OOH-DNR form, dated 02/17/22, was invalid because the attending physician's date signed, license number, and printed name were missing. Resident #44, a cognitively intact male with diagnoses including unspecified intracranial injury and dementia, had his care plan indicating a DNR status, but the form was not properly executed by the physician. Similarly, Resident #65's OOH-DNR form, dated 03/06/24, was also invalid due to the same missing physician information. Resident #65, a severely cognitively impaired male with diagnoses including cirrhosis of the liver and Hodgkin lymphoma, had his care plan indicating a DNR status. During an interview, the Social Worker (SW) acknowledged the missing documentation and agreed that the forms needed correction. The Administrator was also informed and agreed on the need for immediate correction. The SW, who had recently taken the position, stated she would audit all DNR forms to ensure their validity.
Pest Control Deficiency in Men's Secure Unit
Penalty
Summary
The facility failed to maintain an effective pest control program in the Men's Secure Unit. During an observation, a surveyor found a dead roach in the bottom of a handrail and a live roach in the bathroom of a resident's room. The Licensed Vocational Nurse (LVN) on duty mentioned that pest control had sprayed three days prior but was unsure if the Men's Unit was included. The LVN also stated that housekeeping cleans daily but had not yet been to the unit that day. The Administrator acknowledged awareness of pest control issues but had not heard of specific bug issues in the unit. A review of the pest control records showed that the pest control company visits monthly and upon request, with the last visit recorded on April 1, 2024.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from verbal abuse, physical abuse, and involuntary seclusion. On 01/11/24, CNA A was reported to have pinched, pulled, and verbally abused Residents #2, #5, and #6. Additionally, CNA A was observed arguing disrespectfully with Resident #4 and being physically aggressive with Resident #7. Residents #1 and #3 also reported verbal abuse by CNA A, although the exact dates were not specified. These incidents were corroborated by witness statements from other staff members who observed or were informed about the abusive behavior. Resident #2, a female with severe cognitive impairment, was found with a slight discoloration on her left forearm. Resident #5, also with severe cognitive impairment, and Resident #6, with Alzheimer's disease, were subjected to similar abusive actions by CNA A. Resident #4, with severe cognitive impairment, was argued with in a disrespectful manner by CNA A. Resident #7, with severe impairment, was aggressively handled by CNA A, who forcefully sat her down and shoved a baby doll into her arms. Residents #1 and #3, both with moderate to intact cognition, reported verbal abuse by CNA A, which was not initially addressed by the facility's administration. Interviews with various staff members revealed that CNA A had a history of being impatient and aggressive with residents, particularly those in the women's secure unit. Despite complaints from residents and staff about CNA A's behavior, the facility's administration did not take immediate action to address these concerns. It was only after the incidents on 01/11/24 that CNA A was suspended and an investigation was initiated. The facility's failure to promptly address the abusive behavior of CNA A led to multiple residents experiencing physical and verbal abuse, as well as involuntary seclusion.
Failure to Report Allegations of Abuse Timely
Penalty
Summary
The facility failed to report allegations of abuse, neglect, exploitation, or mistreatment involving two residents within the required time frame. Resident #1 and Resident #3 both reported not wanting care from CNA A due to verbally abusive behavior. Despite these reports, the facility did not notify the State Survey Agency as required. Resident #1, who had moderate cognitive impairment, reported being yelled at multiple times by CNA A and informed a nurse and the administrator, but no action was taken. Similarly, Resident #3, who had intact cognition, reported being yelled at by CNA A and informed a CNA, the ADON, and the administrator, but again, no action was taken. Interviews with staff revealed that there were known issues with CNA A's communication and behavior, but these were not properly documented or addressed. LVN B and MA C acknowledged that CNA A's behavior could overwhelm residents due to a language barrier and inappropriate responses. The ADON admitted that she did not investigate why residents did not want CNA A to care for them and failed to document any complaints. The facility's grievance records showed no complaints related to CNA A, indicating a lack of proper documentation and follow-up on resident grievances.
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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