Rock Creek Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Sulphur Springs, Texas.
- Location
- 1414 College Street, Sulphur Springs, Texas 75482
- CMS Provider Number
- 676235
- Inspections on file
- 29
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Rock Creek Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with vascular dementia, hypertension, major depressive disorder, and CKD stage 3, who was cognitively intact and required supervision/touching assistance for bathing, did not receive the majority of scheduled showers over a month. Facility records showed multiple missed showers with blanks or “not applicable” entries on Documentation Survey Reports, and there were no corresponding shower refusal sheets or EMR documentation of refusals. The resident reported that staff did not routinely come to get her for showers and that she had to request them, stating she did not refuse showers. A CNA shower aide and the DON confirmed that blanks indicated showers were not done, that refusals should be documented, and that residents were expected to receive showers several times per week, consistent with the facility’s bathing policy.
A Treatment Nurse failed to follow Enhanced Barrier Precautions during wound care for a resident on EBP, despite posted signage and available PPE indicating the need for a gown and gloves. The nurse performed multiple steps of wound care on an open back wound, including dressing removal, cleansing, and application of calcium alginate with silver and foam bordered dressing, while only using gloves and never donning a gown. In interviews, the nurse acknowledged that EBP requires gown and glove use for open wounds and stated she forgot due to focusing on the resident’s pain, and the DON confirmed that staff are expected to wear a gown, gloves, and additional PPE as needed for residents on EBP, consistent with the facility’s written EBP policy.
Two residents requiring Enhanced Barrier Precautions did not have proper signage or PPE carts outside their rooms, and staff failed to use gowns, change gloves, or perform hand hygiene during high-contact care activities. Facility leadership and staff were unaware of these lapses until identified by surveyors, despite facility policies requiring these infection control measures.
Surveyors observed that expired bags of spinach were left in the facility's only walk-in refrigerator, with the contents visibly spoiled and leaking onto other items. The DM admitted missing the expired items during checks, and both the Administrator and DON confirmed that food should be monitored and discarded by the use by date, as required by facility policy and food safety codes.
A resident with Alzheimer's and dementia was injured during an improper mechanical lift transfer when a CNA attempted the transfer without the required second staff member. The resident fell from the lift sling, sustaining a significant head injury. The care plan required two staff members for transfers, but this protocol was not followed, leading to the deficiency.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to enhanced barrier precautions during foley catheter care for two residents. Observations showed that staff did not wear protective equipment or perform hand hygiene, despite clear signage and care plans requiring these measures. Interviews revealed a lack of understanding and adherence to infection control policies, with staff admitting to forgetting or being unsure of the requirements.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, one with lung cancer and another with heart failure, as required by policy. This delay in care planning could risk inadequate care. Staff interviews revealed confusion about responsibilities for completing these plans.
A resident with multiple health conditions did not receive her fentanyl patch as prescribed every 72 hours, due to discrepancies between the MAR and controlled drug record. The medication aide administered the patch on consecutive days without verifying the correct schedule, leading to potential therapeutic issues. Staff interviews highlighted the importance of accurate documentation and adherence to medication administration protocols.
The facility failed to provide meals according to dietary orders for three residents, leading to potential risks of malnutrition and choking. A resident with a potential for malnutrition received an incorrect portion size, another resident did not receive the double protein portion ordered, and a third resident was served cubed instead of chopped meat. The Dietary Manager and DON acknowledged these errors, highlighting the importance of adhering to physician orders.
The facility failed to maintain food safety standards in its kitchen, as observed during a survey. A sanitation bucket lacked proper sanitizer levels, and a dietary aide entered the kitchen without a hair net, risking cross-contamination. The Dietary Manager and Administrator expected staff to adhere to sanitation protocols to ensure a clean environment for residents.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including an LVN not wearing enhanced barrier precautions during IV medication administration, CNAs contaminating clean linens with soiled ones, and the lack of COVID-19 or flu testing for symptomatic residents. Additionally, a resident with a stage 4 pressure ulcer did not receive proper wound care, as staff were observed not wearing PPE.
The facility failed to maintain a medication error rate below 5%, resulting in a 19.23% error rate. Two residents received medications outside prescribed parameters, with blood pressure medications not withheld despite low diastolic readings. Medication aides were unaware of specific hold parameters, and the DON acknowledged potential system entry errors. The importance of adhering to medication administration policies was emphasized.
Two residents in an LTC facility experienced significant medication errors. One resident received losartan potassium despite a diastolic blood pressure below the hold parameter, while another received levetiracetam late and nifedipine against the hold parameter. Medication aides were unaware of the unusual hold parameters, and the DON noted potential system entry errors. The facility's policy emphasizes adherence to medication administration protocols.
The facility failed to ensure proper labeling and storage of medications for two residents. A resident with orthostatic hypotension had hydrocortisone cream 1% on her nightstand without an order, while another resident with macular degeneration had eye drops at her bedside without an order. Both residents were assessed as unable to self-administer medications. The facility's policy did not address these storage issues, and staff interviews confirmed the lack of compliance with medication storage protocols.
The facility failed to provide timely lab services for two residents, missing several physician-ordered tests. A resident with hypothyroidism did not receive required CBC, CMP, Lipid panel, TSH, and T4 tests, while another with hypertension missed CBC, CMP, TSH, and Lipid tests. Staff interviews revealed systemic issues in lab monitoring, with the ADON and DON acknowledging lapses in oversight. The facility lacked a specific policy for lab monitoring, contributing to the deficiency.
A facility failed to uphold resident dignity by allowing a CNA to feed two residents simultaneously due to staffing shortages. This practice was observed despite the resident's care plan requiring one-person assistance. Interviews revealed that this was a common practice to manage staff utilization, potentially affecting the resident's quality of life and willingness to eat in the dining room.
A resident with multiple health conditions was unable to reach her call light after it fell to the floor. Despite activating the call light, a CNA turned it off without addressing the resident's needs or ensuring it was within reach. The resident expressed frustration over staff frequently turning off her call light without returning. The facility's leadership acknowledged the expectation for staff to ensure call lights are accessible and answered promptly, but the policy was not provided.
A facility failed to provide a SNF ABN to a resident discharged from skilled services before exhausting covered days, leaving them unaware of potential financial liability. The resident, with severe cognitive impairment, was receiving therapy under Medicare Part A. The MDS Coordinator admitted the oversight, highlighting the importance of notifying residents and families about possible out-of-pocket charges.
A resident reported a missing watch, but the grievance was not documented or resolved promptly. The Social Worker admitted the grievance slipped through the cracks, and the grievance form was incomplete. Interviews with staff revealed that the grievance process was not properly followed, leading to a delay in addressing the resident's concern.
A facility failed to transmit a resident's MDS discharge assessment to CMS within the required timeframe due to the responsible nurse being on PTO. The resident, who had COVID-19, was discharged to the hospital, but the assessment was submitted late, as confirmed by interviews with the MDS Coordinator and the Regional Reimbursement Nurse.
A resident with metabolic encephalopathy and mild cognitive impairment sustained a skin tear during a transfer due to an inaccurate care plan that did not reflect her current ADL status. The care plan incorrectly stated she required two staff and a Hoyer lift, while staff reported fluctuating assistance needs. The MDS Coordinator and DON admitted the care plan was not updated, leading to potential risks.
A resident with severe cognitive impairment and limited mobility was not provided with the prescribed brace for her right arm, necessary to prevent further contracture. Despite care plan instructions, the brace was repeatedly found off the resident, and staff interviews revealed confusion over responsibility for its application.
A resident with severe cognitive impairment was injured during a Hoyer lift transfer when the lift's cradle hit her above the right eye. Despite being trained, the CNAs involved failed to prevent the incident, which was observed and reported by the resident's family. The facility's policy emphasizes safe transfers, but the incident indicates a lapse in adherence to these guidelines.
A resident with multiple health issues, including paraplegia and a stage 4 pressure ulcer, did not receive proper incontinent and catheter care, increasing the risk of urinary tract infections. Staff were observed not wearing PPE and failing to follow infection control protocols, despite facility policies requiring such measures.
A resident with pneumonia receiving IV medications through a PICC line experienced a deficiency in care when an LVN failed to follow protocol by not checking the line's patency before administering a saline flush. Despite encountering resistance, the LVN did not notify a physician, contrary to facility policy. The DON confirmed the protocol breach, emphasizing the importance of proper PICC line management.
The facility failed to follow the recipe for pureeing hamburger beef patties during a lunch meal, as the dietary staff did not have access to the recipe due to a computer issue. This could impact the nutritional value of the meal provided to residents.
Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing assistance and maintain grooming and personal hygiene for a cognitively intact resident who required supervision or touching assistance with bathing. The resident, an older female with vascular dementia, hypertension, major depressive disorder, and stage 3 chronic kidney disease, was care planned for supervision as needed with bathing and was scheduled for showers on Mondays, Wednesdays, and Fridays. Documentation Survey Reports for February 2026 showed the resident was scheduled for 12 showers/baths but did not receive 7 of them, with missed showers on multiple specified dates. On some dates, the Documentation Survey Report listed scheduled bathing as “not applicable,” and on others there were blank spaces where showers were scheduled, both of which the DON and CNA A indicated meant the shower was not done. The EMR contained no shower refusal sheets for the month, and the DON confirmed there were no unuploaded refusal sheets for this resident. During interviews, the resident stated she did not remember if she had missed showers over the past two months but reported that staff did not come to get her for showers and that she had to pursue getting a shower if she wanted one. She stated she did not refuse showers and that when she did not receive her scheduled showers, she felt “yucky.” CNA A, who worked as the shower aide, reported that residents were to receive showers every other day, that a blank on the Documentation Survey Report indicated a shower was not done, and that refusals should be documented on a shower refusal sheet and in the Documentation Survey Report. The DON stated she expected residents to receive showers three times a week and that refusals occurring more than twice in one week should be documented in progress notes. Review of the facility’s bathing policy indicated that bathing is done to remove soil, dead epithelial cells, microorganisms, and body odor to promote comfort, cleanliness, circulation, and relaxation, and that aging skin can be maintained by bathing every two days or with partial bathing as needed, underscoring that the resident’s scheduled bathing was not provided as planned or documented as refused.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) protocol during wound care for Resident #2, who had an open back wound requiring treatment with calcium alginate with silver and a foam bordered dressing. On 3/3/26 at 1:32 p.m., a Treatment Nurse performed wound care in a room where EBP signage and PPE, including a red sign indicating the need for a personal care gown and gloves, were posted outside the resident’s room. The Treatment Nurse knocked, entered, assessed the resident’s pain, performed hand hygiene, and donned gloves, but did not put on a gown at any point during the wound care procedure. The nurse removed the old dressing, cleansed the wound per physician orders, applied the ordered dressings, and disposed of supplies, changing gloves and performing hand hygiene between steps, but never donned a gown despite the posted EBP requirements. During an interview later that afternoon, the Treatment Nurse stated that EBP stands for enhanced barrier precautions and acknowledged that EBP includes wearing a gown and gloves when providing care, specifically for open wounds and for urinary catheter or colostomy care. The nurse explained that she forgot to put on a gown because she was focused on the resident’s pain, and stated that she usually wears a gown and gloves when performing wound care, recognizing that EBP is important to prevent cross contamination, spread of bacteria, and for infection control. In a separate interview, the DON stated that when a resident is on EBP, staff are expected to wear a gown, gloves, and mask or face shield if needed when providing direct care, and that EBP is necessary for residents with open wounds, urinary catheters, PICC lines, and PEG tubes. The facility’s Enhanced Barrier Precautions policy indicated that EBP is an infection control intervention using targeted gown and glove use during high-contact resident care activities to reduce MDRO transmission, to be used in conjunction with standard precautions.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling catheters and other risk factors. Certified Nursing Assistants (CNAs) providing incontinent and catheter care to one resident did not perform hand hygiene or change gloves between dirty and clean tasks, and used the same gloves and wipes for multiple care activities, including handling clean briefs and linens. The CNAs also did not wear gowns as required for EBP, and there was no EBP signage or PPE cart outside the resident's room at the time of care. The CNAs acknowledged their failure to follow proper infection control procedures and stated that they were only provided gowns after informing a nurse that a surveyor would be observing care. Another resident with an indwelling catheter and EBP orders also did not have the required EBP signage or PPE cart outside her room. Staff assigned to this resident were unaware of the need to use gowns and gloves during care activities, and did not use the appropriate PPE. The charge nurse for this resident confirmed awareness of the EBP order but did not ensure the necessary signage or PPE cart was in place, only realizing the omission when questioned by the surveyor. The signage and cart were only placed outside the room after the deficiency was identified during the survey. Interviews with facility leadership, including the Director of Nursing (DON), Infection Preventionist (IP) nurse, and interim Administrator, revealed that they were not aware that the required EBP signage and PPE carts were missing for these residents. The facility's policies required hand hygiene, glove changes between dirty and clean tasks, and the use of gowns and gloves for residents on EBP during high-contact care activities. The IP nurse stated she was responsible for ensuring signage and PPE availability but was unaware of the lapses until the survey. The DON and Administrator confirmed expectations for proper infection control practices, which were not met in these instances.
Expired Food Not Removed from Refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation in the facility's only walk-in refrigerator, two bags of spinach with a use by date that had already passed were found stored on the top shelf. The spinach was visibly spoiled, appearing dark green and greenish brown, wet, slimy, and had leaked onto boxes below. The Dietary Manager (DM) acknowledged responsibility for checking use by dates and removing expired items, admitting that these bags of spinach were missed. The Administrator and Director of Nursing (DON) both confirmed their expectations that food should be monitored for expiration and discarded if expired, noting that failure to do so could result in contamination or illness. A review of the facility's food storage policy and the U.S. Public Health Service Food Code confirmed the requirement for date marking and timely removal of expired, ready-to-eat, time/temperature control for safety foods. The policy and code specify that perishable foods must be consumed or discarded by the use by date to prevent spoilage and potential foodborne illness. The facility's failure to adhere to these standards was directly observed and confirmed through staff interviews and policy review.
Improper Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, resulting in an incident involving a resident who was improperly transferred using a mechanical lift. The resident, an elderly female with Alzheimer's, dementia, and other conditions, was dependent on staff for transfers. On the day of the incident, a CNA attempted to transfer the resident using a mechanical lift without the required assistance of a second staff member. During the transfer, the resident's roommate, disturbed by the noise and light, pushed the Geri-chair, causing the resident to fall from the lift sling and sustain a significant head injury. The resident's care plan indicated a need for two staff members to assist with mechanical lift transfers, which was not adhered to during the incident. The resident, who was at high risk for falls and unable to stand, suffered a laceration to the scalp with exposure of the underlying skull, requiring emergency medical attention and repair with 22 staples. The facility's hydraulic lift policy did not specify the number of staff required for safe transfers, and the lift's owner's manual also lacked this information. Interviews and record reviews revealed that the CNA involved had previously been checked off on mechanical lift skills, including the requirement for a two-person assist. However, during the incident, this protocol was not followed, leading to the resident's injury. The facility's failure to ensure proper staff adherence to transfer protocols and to maintain a safe environment for residents was identified as a deficiency by surveyors.
Removal Plan
- Suspending CNA A pending investigation.
- In-servicing staff regarding KARDEX use in the EMR and Hydraulic Lift Use.
- Staff checkoffs by the DOR regarding Mechanical Lift Transfers.
- Ensuring 100% of staff in-serviced regarding mechanical lift use and KARDEX use in the EMR.
- Requiring staff to receive mechanical lift training from the DOR prior to being able to work the floor.
- Ongoing mechanical lift training until all staff had been trained/checked-off.
Infection Control Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of adherence to enhanced barrier precautions during foley catheter care for two residents. Observations revealed that CNA B and the DON did not wear the required protective equipment while providing care to a male resident with an indwelling catheter, despite clear signage indicating the need for enhanced barrier precautions. Similarly, RN A and CNA C did not follow the necessary precautions or perform hand hygiene during glove changes while caring for a female resident with a similar condition. The male resident, who was admitted with obstructive and reflux uropathy and benign prostatic hyperplasia, had a comprehensive care plan that required the use of gloves and gowns during catheter care. However, during an observation, both CNA B and the DON neglected to apply these precautions. The female resident, diagnosed with neuromuscular dysfunction of the bladder, also had a care plan mandating enhanced barrier precautions. Despite this, RN A and CNA C failed to adhere to these protocols, and CNA C admitted to forgetting to sanitize her hands during glove changes. Interviews with the staff involved revealed a lack of understanding and adherence to the infection control policies. CNA C and RN A expressed uncertainty about the requirements for enhanced barrier precautions, and both acknowledged the importance of hand hygiene, which was not performed. The DON admitted to forgetting to apply the necessary precautions due to being in a hurry. The facility's catheter care policy did not address hand hygiene or enhanced barrier precautions, contributing to the oversight.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. Resident #1, a female with multiple diagnoses including lung cancer, COPD, and diabetes, was admitted on 8/26/24. However, her baseline care plan was not completed within the required timeframe, with only an activity-related care plan initiated on 8/27/24. The comprehensive care plan was not initiated until 8/30/24, and the baseline care plan was acknowledged on 8/29/24, indicating a delay in the development of a complete care plan. Similarly, Resident #2, who was admitted on 8/30/34 with conditions such as heart failure and hypertension, also did not have a baseline care plan completed within 48 hours. The comprehensive care plan for Resident #2 was not initiated until 9/3/24, and the baseline care plan was acknowledged on 8/31/24. Interviews with facility staff revealed confusion and lack of clarity regarding the responsibility for completing baseline care plans, with different staff members providing varying accounts of the process and responsibilities. The facility's policy mandates the completion and implementation of a baseline care plan within 48 hours of admission to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events. However, the facility did not adhere to this policy, as evidenced by the lack of timely baseline care plans for Residents #1 and #2. This failure could potentially place newly admitted residents at risk of receiving inadequate care and services.
Failure in Medication Administration Timing
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of a fentanyl transdermal patch. The resident, a female with a history of lung cancer, neuroendocrine tumors, alcoholic cirrhosis, COPD, and diabetes, was supposed to receive a fentanyl patch every 72 hours for pain management. However, the records indicated that the patch was administered on consecutive days, 8/29/24 and 8/30/24, instead of the prescribed 72-hour interval. The discrepancy arose because the Medication Administration Record (MAR) did not match the controlled drug record, and the medication aide (MA B) did not verify the correct schedule. MA B administered the patch according to the MAR, despite noticing the inconsistency with the 72-hour order. The aide did not question the discrepancy due to a lack of nursing qualifications and the belief that the orders were frequently changing. This led to the resident receiving the medication earlier than prescribed, which could potentially affect the therapeutic benefit. Interviews with staff, including the Hospice Nurse, RN A, LVN C, and the Director of Nursing (DON), highlighted the importance of accurate documentation and adherence to the 5 rights of medication administration. The DON emphasized that any discrepancies should be reported to the charge nurse before administering medication. The facility's policy required medications to be administered by licensed personnel and documented immediately, but this protocol was not followed in this instance.
Failure to Provide Meals According to Dietary Orders
Penalty
Summary
The facility failed to ensure that three residents received meals prepared according to their specific dietary needs, as ordered by their physicians. Resident #54, who had a potential for malnutrition, did not have diet orders addressing her nutritional needs, and she received a single serving of pot roast instead of the one-and-a-half pieces of meat she was supposed to receive. This oversight was acknowledged by the Dietary Manager and the Director of Nursing (DON), who both stated that the correct portion was crucial to prevent weight loss. Resident #41, who was on a regular diet with double protein portions, also received an incorrect meal serving. During an observation, it was noted that she received a single serving of pot roast instead of the double portion ordered by her physician. The Assistant Director of Nursing (ADON) confirmed the error and returned the tray to the kitchen for correction. The Dietary Manager and DON both recognized the importance of following physician orders to prevent malnutrition. Resident #76, who required chopped meat due to her dietary order, was served cubed chicken parmesan instead. The ADON identified the discrepancy and returned the tray for correction. The Dietary Manager and DON acknowledged the error, emphasizing the risk of choking and weight loss if dietary orders are not followed. The facility's policies did not adequately address the specific dietary needs, such as chopped or double portions, contributing to these deficiencies.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. On one occasion, a sanitation bucket used for cleaning food preparation surfaces was found to contain a brownish clear liquid with debris and no detectable sanitizer, despite staff claims that it had been prepared correctly earlier. This failure to maintain appropriate sanitization levels could lead to the spread of bacteria, as the purpose of the sanitizer is to prevent such contamination. Additionally, a dietary aide was observed entering the kitchen without wearing a hair net, which is required to prevent cross-contamination and hair from getting into residents' food. The dietary aide explained that the hairnets available at the kitchen's entryway were inadequate for containing his hair, leading him to retrieve a hair net from inside the kitchen. The Dietary Manager and Administrator both expressed expectations that staff would maintain proper sanitation levels and wear hair nets at all times to ensure a clean and healthy environment for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a Licensed Vocational Nurse (LVN) who did not wear enhanced barrier precautions, specifically a gown, while administering intravenous medications through a PICC line for a resident diagnosed with pneumonia. This oversight occurred despite the resident's care plan indicating the need for such precautions to prevent the spread of infection. Another deficiency was observed when two Certified Nursing Assistants (CNAs) contaminated clean linens with soiled ones while providing assistance with activities of daily living (ADLs) for a resident. The CNAs placed clean linens on top of soiled ones, which they acknowledged was against infection control practices. This action could potentially lead to cross-contamination and the spread of infections among residents. Additionally, the facility did not test two residents for COVID-19 or influenza when they exhibited respiratory symptoms, despite having a history of respiratory infections. The facility's policy, aligned with CDC guidelines, required testing for symptomatic individuals, but this was not followed. Furthermore, a resident with a stage 4 pressure ulcer did not receive proper wound care, as evidenced by a family member's report and video footage showing staff not wearing personal protective equipment during care. These failures highlight significant lapses in infection control practices within the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 19.23 percent error rate. This was observed in the cases of two residents. One resident was administered Centrum Silver as ordered, but their losartan potassium, a blood pressure medication, was not withheld despite a diastolic blood pressure reading of 63, which was below the ordered parameter of holding the medication for a diastolic blood pressure less than 90. Another resident received their levetiracetam and baclofen medications late, and their nifedipine, also a blood pressure medication, was not withheld despite a diastolic blood pressure reading of 84, which was also below the ordered parameter. During observations, it was noted that the medication aides were unaware of the specific hold parameters for the blood pressure medications, which were not the usual parameters they were accustomed to. The aides did not notify the charge nurse to clarify the orders with the doctor, leading to the administration of medications outside the prescribed parameters. The Director of Nursing (DON) acknowledged that the parameters might have been entered incorrectly into the system, and the medication aides likely overlooked the unusual parameters. Interviews with the medication aides and the DON revealed a lack of awareness and communication regarding the specific medication parameters. The aides admitted to administering medications late due to facility circumstances and not adhering to the prescribed hold parameters, which could have led to adverse reactions. The DON and the Administrator emphasized the importance of following the medication administration policy to ensure the effectiveness and safety of the medications administered to residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two of the five residents reviewed for medication administration. Resident #72 was administered losartan potassium, a blood pressure medication, despite having a diastolic blood pressure of 63, which was below the ordered parameter of holding the medication for a diastolic blood pressure less than 90. This error occurred on June 18, 2024, when Medication Aide L prepared and administered the medication without adhering to the specified hold parameters. Resident #73 experienced two medication administration errors. Firstly, the resident's levetiracetam, an anticonvulsant medication, was administered late. Secondly, nifedipine, another blood pressure medication, was given despite the resident having a diastolic blood pressure of 84, which was below the ordered hold parameter of less than 90. Medication Aide K, who administered these medications, was unaware of the specific hold parameters and did not notify the charge nurse for clarification. The errors were attributed to the medication aides' unfamiliarity with the unusual hold parameters and the potential incorrect entry of these parameters into the system. Interviews with the Director of Nursing (DON) and the Administrator revealed that the normal hold parameters for diastolic blood pressure were less than 60, not less than 90, indicating a possible error in the system entry. The DON and Administrator emphasized the importance of adhering to the physician's orders to prevent adverse effects and ensure the effectiveness of the medications. The facility's medication administration procedures policy highlighted the need to follow the 10 rights of medication administration, including the right time and right assessment, to maximize therapeutic effects and prevent significant medication interactions.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards, as observed in the cases of two residents. Resident #3, a female with orthostatic hypotension, was found with a tube of hydrocortisone cream 1% on her nightstand, despite not having the ability to self-administer medications. The cream was observed on two separate occasions, and Resident #3 could not recall who provided it to her. Her medical records indicated she had an order for hydrocortisone cream 2.5%, not 1%, and she was assessed as unable to self-administer medications. Similarly, Resident #13, a female with macular degeneration, was observed with a bottle of equate dry eye relief on her bedside table. She stated she used the drops herself, although her records did not show an order for these eye drops, and she was also assessed as unable to self-administer medications. The presence of these medications at the bedside was confirmed by LVN T, who noted that neither resident had an order to self-administer the medications found in their rooms. Interviews with the DON and the Administrator revealed that all staff were responsible for ensuring medications were stored appropriately, and that a self-medication assessment and order were required before residents could keep medications at their bedside. The facility's policy on medication storage, revised in 2012, did not address these specific storage issues, and the DON acknowledged that routine checks were conducted to ensure compliance, although no issues had been noticed previously.
Failure to Obtain Timely Laboratory Services for Residents
Penalty
Summary
The facility failed to ensure laboratory services were obtained to meet the needs of two residents, leading to a deficiency in providing timely and necessary lab tests. Resident #3, a female with hypothyroidism, had physician orders for several lab tests, including CBC, CMP, Lipid panel, TSH, and T4, which were not conducted in January and April 2024 as required. Similarly, Resident #22, a female with hypertension, had orders for CBC, CMP, TSH, and Lipid tests, which were not completed in October 2023, January 2024, and April 2024. These omissions were identified during a review of the residents' electronic medical records. Interviews with facility staff revealed systemic issues in the process of obtaining and monitoring lab services. The Assistant Director of Nursing (ADON) acknowledged that floor nurses were initially responsible for pulling lab results daily, while the ADON and Director of Nursing (DON) were tasked with entering orders and completing lab requisitions. However, an audit conducted in April 2024 revealed that several residents' quarterly labs were not completed, prompting the ADON to rewrite lab requisitions. Despite these efforts, the labs for Residents #3 and #22 were still missed, and the ADON admitted to not knowing how this oversight occurred. Further interviews with the DON and the Administrator highlighted a lack of effective monitoring and oversight of lab orders. The DON admitted that while an audit ensured lab orders were in place, it did not guarantee that labs were drawn. The Administrator emphasized the importance of adhering to lab schedules to ensure residents receive necessary medications. The facility's policy on physician's orders was reviewed, but it was noted that there was no specific policy or procedure regarding lab monitoring, contributing to the deficiency.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as required by resident rights, by allowing a CNA to feed two residents simultaneously during a lunch meal. This practice was observed during a survey, and it was noted that the CNA was feeding both residents at the same time due to insufficient staffing. The resident in question, an elderly female with severe cognitive impairment and dysphagia, required one-person assistance with eating according to her care plan. However, the CNA's actions were contrary to this plan, potentially compromising the resident's dignity and quality of life. Interviews conducted with the resident's family member, the CNA, the DON, and the Administrator revealed that feeding two residents at once was a common practice due to staffing shortages. The family member expressed concern that the resident was rushed during meals, while the CNA acknowledged the importance of giving each resident the attention they deserve. The DON and Administrator both indicated that this practice was a means of managing staff utilization, although it could negatively impact the resident's willingness to eat in the dining room. The facility's policy on resident rights emphasizes the importance of treating each resident with respect and dignity, which was not upheld in this instance.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure that a resident's call light was answered timely and was within reach, which compromised the resident's ability to request assistance. The resident, an elderly female with cerebrovascular disease, anxiety disorder, flaccid hemiplegia affecting the right side, and obesity, was observed in her wheelchair with the call light on the floor, out of reach. Despite having no cognitive impairment, the resident was dependent on staff for assistance with activities of daily living, including toilet hygiene and transfers. On the day of the incident, the resident activated the call light, which fell to the ground, and was unable to retrieve it. A CNA entered the room, turned off the call light, and left without addressing the resident's needs or ensuring the call light was accessible. The resident expressed frustration over the situation, stating that staff frequently turned off her call light without returning to assist her. The CNA admitted to not realizing the call light was on the ground and acknowledged the importance of ensuring it was within reach. The Director of Nursing and the Administrator both stated that staff were expected to ensure call lights were accessible and answered promptly. However, the facility's policy on call lights was not provided upon request. This deficiency in accommodating the resident's needs and preferences was observed and documented by surveyors.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to inform a resident of changes in Medicare/Medicaid coverage and potential financial liability for services not covered. Specifically, the facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who was discharged from skilled services before exhausting their covered days. This oversight was identified during a review of the resident's records and interviews with facility staff. The resident, a male with severe cognitive impairment, was receiving speech, occupational, and physical therapy under Medicare Part A services, which began on April 19, 2024, and ended on May 9, 2024. However, the SNF ABN, which would have informed the resident and their family of the option to continue services at their own expense, was not completed. Interviews with the MDS Coordinator and the Administrator revealed that the responsibility for issuing the SNF ABN lay with the MDS Coordinators, and the regional coordinator was tasked with monitoring and oversight. The MDS Coordinator admitted that the form was missed, acknowledging its importance in notifying residents and families about potential out-of-pocket charges. The facility's policy, effective since April 30, 2018, mandates the issuance of a SNF ABN to transfer financial liability to the beneficiary. The failure to provide this notice could result in residents being unaware of changes to their service coverage.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly resolve a grievance reported by a resident regarding a missing watch. The resident, who had no cognitive impairment and valued her personal belongings, reported the missing watch to the Social Worker on June 6, 2024. However, the grievance was not documented or followed up on until June 20, 2024, when the state surveyor requested the grievance report. The grievance form was incomplete, lacking critical information such as the individual assigned to take action, the resolution date, and the corrective action taken. Interviews with the Social Worker, DON, and Administrator revealed that the grievance process was not properly followed. The Social Worker admitted that the grievance slipped through the cracks and was not addressed within the expected timeframe. The DON and Administrator acknowledged that grievances should be documented and resolved promptly, but in this case, the grievance was not reported to the appropriate department or followed up on, leading to a delay in addressing the resident's concern.
Delayed Transmission of MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment for a resident was electronically completed and transmitted to the CMS System within the required 14 days after completion. The resident, an elderly female with a diagnosis including COVID-19, was discharged to the hospital. However, the discharge MDS assessment was not transmitted until several days past the deadline, which was attributed to the Regional Reimbursement Nurse being on paid time off (PTO) during the period when the assessment should have been submitted. Interviews with facility staff, including the MDS Coordinator and the Regional Reimbursement Nurse, confirmed the oversight. The MDS Coordinator acknowledged the importance of timely transmission to ensure proper documentation prior to discharge. The Regional Reimbursement Nurse admitted responsibility for the delay, citing her absence as the reason for the late submission. The facility Administrator also expressed an expectation for timely completion and submission of discharge assessments, emphasizing the importance of initiating the plan of care based on these assessments.
Inaccurate Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop or implement a comprehensive person-centered care plan for a resident, which did not accurately reflect her current ADL status with transfers. The resident, a female with metabolic encephalopathy and mild cognitive impairment, was initially assessed to require setup or clean-up assistance with transfers. However, the care plan inaccurately stated that she required two staff members and a Hoyer lift for transfers, leading to inconsistencies in the care provided. The discrepancy in the care plan was highlighted by an incident where the resident sustained a skin tear during a transfer. The CNA involved in the transfer stated that the resident did not require much assistance and did not use a gait belt or Hoyer lift, contrary to the care plan. Interviews with staff revealed that the resident's level of assistance fluctuated, and the care plan was not updated to reflect these changes, leading to potential risks for the resident. The MDS Coordinator and DON acknowledged that the care plan did not accurately reflect the resident's needs and that it was overlooked. The facility's policy required ongoing discussions and updates to the care plan based on the resident's changing needs, but this was not adhered to, resulting in the deficiency.
Failure to Apply Prescribed Brace for Resident's Arm Contracture
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited mobility, leading to a deficiency in maintaining or improving the resident's range of motion. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and spinal stenosis, was observed multiple times without the prescribed brace on her right arm, which was necessary to prevent further contracture. Despite the care plan and therapy recommendations indicating the need for the brace, it was repeatedly found lying on a counter instead of being applied to the resident's arm. Interviews with staff revealed a lack of clarity and responsibility regarding who was to apply the brace. The LVN assumed the brace was on when it was not, and the Director of Rehab and DON had differing understandings of who was responsible for applying the brace. The facility's policy on immobilization devices was not followed, resulting in the resident not receiving the necessary intervention to prevent deterioration of her range of motion.
Resident Injured During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using a Hoyer lift, resulting in the resident being hit above the right eye by the lift's cradle. The resident, who has severe cognitive impairment and requires assistance from two staff members for transfers, was involved in an incident where the cradle of the Hoyer lift struck her during a transfer from a chair to a bed. This incident was observed and reported by the resident's family member, who noted that the resident had been hit in the head and face several times during previous transfers. Interviews with the CNAs involved in the transfer revealed that both were trained to use the Hoyer lift and understood the importance of protecting the resident from injury. However, the incident still occurred, indicating a lapse in the execution of their training. The facility's policy on hydraulic lift usage emphasizes safe transfers, yet the incident suggests a failure to adhere to these guidelines. The DON acknowledged the issue with the Hoyer lift's loose swivel and the importance of reporting injuries for assessment, while the Administrator highlighted the interdisciplinary responsibility for ensuring CNA training on lift transfers.
Inadequate Incontinent and Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, leading to a risk of urinary tract infections and decreased quality of life. The resident, an elderly male with multiple health issues including acute cystitis with hematuria, paraplegia, encephalopathy, and a stage 4 pressure ulcer, was always incontinent and had an indwelling catheter. The comprehensive care plan required incontinent care after each episode and catheter care, but observations and interviews revealed that staff did not consistently follow these protocols. Specifically, staff members were observed not wearing personal protective equipment (PPE) during care, failing to change gloves or perform hand hygiene, and not following enhanced barrier precautions. The report includes specific instances where staff did not adhere to infection control measures. A video showed a CNA not changing gloves or performing hand hygiene during incontinent care, and an LVN was observed performing catheter care without wearing gloves. Interviews with staff indicated a lack of adherence to PPE protocols, with some staff members acknowledging the importance of PPE but failing to use it during care. The Director of Nursing and the Administrator both expressed expectations for staff to wear PPE to prevent infections, highlighting a gap between policy and practice. The facility's policy on perineal care emphasized maintaining cleanliness and preventing infections, but the observed practices did not align with these standards.
Failure to Follow PICC Line Protocols
Penalty
Summary
The facility failed to ensure the safe administration of intravenous (IV) fluids for a resident, leading to a deficiency in care. The resident, a male with a diagnosis of pneumonia, was receiving IV medications through a peripherally inserted central catheter (PICC) line. The facility's licensed vocational nurse (LVN) did not follow the established protocol for checking the patency of the PICC line before administering a saline flush. During an observation, the LVN encountered resistance while attempting to flush the line but did not notify the physician as required by the facility's policy. The LVN admitted to not checking for blood return to assess the patency of the PICC line, which is a critical step in ensuring the line is functioning properly. Despite experiencing resistance during the flush, the LVN continued to use the line without consulting a physician, which could indicate an occlusion. The Director of Nursing (DON) confirmed that the protocol was not followed, as the nurse should have stopped using the line and notified the doctor upon encountering resistance. The deficiency was further highlighted by the fact that the LVN had received IV training and was deemed competent in IV skills, including the management of PICC lines. However, the LVN's actions did not align with the facility's policy, which required notifying a physician if resistance was met during a flush. The DON later confirmed that the PICC line was functioning properly and notified the doctor, but the initial failure to follow protocol posed a risk to the resident's safety.
Failure to Follow Pureed Meal Recipe
Penalty
Summary
The facility failed to ensure that the meals served to residents met their nutritional needs during a lunch meal. Specifically, the facility did not follow the recipe for pureeing hamburger beef patties on the specified date. The dietary staff member responsible for preparing the pureed meal did not have access to the recipe because the computer used to print it was not working. As a result, the staff member prepared the pureed meal based on visual consistency rather than following the specific recipe instructions. This deviation from the planned menu and recipe could potentially impact the nutritional value of the meal provided to residents. Interviews with the dietary staff and management revealed that the Dietary Manager typically printed the menu and recipes for the cooks daily, but was unable to do so on the day in question due to technical issues. The Dietary Manager and the Administrator both acknowledged the importance of following the menu and recipes to ensure residents receive the correct amount of food and nutrients. The facility's Dietary Services policy, last revised in 2012, did not specifically address the preparation of pureed meals or the necessity of following pureed recipes.
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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
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.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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