Rose Haven Retreat
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Texas.
- Location
- 200 Live Oak St, Atlanta, Texas 75551
- CMS Provider Number
- 675603
- Inspections on file
- 34
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rose Haven Retreat during CMS and state inspections, most recent first.
Surveyors found that food items in the kitchen were stored on the floor and not properly labeled or dated, including canned goods, frozen meats, vegetables, and prepared foods. Staff interviews confirmed that these practices did not follow facility policy, and that short staffing and equipment issues contributed to the deficiencies. Facility policies require all food to be stored off the floor and labeled with dates, but these were not followed as observed during the survey.
A resident with dementia and schizophrenia, but no cognitive impairment, was found lying in bed with sheets that were visibly stained and soiled on multiple occasions. The resident reported that linens were not changed as expected on shower days, and staff interviews revealed inconsistencies in linen changing practices and a lack of monitoring. Facility policy required clean linens, but the absence of a system to ensure this led to the resident remaining in unsanitary bedding.
A resident's MDS assessment was inaccurately coded to include schizophrenia, despite no supporting documentation in the medical record or physician orders. The error occurred when the MDS Coordinator, responsible for two facilities and working remotely, miscoded the diagnosis, which was then carried over in subsequent assessments. The resident's actual diagnoses included dementia with psychotic disturbance, neurosyphilis, and depressive episodes.
A resident with PTSD was admitted without a trauma screening or identification of potential triggers, despite facility policy and care plan requirements. Key documentation, such as the social service history and 'Make Me Feel Important' form, lacked trauma-related information, and staff interviews confirmed that trauma-informed care practices were not implemented.
A resident with COPD was administered Budesonide via nebulization by an LVN, who failed to instruct the resident to rinse and spit after use as required by the physician's order. The omission was observed during a medication pass, and staff interviews confirmed that the medication should have been administered according to special instructions to ensure proper care.
A nurse left a medication cart unlocked and unattended while out of sight, and two opened Albuterol Sulfate Inhalation Solution vials on the cart were not dated. The nurse admitted to being distracted and unaware the cart was left unsecured, and could not identify who failed to date the opened medications. Facility policy requires medication carts to be locked when not in use and medications to be properly labeled with open and expiration dates.
A resident with dementia and schizophrenia, but no cognitive impairment, reported a broken tooth causing discomfort and difficulty eating. The Social Services Director attempted to arrange dental care but was unable to secure services due to an outstanding balance and insurance issues, and did not notify nursing staff or the DON. The care plan did not address dental needs, and there was no documented follow-up, resulting in the resident not receiving timely dental care.
A laundry aide delivered clean clothing to residents using an uncovered laundry cart inside the facility, contrary to facility policy and expectations from the DON, Housekeeping Supervisor, and Administrator, who all stated that clean laundry should remain covered during transport to prevent cross-contamination.
Surveyors observed cigarette butts on the ground and trash in the designated smoking receptacle, contrary to facility policy requiring safe smoking practices and proper disposal. Staff interviews revealed inconsistent monitoring and enforcement of smoking area cleanliness and safety.
A resident with severe cognitive impairment and a history of elopement managed to leave a secured unit in an LTC facility, resulting in an unwitnessed fall and minor injuries. The incident occurred when a nurse left the unit to attend to other residents, and the facility's door alarms were found to be off. Despite regular maintenance checks, the malfunctioning alarm was not identified, leading to the resident's escape.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including an opened bag of potato chips not securely closed, a tin pan with stuffed green peppers in beef sauce improperly stored in the freezer, baking sheet pans with carbon buildup, and measuring cups stored with openings facing up. Staff acknowledged the deficiencies and the potential risks to residents.
The facility had a medication error rate of 12.5%, with errors including administering medications at incorrect times and not following specific instructions related to food intake and timing before meals. These errors involved four residents and were confirmed through observations and staff interviews.
The facility failed to ensure proper infection control practices, including glove changes and hand hygiene during incontinent care, adherence to Enhanced Barrier Precautions, and isolation for a resident with ESBL. These lapses were observed and confirmed by staff interviews.
A resident with severe cognitive impairment and a history of depression was administered Prozac without the consent of her responsible party. Despite the RP's explicit refusal to give verbal consent over the phone, the medication was given on two occasions. Facility staff admitted to the oversight, acknowledging that the medication should not have been administered without proper consent.
A resident was repeatedly observed without access to their call light, which was found between the mattress and the fitted sheet. Staff interviews confirmed that the call light should have been within reach, as per the care plan and facility policy. The resident expressed concern about not being able to call for assistance.
A resident with severe cognitive impairment and mobility dependence was not assisted out of bed for at least two weeks despite daily requests. Staff misunderstood wound care instructions, leading to the resident's prolonged bed rest, which violated the facility's policy on resident rights and self-determination.
The facility failed to accurately assess a resident's tobacco use, leading to an incomplete MDS and care plan. Despite being listed as a safe smoker and observed waiting for a smoke break, the resident's smoking status was not documented. Interviews with staff confirmed the importance of accurate MDS assessments for proper care planning.
The facility failed to ensure accurate PASRR Level 1 assessment for a resident with schizophrenia, leading to a lack of necessary specialized services. The MDS Nurse did not review the assessment due to the resident's PASRR positive status, and the facility's policy did not address assessment accuracy.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident's smoking habit was not included in the care plan, and another resident's behavioral changes and move to a secured unit were not communicated to the hospice agency, resulting in missed opportunities for timely interventions.
The facility failed to ensure a safe mechanical lift transfer for a resident with severe cognitive impairment and other medical conditions. CNA A operated the lift with the base legs closed, contrary to the correct procedure of keeping them open for stability, which could have led to the lift tipping and causing injury. Multiple staff members confirmed the correct procedure, highlighting a training discrepancy.
Deficient Food Storage, Labeling, and Dating Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, and dating of food items. Food was found stored directly on the floor in the dry pantry, including boxes of canned goods, chips, coffee, and vegetables, none of which were dated. In the large freezer, several plastic bags containing various foods such as hamburger patties, chicken tender strips, sausage patties, onions, peppers, and French fries were not labeled or dated. The white freezer contained bags of unknown meat that were also not labeled or dated, and there was evidence of a melted and refrozen substance at the bottom of the freezer. In the refrigerator/cooler, a metal container of chicken noodle soup and a bag of sandwiches with resident names were not labeled or dated, nor was a partial bag of biscuits. Interviews with dietary staff and management confirmed that facility policy requires all food items to be labeled and dated when placed in storage, and that food should not be stored on the floor. Staff acknowledged that failure to label and date food could result in serving expired or spoiled food to residents, potentially causing illness. Staff also reported that the kitchen was short-staffed, the dishwasher was out of order, and that these factors contributed to the lapses in proper food storage and labeling. The dietary manager and administrator both stated that they expected staff to follow established policies for food storage, labeling, and dating, regardless of staffing or equipment issues. Record review of facility policies confirmed the requirement for all foods to be stored off the floor, covered, labeled, and dated, with special attention to items belonging to residents. The policies also emphasized the importance of safe food handling practices to prevent foodborne illness. Despite these policies, the observed deficiencies in food storage, labeling, and dating were not addressed at the time of the survey, as confirmed by staff interviews and direct observation.
Failure to Provide Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified when a resident's bed linens were observed to be unclean, with numerous brown stains and a crusty yellow substance present on the top sheet. The resident, a female with a history of dementia and schizophrenia but no cognitive impairment per her most recent MDS, was found lying in the soiled bed linens on multiple occasions. The resident reported that her sheets were typically changed on her scheduled shower days, which were Monday, Wednesday, and Friday, but stated that her sheets had not been changed after her most recent shower. She expressed discomfort and dissatisfaction with the condition of her bedding. Interviews with facility staff revealed inconsistencies and lapses in the process for changing bed linens. Nursing assistants confirmed that linens should be changed on shower days and as needed if visibly soiled, but one NA noted that clean linens from the laundry often arrived stained and that she had not reported this issue. The Housekeeping Supervisor stated that laundry staff were trained to remove stained or torn linens, but also indicated that CNAs were responsible for changing linens if they became soiled. The CNA Supervisor and DON both stated that linens should be changed on shower days and as needed, but there was no system in place to monitor the condition of bed linens, and it was unclear if the resident had refused linen changes. The facility's policy required clean bed and bath linens in good condition to maintain a homelike environment. Despite this, the lack of a monitoring system and failure to ensure linens were changed as required resulted in the resident remaining in soiled bedding, which was directly observed and confirmed by both the resident and staff interviews.
Inaccurate MDS Assessment Due to Miscoded Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's active diagnoses. Specifically, the MDS assessment for one resident incorrectly included a diagnosis of schizophrenia, despite the absence of supporting documentation in the resident's medical record and physician orders. The resident's medical history included dementia with psychotic disturbance, neurosyphilis, and depressive episodes, but not schizophrenia. The error was identified during a review of the resident's face sheet, care plan, and physician orders, which did not list schizophrenia as an active diagnosis. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for assessments at two facilities and often worked remotely, miscoded the diagnosis, possibly due to confusion with another resident with a similar last name. The incorrect diagnosis of schizophrenia was first entered in a previous assessment and subsequently carried over to later assessments. The facility's policy requires that MDS assessments accurately reflect each resident's status, but this was not followed in this instance, resulting in an inaccurate assessment for the resident.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of PTSD received trauma-informed and culturally competent care in accordance with professional standards. Upon admission, no trauma screening was completed to identify possible triggers, despite the resident's documented history of PTSD. The initial social service history assessment lacked screening questions related to trauma, and the 'Make Me Feel Important' form, intended to identify specific triggers and de-escalation interventions, was not filled out for the resident. Interviews with facility staff, including the Social Services Director and Administrator, confirmed that trauma screening was not part of the admission process and that staff were unaware of the omission. The resident's care plan noted a history of being fearful and easily annoyed due to PTSD, with a goal to manage symptoms and avoid fearful episodes. However, there was no evidence of trauma-specific services or interventions being provided. The facility's policy required a trauma screening tool to be implemented as part of the admissions process, but this was not followed. Staff interviews revealed a lack of awareness and implementation of trauma-informed care practices, and the necessary documentation to identify and mitigate potential triggers for the resident was incomplete or missing.
Failure to Ensure Proper Administration of Inhalation Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician orders and manufacturer guidelines during the administration of Budesonide, an inhalation medication, to a female resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who had intact cognition and was able to communicate clearly, had a physician order specifying that she should rinse and spit after each use of Budesonide via nebulization. During a medication pass, the LVN administered the medication but only provided a glass of water afterward, without instructing the resident to rinse and spit as required. Interviews with the LVN, Director of Nursing (DON), and Administrator confirmed that the medication should have been administered according to the physician's order and that special instructions, such as rinsing and spitting, were necessary to prevent adverse effects. The facility's medication administration policy also required medications to be given per orders and manufacturer guidelines. The failure to follow these instructions was observed and acknowledged by staff, constituting a deficiency in pharmaceutical services for the resident.
Medication Cart Security and Labeling Deficiencies
Penalty
Summary
A deficiency was identified when a nurse failed to lock a medication cart on a secured unit while it was unattended. The nurse entered a resident's room and was engaged in conversation for approximately ten minutes with the privacy curtain pulled, leaving the medication cart out of her line of sight and unlocked. The nurse acknowledged being distracted and not realizing the cart was left unsecured, despite the presence of narcotics on the cart and the risk posed by residents with dementia. Additionally, two Albuterol Sulfate Inhalation Solution vials on the same medication cart were found to be undated after being opened. The nurse was unable to determine who had opened the vials and stated that it was the responsibility of the person opening the medication to date it. Facility policies reviewed indicated that medication carts must be locked when not in use and that medications must be labeled with the date dispensed and expiration date when applicable.
Failure to Provide Timely Dental Services for Resident with Broken Tooth
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental services when she reported a broken tooth causing discomfort. The resident, who had a diagnosis of dementia without behaviors and schizophrenia but was assessed as having no cognitive impairment, communicated her dental issue to staff. Despite her ability to express her needs and the care plan indicating she required assistance with oral hygiene, the care plan did not address any dental issues, and there was no documentation of follow-up for her reported discomfort. The Social Services Director was aware of the resident's dental concern and attempted to arrange care through the facility's mobile dentistry provider. However, the provider refused service due to an outstanding balance. The Social Services Director also attempted to contact other community dental providers, but none accepted the resident's insurance. Documentation showed that after the initial report of dental discomfort, there were no further notes addressing the resident's pain or discomfort, and the nursing staff was not notified of the issue. Interviews revealed that the Social Services Director did not inform nursing staff or the DON about the resident's dental concerns, and the Administrator was not notified until days after the issue was identified. The facility's policy required routine and emergency dental services to be available and for social services to assist with appointments and arrangements, but these procedures were not followed. As a result, the resident experienced ongoing discomfort and difficulty eating due to the lack of timely dental care.
Uncovered Laundry Cart During Clean Linen Delivery
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during the delivery of clean laundry. During observation, a laundry aide was seen transporting an uncovered laundry cart with clean clothes exposed while delivering to residents inside the facility. The laundry aide stated that while she covered the cart when transporting laundry from the outside laundry building, she was not required to keep it covered once inside the facility. This practice was inconsistent with the facility's policy, which requires clean linen to remain covered to protect it from environmental contamination. Interviews with the DON, Housekeeping Supervisor, and Administrator confirmed that the expectation was for clean laundry to be covered at all times during transport, both inside and outside the building, to prevent cross-contamination. The facility's policy also specified that clean linen should be protected from environmental contaminants by keeping carts covered. The failure to follow these protocols was observed and acknowledged by facility leadership.
Failure to Maintain Safe and Clean Smoking Area
Penalty
Summary
The facility failed to follow its established smoking policy for the designated smoking area. During an observation, surveyors found two red-tipped cigarette butts on the sidewalk near the door to the smoking area, despite a posted sign instructing not to throw cigarette butts on the ground. Additionally, a used white tissue was found in the red metal can intended for cigarette disposal. The facility's smoking policy requires that ashtrays be emptied only into designated receptacles and that safe smoking practices be maintained. Interviews with staff revealed a lack of consistent monitoring and enforcement of the smoking area’s cleanliness and safety. The Social Services Director, responsible for supervising a smoke break, did not notice the cigarette butts or tissue during her oversight. The Housekeeping Supervisor and Maintenance Assistant both stated they were responsible for keeping the area clean, but acknowledged that trash and cigarette butts were sometimes left unattended. The Administrator confirmed that staff were expected to ensure proper disposal of cigarette butts and trash to maintain fire safety, in accordance with facility policy.
Resident Elopement Due to Inadequate Supervision and Faulty Alarms
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that adequate supervision was provided to prevent elopement for a resident. The resident, a male with severe cognitive impairment and a history of elopement, was admitted to the facility's secured unit due to his risk of wandering. Despite being on a secured unit, the resident managed to leave the facility premises, resulting in an unwitnessed fall and minor injuries. On the day of the incident, the resident was last seen by a nurse between 3 PM and 3:30 PM while vital signs were being taken. The nurse then left the secured unit to attend to other residents, during which time the resident eloped. The facility's Business Office Manager (BOM) was alerted by a neighbor that the resident was seen outside, prompting staff to search for and eventually find the resident down the road from the facility. The resident was assessed for injuries and sent to the emergency room for further evaluation. Interviews and observations revealed that the door alarms were not functioning properly, as the alarm on the back door was found to be off. Staff members, including the nurse and CNA on duty, did not hear any alarms during the incident. The facility's maintenance logs indicated that door checks were conducted regularly, but the malfunctioning alarm was not identified prior to the incident. The resident's care plan noted his risk for elopement, but the supervision and security measures in place were insufficient to prevent his escape.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an initial tour, surveyors observed an opened bag of potato chips that was not securely closed in the dry goods pantry, and a tin pan with stuffed green peppers in beef sauce in the freezer with the top cover lifted, exposing the food to potential contamination. Additionally, there were approximately seven baking sheet pans with thick black carbon buildup on the outside and rim, and two measuring cups were stored with the top openings facing up, which could collect dust. Interviews with kitchen staff revealed that they were aware of the proper procedures for food storage and handling but failed to consistently implement them. The staff also acknowledged the presence of pests in the past and the use of foil to line the baking sheet pans due to the carbon buildup that could not be removed despite scrubbing and using degreasers. The dietary manager admitted to not placing an order for new pans due to financial reasons and confirmed that the opened bag of potato chips was discarded because its open date was unknown. The stuffed bell peppers were inspected and served as an alternate meal despite the initial improper storage. The facility's policy on dietary services, dated 2007, emphasized the importance of preventing food contamination and foodborne illness by ensuring proper receipt and storage of food supplies and handling utensils in a way that avoids contact with surfaces that come into contact with food or drink. The assistant dietary manager and dietary manager both acknowledged the deficiencies and the potential risks to residents if food was not stored properly or if baking pans were not free of carbon buildup. The facility had been dealing with a pest issue, which had improved with weekly pest control services. However, the observed deficiencies in food storage and handling practices could place residents at risk of foodborne illness and food contamination.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that it was free of a medication error rate of 5 percent or greater, resulting in a medication error rate of 12.5%. This was based on 4 errors out of 32 opportunities, involving 4 of 6 residents reviewed for medication administration. The errors included administering medications at incorrect times and not following specific instructions related to food intake and timing before meals, which could affect the therapeutic benefits of the medications and the residents' health conditions. One resident, a [AGE] year-old female with diagnoses including gout and chronic pain, received Acetaminophen-codeine 300-30mg at 10:30 a.m. instead of the prescribed 8:00 a.m. Another resident, a [AGE] year-old male with a history of cerebral infarction, was given Aspirin 81mg at 9:31 a.m. instead of 8:00 a.m. and without food, contrary to the physician's orders. These deviations from the prescribed medication schedules could potentially compromise the effectiveness of the medications and the residents' health. Additionally, a [AGE] year-old male with gastro-esophageal reflux disease received Esomeprazole Magnesium 20mg at 9:23 a.m. instead of the ordered 7:00 a.m. Similarly, a [AGE] year-old female with severe cognitive impairment and gastro-esophageal reflux disease was administered Omeprazole 40mg at 9:56 a.m. instead of 7:00 a.m. and not 30-60 minutes prior to eating as required. These errors were observed during medication administration and confirmed through interviews with the staff, who acknowledged the importance of adhering to the specified times and instructions for medication administration.
Infection Control Failures
Penalty
Summary
The facility failed to ensure an effective infection prevention and control program, leading to multiple instances of cross-contamination and improper hygiene practices. One incident involved a CNA who did not change gloves or perform hand hygiene while providing incontinent care to a resident. The CNA touched various clean items and the resident's skin without changing gloves, despite knowing the correct procedures. This was confirmed by interviews with the CNA, LVN, and DON, who all acknowledged the risk of cross-contamination and increased infection risk due to these actions. Another incident involved two CNAs who did not follow Enhanced Barrier Precautions (EBP) while providing care to a resident with a colostomy and wound. Despite a sign indicating the need for gown and gloves, the CNAs did not don the required protective equipment. The CNA admitted to not understanding the full importance of EBP, even though they had recently received in-service training on the topic. This lapse was observed and confirmed by the WCN, ADON, and the CNA herself. Additionally, the facility failed to isolate a resident after urine cultures revealed the presence of ESBL, an antibiotic-resistant organism. The resident was not placed on contact isolation, and there were no physician orders or nursing notes indicating isolation status. Interviews with the DON and the resident confirmed that isolation protocols were not followed, increasing the risk of spreading the infection. The facility's infection control logs and policies were reviewed, revealing inconsistencies in the application of isolation precautions and EBP guidelines.
Failure to Obtain Informed Consent for Medication Administration
Penalty
Summary
The facility failed to ensure that Resident #102 was fully informed and had given consent before administering Prozac, an antidepressant medication. Resident #102, who had severe cognitive impairment and a history of depression, was given Prozac without the consent of her responsible party (RP). The RP had explicitly stated that he did not feel comfortable giving verbal consent over the phone and wanted to see Resident #102 in person before making a decision. Despite this, the medication was administered on two occasions without the required consent. Interviews with the facility staff, including the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) F, revealed that the standard procedure was to obtain written consent for psychotropic medications either during admission or before starting a new medication. The ADON confirmed that the RP had not given consent and that the medication should not have been administered. LVN F admitted to administering the Prozac but was unsure if consent had been obtained. The Director of Nursing (DON) also acknowledged that the medication should not have been given without the RP's consent. The facility's policy on resident rights and a document from Texas Health and Human Services both emphasize the necessity of obtaining consent for psychiatric medications. Despite these guidelines, the facility failed to adhere to the protocol, resulting in the administration of Prozac to Resident #102 without proper consent. This failure could potentially place residents at risk of receiving medications without their knowledge or consent, leading to adverse reactions or other negative outcomes.
Failure to Ensure Resident Access to Call Light
Penalty
Summary
The facility failed to ensure that a resident had access to a call light, which is a critical component for requesting assistance. The resident, who was [AGE] years old and had diagnoses including high blood pressure, anxiety disorder, pain, and shortness of breath, was observed multiple times without access to their call light. The call light was found draped over the head of the mattress and between the mattress and the fitted sheet, making it inaccessible. The resident was unable to locate the call light and expressed concern about how to call for assistance. The care plan for the resident indicated that the call light should be kept within reach at all times, but this was not adhered to during the observations on multiple occasions over two days. Interviews with staff, including a CNA, RN, DON, and the Administrator, confirmed that the call light should have been within reach and that its inaccessibility could prevent the resident from voicing their needs or calling for help, potentially leading to falls or other injuries. The CNA responsible for the resident on the day in question did not notice the call light's position and assumed it was under the covers. The RN and DON both stated that call lights should not be between the mattress and the fitted sheet and should always be within the resident's reach. The Administrator emphasized that all staff members entering a resident's room are responsible for ensuring the call light is accessible. The facility's policy on answering call lights, dated October 2010, also indicated that call lights should be within easy reach of residents when they are in bed or confined to a chair.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote resident self-determination through support of resident choice for a resident who requested to be assisted out of bed. The resident, who had severe cognitive impairment and was dependent on staff for mobility, expressed a desire to go outside and be out of bed daily. Despite these requests, the resident was not assisted out of bed for at least two weeks. Staff interviews revealed that the resident's requests were ignored due to a misunderstanding about the resident's wound care needs, with some staff believing that the resident should remain in bed to allow a bedsore to heal. However, the wound care nurse clarified that there was no medical reason preventing the resident from being out of bed, other than the resident's non-compliance with wound care instructions. The Director of Nursing (DON) and other staff members acknowledged that the resident had the right to get out of bed and that his requests should have been honored. The DON admitted that the resident's prolonged bed rest could have psychosocial impacts. The facility's policy on resident rights, which includes the right to self-determination and support from the facility in exercising these rights, was not followed in this case. The failure to assist the resident out of bed as requested led to a deficiency in promoting and facilitating resident self-determination and choice.
Failure to Accurately Assess Resident's Tobacco Use
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident, specifically regarding tobacco use. Resident #36, who has diagnoses including post-traumatic stress disorder, unspecified mood disorder, and high blood pressure, was not identified as a tobacco user in his most recent MDS assessment. Despite being listed as a safe smoker on a separate list and observed waiting for a smoke break, his MDS and care plan did not reflect his smoking status. This discrepancy was confirmed through interviews with the MDS Nurse, DON, and Administrator, all of whom acknowledged the importance of accurate MDS assessments for proper care planning. The MDS Nurse admitted that tobacco use should have been marked on the MDS and that an inaccurate MDS could lead to an incorrect care plan, potentially affecting the resident's safety and care. The DON and Administrator also confirmed that the resident's smoking status should have been included in the MDS and care plan. The facility's policy on MDS assessment data accuracy, which aligns with federal regulations, was not followed in this instance, leading to the deficiency.
Failure to Ensure Accurate PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that Resident #27, who had a diagnosis of schizophrenia, was provided an accurate Preadmission Screening and Resident Review (PASRR) Level 1 assessment. The PASRR Level 1 assessment for Resident #27 did not reflect his mental illness, specifically schizophrenia, which was documented in his medical records and care plan. The MDS Nurse, who was responsible for reviewing PASRR Level 1 assessments for accuracy, did not review Resident #27's assessment because he was already PASRR positive. The MDS Nurse admitted that she had not reviewed PASRR positive residents' assessments since her employment began, focusing only on PASRR negative residents. The Director of Nursing (DON) and the Administrator also acknowledged that the MDS Nurse was responsible for ensuring the accuracy of PASRR Level 1 assessments, but the process failed to verify the information accurately for Resident #27. The deficiency was identified during a review of Resident #27's records, which showed inconsistencies between the PASRR Level 1 assessment and other medical documentation. The PASRR Level 1 assessment dated 04/19/18 indicated no evidence of mental illness, despite Resident #27 having an active diagnosis of schizophrenia. Interviews with the MDS Nurse, DON, and Administrator revealed a lack of thorough review and verification of PASRR Level 1 assessments, leading to the oversight. The facility's policy on PASRR did not address the accuracy of these assessments, contributing to the failure to provide Resident #27 with the necessary specialized services for his mental health condition.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. For one resident, the facility did not include smoking in the care plan despite the resident being a known smoker. This oversight was due to the resident not being marked as a tobacco user on the MDS, which the MDS Nurse acknowledged as a safety issue. The resident was observed waiting for a smoke break, and both the MDS Nurse and the DON confirmed that the care plan should have included smoking to ensure proper care and safety measures were in place. For another resident receiving hospice services, the facility failed to notify the hospice agency of significant behavioral changes and the resident's move to a secured unit. The resident exhibited severe cognitive impairment and behavioral issues, including sexual inappropriateness and exit-seeking behavior. Despite these changes, the LVN did not inform the hospice agency, which could have provided additional support and interventions. The hospice representative and the resident's RP both expressed concerns about the lack of communication, and the DON confirmed that the hospice agency should have been notified according to the care plan. These failures highlight the facility's inability to maintain accurate and comprehensive care plans, which are essential for coordinating care and ensuring residents' needs are met. The lack of proper documentation and communication with relevant parties, such as the hospice agency, resulted in missed opportunities for timely interventions and appropriate care for the residents involved.
Improper Mechanical Lift Transfer Procedure
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided adequate supervision to prevent avoidable accidents. Specifically, CNA A did not perform a safe mechanical lift transfer for Resident #13. During an observation, CNA A operated the mechanical lift with the base legs closed while lowering Resident #13 into her bed, contrary to the correct procedure of keeping the base legs open for stability. This incorrect procedure was confirmed by multiple staff members, including LVN F, the DON, and the CNA Coordinator, who all stated that the base legs should be open to prevent the lift from tipping and potentially injuring the resident. Resident #13, a [AGE] year-old female with severe cognitive impairment, dementia, stroke, hemiplegia, and osteoporosis, was dependent on staff for transfers and required the use of a mechanical lift with two staff members. The care plan for Resident #13 indicated that she should be transferred using a mechanical lift with the base legs open for stability. However, during the observed transfer, CNA A closed the base legs while lowering the resident, which could have led to the lift tipping and causing injury. Interviews with staff revealed that CNA A had been taught at another facility to close the base legs when lowering a resident, which contradicted the facility's training and best practices. The DON and CNA Coordinator emphasized the importance of keeping the base legs open for stability during transfers. The facility's records showed that CNA A had completed a departmental orientation checklist, including transferring patients with a mechanical lift, but the incorrect procedure was still followed during the observed transfer. The operation guide and best practices for using patient lifts also indicated that the base legs should be open for optimum stability and safety.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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