San Antonio North Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 501 Ogden, San Antonio, Texas 78212
- CMS Provider Number
- 455817
- Inspections on file
- 59
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at San Antonio North Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with acute and chronic kidney disease, muscle weakness, incontinence, and a need for assistance with personal care was found to be living in a room with a persistent, strong urine odor detectable from the hallway and markedly stronger inside the room. Surveyors observed an unmade bed with a yellowish/brown mattress protector and sheet and later noted that, even after the bed was made, the urine odor remained overwhelming. Staff interviews revealed that housekeeping cleaned the room multiple times daily and had already replaced the mattress, but the odor persisted and staff frequently complained about it. Maintenance acknowledged the room had smelled this way for an extended period and stated that, although they continued cleaning, the flooring could not be stripped. Administration reported ongoing issues with the resident not getting out of bed to use the toilet and refusing to use provided briefs, contributing to the continued unsanitary and uncomfortable environment.
The facility failed to maintain safe and adequate lighting and electrical service in three resident rooms, resulting in nonfunctional over‑bed lights and intermittent or absent power to room lights and televisions. One cognitively intact male resident with traumatic brain injury, PTSD, and a fall risk reported having no electricity in his room for weeks, with nonworking room lights, over‑bed lights, and television, and described nearly falling while going to the bathroom in the dark. Another male resident with left‑sided hemiplegia, diabetes, major depressive disorder, and PTSD reported his television repeatedly shorting out in a dark room where the over‑bed light did not work. A female resident with hypertension, anxiety, age‑related physical disability, and a history of falls related to gait and balance problems reported that her bathroom light sometimes did not work and described falls when attempting to return to bed and when the bathroom light was out. Observations confirmed dark rooms partially lit only by hallway light, nonfunctional over‑bed lights, and electrical issues, despite a facility policy requiring adequate lighting and maintenance rounds to ensure functioning lights.
Three residents with varying levels of cognitive function and multiple comorbidities reported abusive interactions with an LVN, including verbal disrespect, bullying behavior, and physical contact. One resident described the LVN as a bully who inappropriately questioned her about giving $200 to another resident. Another resident, who used a wheelchair and was cognitively intact, reported that the LVN unplugged the television while he was playing chess, blocked his access to the nurses’ station and the Administrator’s phone number with a med cart, and grabbed his arm and pushed his chest, which staff corroborated. A third resident with schizophrenia and severe cognitive impairment recalled that the LVN refused to let him go outside to listen to his radio after he had signed himself out and told him to shut up and go back upstairs, while he also told her to shut up. These actions show that residents were not protected from verbal and physical abuse by staff.
A staff member worked 88 shifts administering medications and performing duties as a Medication Aide without holding a valid MA certificate or CNA certification. The staff member was incorrectly listed as an LVN, and her GVN permit had expired. Despite this, she continued to work under RN supervision, and her credentials were not properly verified or maintained by facility leadership. No negative outcomes were documented for residents during this period.
A resident with chronic pain and a history of self-harm was receiving opioid medication when pharmacy recommendations regarding their drug regimen were communicated to facility staff but not documented as reviewed or addressed by a provider. The ADON forwarded the recommendations but did not follow up when no response was received, and the physician was unaware of the outstanding recommendations. Facility policy required such documentation and follow-up, but this was not completed.
Two residents experienced deficiencies in their bathroom environments, including an unpainted and scratched door, a rusted door post, and an unsecured toilet. These issues were confirmed by facility leadership and were not addressed in accordance with the facility's preventative maintenance policy.
Surveyors identified deficiencies in kitchen cleanliness and maintenance, including dirty ceiling tiles, a missing light bulb, a rusted ceiling vent, and damaged floor molding and wall in the employee bathroom. Staff interviews confirmed awareness of these issues, which were found to be inconsistent with professional standards for food service safety.
A resident's Medication Administration Record contained blank spaces for medication administration and monitoring on a specific date, with no corresponding progress notes. The assigned nurse did not document whether medications or required monitoring were provided or refused, despite facility policy and physician orders requiring complete and timely documentation. The DON confirmed the lack of documentation and the expectation for staff to record all medication-related actions.
Surveyors found that a dumpster had its sliding door left open and was full of garbage bags. The Food Service Director acknowledged the requirement to keep lids closed for pest control, while the Administrator was unaware of the specific regulation. Facility policy and federal food code require garbage containers to be kept covered.
The Maintenance and Housekeeping Office, containing tools and cleaning equipment, was found open and unattended near resident rooms and the nurses' desk. Staff confirmed the office was usually kept locked due to the presence of potentially unsafe items, but the Maintenance Director left it open, believing it was safe because a housekeeper was nearby. The DON stated the expectation was for the office to be secured at all times.
A resident with moderate intellectual disability, who requires cues for toileting, was found sitting in urine in a dining room chair after staff failed to provide timely incontinent care. The resident was last changed before dinner and not checked again until family members discovered her wet and reported it to staff, who then provided care. Facility policy requires prompt assistance with hygiene and toileting, but this was not followed in the incident.
A resident with multiple chronic conditions did not have wound care treatments consistently documented on the TAR, with several treatment days left blank. The responsible nurse stated that documentation was sometimes missed due to absence or oversight, and refusals by the resident were not always recorded. The DON confirmed these documentation gaps, which were not in line with facility policy requiring complete and accurate records of wound care.
A medication cart was found unlocked and unattended near the nurses' station, containing both OTC and resident medications, while multiple residents and staff were present in the area. The assigned LVN confirmed the cart should not have been left unlocked, and facility leadership reiterated that medication carts must be secured when unattended, as per facility policy.
A resident with a history of cerebral infarction, kidney disease, and dementia was not assisted in obtaining dental services after her top dentures were reported missing. Despite family notification and care plan documentation of oral health risks, facility staff were unaware of the missing dentures and did not arrange for dental care, leaving the resident without her upper dentures and at risk while continuing to eat a regular diet.
Three residents in the facility were found without access to their call lights, which were placed out of reach. One resident with severe cognitive impairment had her call light four feet away, another resident with no cognitive impairment had his call light behind his bed, and a third resident with Alzheimer's and legal blindness had his call light under a wheelchair. Staff interviews confirmed the expectation for call lights to be accessible, but this was not adhered to, leading to the deficiency.
A resident with severe cognitive impairment did not have a privacy curtain during incontinent care, compromising her privacy. Despite staff awareness and facility policies emphasizing privacy, the curtain had been missing for an extended period. The Housekeeping Director acknowledged the issue, and the facility's training on privacy was not effectively implemented.
A resident with multiple health conditions did not have accurate documentation of wound care treatments in their TAR, as required by professional standards. The facility failed to ensure that the treatments were properly recorded, with nursing staff not documenting the care provided. This lack of documentation could risk the resident not receiving appropriate care.
A resident with dementia and schizoaffective disorder was transferred to a hospital without notifying the legal guardian, leading to a deficiency in discharge rights. The facility assumed the hospital would communicate with the guardian, but no documentation of this was found. The resident was later admitted to another nursing home without the guardian's knowledge.
Two residents requiring oxygen therapy were found with empty humidifier bottles on their oxygen concentrators, which had not been changed as required. One resident had intact cognition and required oxygen for shortness of breath, while the other had severe cognitive impairment and multiple health issues. The night shift was responsible for changing the bottles weekly, but this was not done, posing a risk of dry nasal passages.
The facility failed to maintain a safe and sanitary environment, with issues including a broken electrical outlet, a roof leak causing water accumulation, missing floor paneling, and stained ceiling panels. The Maintenance Director and Administrator were unaware of some issues until the day of observation.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to call for assistance. One resident with schizoaffective disorder and unsteadiness had her call light wrapped on the wall, while another with muscle weakness and diabetes had his on the nightstand, both out of reach. The CNA admitted to not repositioning the call lights, and the DON acknowledged the importance of accessibility to prevent falls.
The facility failed to provide a safe, clean, and homelike environment for two residents. One resident's restroom had barrels of soiled linens and trash, while another's shower area was soiled with a dark brown substance. These conditions were confirmed by the Director of Housekeeping and the ADON, respectively.
A resident with a history of muscle weakness, insomnia, and Type II Diabetes was observed smoking an electronic cigarette in his room, despite being assessed as a supervised smoker. The facility's policy required smoking in designated areas, but the resident stated he makes his own rules. Staff interviews confirmed the resident's non-compliance and the potential fire hazard.
A resident was prescribed Xanax for anxiety on a PRN basis indefinitely, contrary to the facility's policy limiting such orders to 14 days. The resident, with moderately impaired cognition and multiple diagnoses, was at risk due to this oversight. The DON confirmed the error, noting that the ADON was responsible for daily oversight, but monitoring was done randomly, leading to the deficiency.
A facility failed to ensure safe storage of food in a resident's personal refrigerator, as observed by surveyors. The refrigerator contained open and undated lunch meat, which was confirmed by a CNA and the DON. The facility's policy requires labeling and dating of perishable foods, but this was not being monitored by the night shift nurses.
The facility failed to maintain proper garbage storage, as observed on two occasions where a garbage bin lid was left open, exposing waste. The Dietary Director and Administrator acknowledged the requirement for lids to remain closed to prevent pest issues, aligning with the facility's policy on garbage disposal.
A resident with severe cognitive impairment and complex medical conditions did not receive adequate foot care or access to podiatry services, resulting in overgrown toenails and a sore on her toe. Despite requests from the family and orders for podiatry services, the resident was not seen by a podiatrist during their visits to the facility. The facility's staff failed to document or provide routine nail care, leading to missed care and potential health risks.
A resident with dementia, depression, and anxiety was not monitored according to his care plan, which required staff to report his fear of being alone. An LVN failed to document or report this fear, leading to the resident's suicide attempt. The facility's failure to implement a comprehensive care plan resulted in Immediate Jeopardy.
A resident with dementia, depression, and anxiety in a LTC facility displayed increased fear and requested staff presence, but interventions were not implemented, leading to a suicide attempt. Despite a care plan requiring monitoring and psychiatric consultation, behavior monitoring was not conducted, and staff failed to communicate the resident's fear and suicidal ideation to the psychiatric team. This deficiency was identified as an Immediate Jeopardy situation.
The facility failed to monitor residents for side effects and effectiveness of psychotropic medications, as required by their care plans. Six residents with various cognitive and mood disorders were not monitored for target behavior symptoms or side effects, despite being prescribed multiple psychotropic medications. Interviews with staff indicated a belief in adequate monitoring, but no specific orders or documentation supported this.
A resident with dementia, depression, and anxiety attempted suicide by using a shirt as a noose. Despite the incident being documented and the resident being hospitalized, the facility failed to report the event to the State Survey Agency within the required timeframe. The administrator did not consider the incident reportable, contrary to facility policies and state guidelines.
A resident with dementia and depression attempted suicide, but the LTC facility failed to investigate the incident thoroughly. Despite the resident's admission to a hospital for a suicide attempt, the facility did not document or investigate the event, citing inconsistencies in staff reports. The facility's policies require investigation and reporting of such incidents, but these were not followed.
A facility failed to maintain a medication error rate below 5%, resulting in a 44% error rate. A resident with multiple health conditions received medications over an hour and a half late, potentially affecting therapeutic outcomes. The CMA responsible reported consistent delays due to workload but did not escalate the issue to higher management. Facility policies lacked guidance on administration timeliness.
Persistent Urine Odor and Unsanitary Room Environment for a Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide a safe, sanitary, comfortable, and homelike environment for one resident. The resident was admitted with acute kidney failure, chronic kidney disease, muscle weakness, and a need for assistance with personal care, and had a care plan indicating incontinence related to impaired mobility and behaviors, with use of briefs. The MDS showed the resident had a BIMS score of 15, sometimes refused care 1–3 days per week, and required substantial assistance to toilet. On the survey date, surveyors noted a strong urine odor on the second-floor hallway upon exiting the elevator, which intensified near and inside the resident’s room. Inside the room, the bed was unmade, with a mattress protector and sheet that were faded yellowish/brown, and there was a strong ammonia-like urine odor; the resident stated he could not smell the odor. Later the same day, surveyors again noted a persistent urine odor in the hallway even with the resident’s door closed, and upon opening the door, the urine odor was so strong the surveyor could only remain in the room for a few minutes, despite the bed having been made. A housekeeper reported working the 12:00 pm–8:00 pm shift and cleaning the resident’s room about three times a day, with the 6:00 am–2:00 pm shift also cleaning the room once daily. The housekeeper stated the resident’s mattress had been changed in an attempt to address the odor, but this did not help, and that staff frequently complained about the smell. The Maintenance Director acknowledged the room had smelled that way “for a while” and that cleaning had not resolved the issue; he stated the room floors could not be stripped and that they continued to try to clean the room. The Administrator reported ongoing issues with the resident not getting out of bed to use the toilet and refusing to use the briefs provided, contributing to the persistent urine odor and unsanitary room conditions.
Failure to Maintain Safe and Adequate Lighting and Electrical Service in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining adequate and functional lighting and electrical service in three resident rooms. In rooms #10, #11, and #12, over‑bed lights were nonfunctional and there were additional electrical issues affecting other electronics. The Maintenance Supervisor reported that he had replaced outlets in these rooms and identified a wiring problem, particularly in one room, but stated he did not have the equipment to fix it. He also stated that the circuit breaker for the affected circuit would not stay on, so he turned it off as a precaution, which also disabled the over‑bed lights, and that the building had old wiring. One male resident in room #11, with diagnoses including major depressive disorder, schizoaffective disorder bipolar type, traumatic brain injury, and PTSD, and care planned for PTSD, traumatic brain injury, and risk for falls, reported that there had been no electricity in his room since about a week before Halloween. He stated that the room lights, television, and over‑bed lights did not work, and that he almost fell going to the bathroom because the room was dark. During observation, the room was dark except for light from the hallway, and attempts by the investigator to turn on the main room light and over‑bed lights were unsuccessful; the resident’s television also did not work when he attempted to turn it on. Another male resident in room #12, with left‑sided hemiplegia, type 2 diabetes, major depressive disorder, and PTSD, and care planned for PTSD, major depressive disorder, fall precautions due to hemiplegia, and mild cognitive impairment, was observed in a dark room partially lit by the hallway while watching television. He reported that his television would short out and stop working and that he had been told the facility was working on the problem. The over‑bed light in his room did not work when tested. A female resident in room #10, with hypertension, anxiety disorder, and age‑related physical disability, care planned for falls, gait/balance problems, and falls related to seizures, reported that her bathroom light sometimes did not work. She stated she had fallen when trying to get back into bed after using the bathroom and once when the bathroom light did not work, though she was not injured. Observation showed the main room light only partially illuminated the room and the over‑bed lights did not function. The facility’s own policy required maintaining adequate and comfortable lighting levels in all areas and periodic rounds by the Maintenance Director to ensure functioning lights.
Failure to Protect Residents From Verbal and Physical Abuse by an LVN
Penalty
Summary
The facility failed to protect three residents from abuse by LVN B, in violation of its abuse, neglect, and exploitation policy. One resident, an older female with anxiety disorder, hypertensive heart disease, and major depressive disorder, had a BIMS score of 13 indicating no cognitive impairment and was care planned for depression, anxiety, and fall precautions. She reported that LVN B was not nice, acted like a bully, and that the situation involving her money "went too far," stating it was none of the nurse’s business what she did with her money. Staff interviews indicated that LVN B questioned this resident about giving $200 to another resident and continued to antagonize her about the money. Another resident, a 66-year-old male with end stage renal disease, type 2 diabetes, and anxiety disorder, had a BIMS score of 15 indicating he was cognitively intact and was care planned for dialysis and right below-knee amputation. He reported that he and LVN B were "going back and forth" verbally, and that she hit him, pushed his wheelchair, and pushed him in the chest in front of other workers, after which he hit her back. Multiple staff interviews (MA C and CNA D) described that this resident and another were playing chess and listening to the television when LVN B repeatedly told him to turn the television down, unplugged the television when he did not comply to her satisfaction, told him to go back to his room, blocked his access to the nurses’ station and the posted Administrator’s phone number by using a medication cart, and grabbed his arm/wrist and held it against his chest. CNA D stated the resident said it hurt and sounded like he was about to cry while asking if she was going to let him go. A third resident, an older male with type 2 diabetes, COPD, schizophrenia, and anxiety disorder, had a BIMS score of 5 indicating severe cognitive impairment but was able to be interviewed and recall the incident with LVN B. He stated he was angry about what the nurse did, described her as very disrespectful with a bad attitude, and said he had signed himself out and wanted to listen to his radio on the porch, but she would not enter the code to allow him to go outside. The Administrator reported that another staff member (MA E) recorded an incident in which LVN B told this resident he could not go outside on the front porch to listen to music after he had signed himself out, and that during the exchange the resident told LVN B to shut up and she told him to shut up, further telling him he needed to go back upstairs, that he did not live on that unit, and that he should go upstairs to "disrespect" the nurses there. These events, as reported by residents and staff, demonstrate that the facility did not ensure residents’ right to be free from verbal and physical abuse by staff.
Uncertified Staff Administered Medications Without Proper Credentials
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and valid certifications required to provide care and administer medications to residents. Specifically, Staff Member A worked a total of 88 shifts administering medications and performing duties as a Medication Aide (MA) without holding a valid MA certificate or CNA certification during the period in question. Staff Member A was listed incorrectly as an LVN on the staff roster, and her Graduate Vocational Nurse (GVN) permit had expired. Despite this, she continued to work under the supervision of an RN, and her credentials were not properly verified or maintained by the facility's Human Resources Director (HRD) or Director of Nursing (DON). The facility's own policy required verification of licensure and certification, but this was not followed, and Staff Member A was allowed to work without the necessary credentials. Record reviews confirmed that Staff Member A signed as a CMA on facility training and administered medications to residents, although there were no documented hospitalizations, harm, or negative outcomes related to her actions. Interviews with the DON, HRD, and Administrator revealed a lack of awareness and oversight regarding Staff Member A's expired or missing certifications. The DON acknowledged that Staff Member A was not an MA and had not taken the MA test, and the HRD confirmed that Staff Member A's GVN was expired upon hire. The Administrator was unaware of the lack of a current MA certificate. The facility's failure to ensure proper licensure and certification for staff directly led to this deficiency.
Failure to Document Physician Review of Pharmacy-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician documented in the medical record that identified medication regimen irregularities had been reviewed and what, if any, actions were taken to address them for one resident. Specifically, pharmacy recommendations regarding the resident's medication regimen in August and September were communicated to the facility, but there was no documentation in the resident's progress notes indicating that a provider had reviewed or responded to these recommendations. The pharmacist reported sending communications about the resident's medications and noted a lack of direct response from the provider, with the process defaulting to continuation of the current regimen in the absence of a response. The ADON stated that her process was to forward pharmacy reviews to providers and await a response, but if no response was received, she did not follow up and the medication regimen continued as ordered. The physician overseeing care was unaware of the unanswered pharmacy recommendations and expected immediate responses to such communications. Review of facility policy indicated that the pharmacist, in collaboration with the facility and medical director, is responsible for developing and revising procedures for pharmaceutical services, but the required documentation and follow-up were not completed in this case. The resident involved had a history of intentional self-harm and chronic pain, was taking opioid medication, and had intact cognition.
Failure to Maintain Safe and Homelike Bathroom Environment for Two Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. For one resident with severe cognitive impairment and multiple medical conditions, the interior-facing bathroom door was observed to be unpainted on the lower third and had multiple scratch marks. For another resident with moderate cognitive function and significant medical diagnoses, the bathroom entrance had a 3-inch rust area on the left door post, and the toilet was not secured to the floor, allowing it to move during use. Both residents were observed using these bathrooms, and one resident reported that the rusted area had been visible for a month and expressed a desire for the toilet to be repaired. During a joint observation with the Administrator and Maintenance Director, it was confirmed that the bathroom door, door post, and toilet required repairs. The facility's Preventative Maintenance Program policy was reviewed and indicated that a program should be in place to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. However, the observed conditions in the bathrooms used by these two residents demonstrated a failure to maintain such an environment as required by policy.
Deficiencies in Kitchen Cleanliness and Maintenance
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's main kitchen and associated areas regarding the storage, preparation, distribution, and serving of food in accordance with professional standards. Specifically, six ceiling tiles in the main kitchen were found to be dirty and stained, and a fluorescent light bulb was missing from an overhead fixture. Additionally, a ceiling air vent in the dish room was noted to have rust on the vent blades. In the employee bathroom located in the main kitchen area, there was a section of missing floor molding and a wall penetration measuring approximately three inches in diameter. Interviews with the Food Service Director, Administrator, and Maintenance Director confirmed awareness of these issues, with each acknowledging that such conditions could affect the cleanliness of the kitchen. Review of facility policy and the U.S. FDA Food Code highlighted the requirement for food service areas and equipment to be maintained in a clean and sanitary manner, with non-food-contact surfaces kept free of dust, dirt, and other debris. The observed failures to maintain these standards were documented during the survey.
Incomplete Medication Administration Record Documentation
Penalty
Summary
A deficiency was identified when a resident's Medication Administration Record (MAR) for July 2025 contained blank spaces on July 5, 2025, instead of the required documentation for medication administration and monitoring. The resident, who had diagnoses including essential primary hypertension, generalized anxiety disorder, and type 2 diabetes mellitus, was prescribed multiple medications and required regular monitoring as outlined in their care plan and physician orders. Review of the MAR showed that documentation was missing for the administration of antihypertensive and antianxiety medications, pain assessment, and blood glucose checks on the specified date. Additionally, there were no progress notes for that day regarding medication administration. Interviews with facility staff confirmed that the nurse assigned to the resident on the date in question did not document the administration or refusal of medications and monitoring. The Director of Nursing acknowledged the blank spaces and stated that it was expected for nursing staff to document all medication administration or refusals. The facility's policy required complete, accurate, and timely documentation in each resident's medical record, which was not followed in this instance.
Improper Disposal of Garbage Due to Open Dumpster Door
Penalty
Summary
Surveyors observed that one of two outdoor garbage dumpsters had a sliding door measuring approximately 4x4 feet left open, with the bin full of garbage bags. This observation was made in the presence of the Food Service Director, who acknowledged awareness that the garbage lid should have been closed for pest control prevention. The Administrator, when interviewed, stated he was not aware of the specific requirement to keep garbage lids closed but agreed it would help maintain pest control. Review of facility policy and federal food code confirmed that all garbage and refuse containers must be kept covered with tight-fitting lids or doors when stored or not in continuous use.
Unsecured Maintenance and Housekeeping Office with Hazardous Items
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment by leaving the Maintenance and Housekeeping Office door ajar and unattended. The office, which contained tools and cleaning equipment, was observed open with no staff present. The office was located on the second floor, near resident rooms and adjacent to the nurses' desk. Housekeeper E was seen in the hallway between the office and a resident's room, but not inside the office itself. Both Housekeeper E and the Maintenance Director confirmed that the office was usually kept locked due to the presence of potentially unsafe items for residents. The Maintenance Director admitted to leaving the office open and unattended, believing it was safe because Housekeeper E was nearby in the hallway. The DON stated that her expectation was for the office to be secured at all times when not in use by staff, as it contained items that could be unsafe for residents. Review of the facility's policy confirmed that hazardous areas, devices, and equipment should be identified and addressed to ensure resident safety.
Resident Left Unattended in Urine Due to Delayed Incontinent Care
Penalty
Summary
A deficiency occurred when a resident with moderate intellectual disability and anxiety disorder, who was assessed as continent of bowel and bladder but requiring cues to use the toilet, was found sitting in urine in a dining room chair. The incident took place in the evening, after the resident had been assisted to the dining room for her meal and had not been attended to for an extended period. Family members discovered the resident in this condition, with a puddle of urine on the floor and a wet brief around her ankle, and reported their concerns to staff present in the room. The male RN on duty at the time was present in the dining room, working on a computer, but did not notice or address the resident's condition until the family brought it to his attention. The CNA assigned to the resident stated she had last changed the resident before dinner and had not checked on her again until after the family reported the incident. The CNA explained that her routine was to perform check and change room by room after dinner, and the dining room was at the end of her route, which contributed to the delay in care. The facility's policy requires that residents unable to perform activities of daily living independently receive necessary assistance with hygiene and toileting. Despite this, the resident was left unattended and wet for an undetermined period, contrary to the facility's expectations and policy. The DON confirmed that staff are expected to immediately address such situations, especially when not engaged in direct resident care.
Incomplete Documentation of Wound Care in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were maintained in accordance with accepted professional standards and practices. Specifically, the Treatment Administration Record (TAR) for a resident with multiple chronic conditions, including chronic heart failure, diabetes with neuropathy, lymphedema, and peripheral vascular disease, contained blanks on four out of fourteen designated wound care treatment days. These blanks indicated that the completion or refusal of prescribed wound care was not accurately documented for the specified dates. The resident was prescribed wound care to be performed twice weekly and as needed, with clear orders for cleansing, application of medication, and dressing changes. Observations and interviews revealed that the resident's dressings were not always changed as scheduled, and the resident herself reported that wound care was not consistently provided on the assigned days. The nurse responsible for treatments acknowledged that documentation was sometimes missed, either because she was not present or because she forgot to document after providing care. In cases where the resident refused care, this was also not consistently recorded on the TAR as required. The Director of Nursing confirmed the presence of documentation gaps and stated that refusals or completed treatments should have been properly recorded on the TAR. Facility policy required detailed documentation of wound care, including the type of care given, date and time, assessment data, and any refusals with reasons. The lack of accurate and complete documentation on the TAR made it difficult to determine whether wound care was provided or refused on the specified dates.
Unattended Medication Cart Left Unlocked in Resident Area
Penalty
Summary
A deficiency was identified when a medication cart (Med Cart 1) was observed unlocked and unattended in a common area near the nurses' station, across from the elevator on the second floor. The cart contained both over-the-counter and resident medications. During the time the cart was left unlocked, multiple residents, including one in a wheelchair who made physical contact with the cart, were present in the vicinity. Staff members, including a CNA and a housekeeper, were also nearby, and several residents were observed walking around the area. The nurse assigned to the cart confirmed that it was not supposed to be left unlocked and acknowledged the presence of mobile and ambulatory residents in the halls. Interviews with facility leadership, including the ADON and DON, confirmed that the facility's policy requires medication carts to be locked when unattended, and that the responsibility for securing the cart lies with the assigned nurse or medication aide. Both leaders emphasized the importance of keeping medication carts locked due to the presence of residents who may not be fully alert and oriented, and the potential for unauthorized access to medications and supplies. Review of the facility's policy corroborated these expectations, stating that all drugs and biologicals must be stored in locked compartments.
Failure to Assist Resident in Obtaining Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to assist a resident in obtaining dental services after her top dentures were reported missing. The resident, who had diagnoses including cerebral infarction, kidney disease, and dementia, was admitted with a top denture as documented on her inventory sheet. Despite an email from the resident's family representative notifying facility leadership of the missing dentures, there was no evidence that the facility took steps to assist the resident in obtaining replacement dentures or dental care. The resident's care plan noted a risk for oral health problems and the need to coordinate dental care, but did not mention the missing dentures. Interviews with staff, including the DON and Administrator, revealed they were unaware of the missing dentures, and both expressed concern about the risk of choking if the resident continued to eat without them. Observation confirmed the resident had no natural upper teeth, and interviews with the resident and staff corroborated that the dentures were lost while in the facility's care. The facility's policy required protection of dentures from loss or damage, but this was not followed. The resident continued to eat a regular diet and gained weight during the period, but her oral health needs were not addressed as required by facility policy and care planning.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs and preferences of three residents by not ensuring their call lights were within reach. Resident #3, a female with severe cognitive impairment and multiple diagnoses including anoxic brain damage and schizoaffective disorder, was found with her call light on the floor approximately four feet away from her bed. Despite her care plan emphasizing dignity and respect, the call light was not accessible, which was confirmed by staff interviews. Resident #6, a male with no cognitive impairment but with a history of lymphedema and schizoaffective disorder, was observed with his call light on the floor behind the headboard of his bed while he was eating lunch. His care plan required the call light to be within reach to prevent falls and ensure prompt assistance, yet it was not accessible, as confirmed by the resident himself. Resident #8, a male with severe cognitive impairment, Alzheimer's disease, and legal blindness, was found with his call light on the floor under a wheelchair, five feet away from his bed. His care plan also required the call light to be within reach due to his risk of falls and need for assistance. Staff interviews confirmed the expectation for call lights to be accessible, but this was not adhered to, leading to the deficiency.
Privacy Deficiency During Incontinent Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during incontinent care, as observed by a surveyor. The resident, a female with severe cognitive impairment and multiple diagnoses including anoxic brain damage and schizoaffective disorder, was dependent on staff for personal care. During an observation, it was noted that the privacy curtain for the resident's bed was missing, which compromised her privacy during care. Interviews with the CNAs involved in the care revealed that they were aware of the missing privacy curtain and attempted to provide privacy by closing the curtains for the other beds in the room. However, the absence of a privacy curtain for the resident's bed meant that her privacy was not fully protected if someone entered the room. The Housekeeping Director acknowledged the missing curtain and stated that it had been down for about a month, although a work order indicated it had been missing since 2022. The facility's policies on resident rights and dignity emphasize the importance of privacy during personal care. Interviews with the Administrator and DON confirmed that staff are trained to use privacy curtains to maintain resident dignity and privacy. Despite this, the lack of a privacy curtain for the resident's bed was not addressed in a timely manner, leading to a deficiency in maintaining the resident's right to privacy during care.
Inaccurate Documentation of Wound Care
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, specifically regarding the administration of bilateral wound treatments. The treatment administration records (TAR) for the resident did not accurately reflect the administration of wound care on two specific dates. This discrepancy was identified during a review of the resident's records, which showed that the TAR was not initialed by a nurse as completed on those dates, leading to a lack of documentation for the treatments that were supposed to be administered. The resident in question was an elderly female with multiple diagnoses, including congestive heart failure, type 2 diabetes, bipolar disorder, and lymphedema. She was dependent on staff for various activities of daily living and had a history of rejecting care. The resident's care plan included specific instructions for wound care due to her risk for pressure injuries and existing vascular wounds on her lower legs. Despite these detailed care plans, the facility's records did not consistently document the completion of the required wound treatments. Interviews with the nursing staff revealed a lack of proper documentation practices. The Wound Care LVN and RN C were involved in the resident's care but failed to document the treatments accurately in the TAR. The Wound Care LVN admitted to not signing off on the TAR for one of the dates and relied on personal notes instead of official documentation. RN C also did not document the wound care he provided, assuming the Wound Care LVN would handle it. This lack of documentation could potentially place residents at risk of not receiving appropriate care, as it obscures whether treatments were administered as prescribed.
Failure to Notify Legal Guardian of Resident's Transfer
Penalty
Summary
The facility failed to adequately prepare and inform the legal guardian of a resident for the resident's transfer to a hospital, resulting in a deficiency in discharge rights. The resident, a male with dementia and schizoaffective disorder, was admitted to the facility with a legal guardian appointed due to his incapacitated status. Despite this, there was no written discharge or transfer notice provided to the legal guardian when the resident was transferred to the hospital. The legal guardian was unaware of the resident's transfer and was unable to follow up, leading to a missing person's report being filed. The facility assumed that the hospital would communicate with the legal guardian regarding the resident's discharge and subsequent placement at another nursing home. However, there was no documentation of these communications or actions. The resident was later found at a different nursing home, claiming to be his own responsible party, with no mention of a legal guardian. The facility's policy required notice of transfer to be provided to the resident and representative, but this was not adhered to, resulting in a lack of preparation and orientation for the resident's discharge.
Failure to Maintain Oxygen Humidifier Bottles
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy. Resident #4, a male with acute kidney failure, respiratory failure, and atrial fibrillation, was observed with an empty oxygen humidifier bottle on his oxygen concentrator. The bottle was dated 5/12/24, indicating it had not been changed as required. Resident #4 had a BIMS score of 15, indicating intact cognition, and his physician's orders included oxygen at 2 liters per nasal cannula as needed for shortness of breath. Similarly, Resident #56, a male with respiratory failure, cirrhosis of the liver, and depression, was also found with an empty humidifier bottle on his oxygen concentrator, dated 5/12/24. Resident #56 had a BIMS score of 7, indicating severe cognitive impairment. Interviews with RN C and the DON revealed that the night shift was responsible for changing and dating the oxygen tubing and humidifier bottles weekly. However, the DON was unaware of why the bottles were not changed and acknowledged the risk of dry nasal passages for the residents due to the empty humidifier bottles.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation, it was noted that a resident's room had a broken electrical outlet with an open electrical connection and no outlet cover. Additionally, another resident's room had a roof leak that resulted in a puddle of water on the floor near the room entrance. In the hallway, a section of floor paneling was missing, and a ceiling panel had water stain marks. Interviews revealed that the Maintenance Director had inadvertently broken the electrical outlet while moving a bed and was unaware of the roof leak until the day of the observation. The Administrator also stated that she had just become aware of the roof leakage. The facility's maintenance policy, dated 2001, indicated that maintenance services should be provided to all areas of the building, grounds, and equipment, following established safety regulations to ensure safety and well-being.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a necessary accommodation for their needs and preferences. Resident #46, a female with schizoaffective disorder, dysphagia, and unsteadiness on her feet, was found to have her call light wrapped on the call light box on the wall, making it inaccessible. Her care plan specifically required the call light to be within reach due to her risk of injury. During an interview, Resident #46 expressed that the call light was often moved away from her, preventing her from calling for assistance. The assigned CNA admitted to forgetting to reposition the call light after providing care. Similarly, Resident #55, a male with muscle weakness, insomnia, and Type II Diabetes, also had his call light out of reach on the nightstand. His care plan also required the call light to be accessible due to his risk of injury. Resident #55 reported that the call light was frequently moved away from him. The CNA responsible for his care confirmed that the call light was usually kept on the nightstand, which was not within the resident's reach. The DON acknowledged that call lights should be within arm's length of all residents and that the lack of accessibility could lead to falls if residents needed assistance.
Failure to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents. In the case of one resident, barrels containing soiled linens and trash were improperly stored in the shower area of the resident's restroom. This was confirmed by the Director of Housekeeping, who acknowledged the issue and indicated that staff had been instructed not to store these items in such a manner. For another resident, the shower chair and the floor of the shower area in the restroom were found to be soiled with a dark brown substance resembling mud or feces. This observation was confirmed by the Assistant Director of Nursing (ADON), who agreed that the condition of the shower area was unacceptable. The facility's policy on resident rights emphasizes the importance of providing a safe, clean, and comfortable environment, which was not upheld in these instances.
Resident Access to Electronic Cigarette in Room
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by allowing a resident to have access to an electronic cigarette. The resident, a male with a history of muscle weakness, insomnia, and Type II Diabetes, was observed smoking an electronic cigarette in his room, despite being assessed as a supervised smoker. His care plan indicated that he should be instructed on smoking locations, yet he stated that he makes his own rules and smokes in his room. Interviews with facility staff revealed that the resident was sometimes non-compliant with the supervision requirement. The assigned nurse confirmed the resident's need for supervision while smoking, and the Administrator acknowledged the potential fire hazard posed by the resident smoking in his room. The facility's policy on safety and supervision of residents emphasized the use of dedicated smoking areas, which was not adhered to in this case.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was not given a psychotropic drug unless it was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was prescribed Xanax, a psychotropic drug, for anxiety on a PRN basis for an indefinite period, which is against the facility's policy that limits PRN orders for psychotropic medications to 14 days. The resident, a female with a moderately impaired cognition as indicated by a BIMS score of 12, was admitted with diagnoses including congestive heart failure, chronic pain syndrome, and muscle weakness. The Director of Nursing (DON) confirmed the oversight during an interview, acknowledging that the order for Xanax should have been limited to 14 days. The DON noted that the Assistant Director of Nursing (ADON) was responsible for overseeing such tasks daily, but the monitoring was done randomly, leading to this oversight. The facility's policy on psychotropic medication use, revised in July 2022, clearly states the 14-day limit for PRN orders, which was not adhered to in this case.
Deficient Food Storage Practices in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of food items in a resident's personal refrigerator, which could lead to foodborne illness. During an observation, it was found that the refrigerator in a resident's room contained open and undated lunch meat. Interviews with a CNA and the DON confirmed that the refrigerator contained unlabeled and undated perishable food items. The facility's policy requires that perishable foods brought by family or visitors be labeled and dated, and the night shift nurses are responsible for monitoring this. However, this monitoring was not being conducted at the time of the survey.
Improper Garbage Storage Leading to Pest Risk
Penalty
Summary
The facility failed to maintain the garbage storage area in a manner that prevents the harborage of pests. On two separate occasions, observations were made with the Dietary Director where one of the two garbage bins used by the facility had a side-lid covering that was left open, exposing bags of garbage. The first observation occurred on June 11, 2024, at 11:15 a.m., and the second on June 12, 2024, at 11:00 a.m. During an interview on June 12, 2024, the Dietary Director acknowledged awareness that the garbage bin lids must remain closed at all times to prevent pest problems. Additionally, the Administrator confirmed understanding of the regulation requiring garbage bins to remain closed to prevent pest issues. A review of the facility's policy on Food-Related Garbage and Refuse Disposal revealed that all garbage and refuse containers must be kept covered with a tight-fitted lid when stored and not in continuous use.
Failure to Provide Adequate Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide adequate foot care and access to podiatry services for a resident, leading to discomfort and potential health risks. The resident, a female with severe cognitive impairment and medically complex conditions, was at risk of developing pressure injuries. Despite having orders to see a podiatrist, the resident's toenails were long and overgrown, causing a sore on her toe. The hospital RN noted that the toenails needed trimming and filing, but the hospital staff was not permitted to perform this procedure, and the resident was not expected to stay long enough to see the hospital's podiatrist. The resident's family member had requested podiatry services months prior, but the resident was not seen during the podiatrist's visits to the facility. The DON stated that nurses were responsible for trimming residents' nails weekly, but there was no documentation of recent care for the resident's toenails. The Treatment Nurse admitted to possibly forgetting to document the last nail trimming, and the ADON found no records of the resident ever being seen by a podiatrist. The lack of documentation and follow-up on podiatry services resulted in missed care, increasing the risk of infection or pain for the resident.
Failure to Implement Comprehensive Care Plan Leads to Resident's Suicide Attempt
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, a male with dementia, depression, and anxiety, was admitted with a BIMS score indicating mild cognitive impairment. His care plan required monitoring for changes in cognitive function and psychosocial well-being, including fear of being alone, which was not adequately followed by the staff. On a specific date, an LVN failed to document or report the resident's expressed fear of being alone, as required by the care plan. The following day, the resident attempted suicide by trying to strangle himself with a shirt. This incident highlighted the failure to monitor and report significant changes in the resident's mental state, which was a critical component of his care plan. Interviews with facility staff, including the Psych NP and MD, revealed that there was no prior indication or report of the resident being at risk for self-harm. The facility's policy required comprehensive, person-centered care plans with measurable objectives, which were not effectively implemented in this case, leading to the identification of Immediate Jeopardy.
Failure to Provide Appropriate Mental Health Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with a mental disorder and psychosocial adjustment difficulties. The resident, a male with dementia, depression, and anxiety, displayed increased signs of fear and requested staff presence due to feeling scared. Despite these signs, Licensed Vocational Nurse (LVN) A did not implement interventions or arrange for psychiatric services promptly. This inaction led to the resident attempting suicide the following day by attempting to strangle himself with a shirt. The resident's medical records indicated a history of moderately severe depression and cognitive impairment. His care plan included monitoring for changes in cognitive function and mood, as well as consulting with psychiatric services. However, the facility's records showed that behavior monitoring was not conducted according to the care plan. A psychiatric follow-up note prior to the incident indicated increased anxiety due to a recent altercation, but no immediate risk for self-harm was identified. Despite this, the resident expressed fear and a desire for company, which was not adequately addressed by the staff. Interviews with facility staff revealed a lack of communication and adherence to the care plan. The psychiatric nurse practitioner and medical director were not informed of the resident's expressed fear or suicidal ideation. The facility's policy required comprehensive, person-centered care plans, but the failure to implement these plans and monitor the resident's condition contributed to the incident. This deficiency was identified as an Immediate Jeopardy situation, indicating a serious threat to the resident's health and safety.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor residents who were prescribed psychotropic medications for side effects and effectiveness, as required by their care plans. This deficiency was observed in six residents who were reviewed for medication management. The facility did not have orders for monitoring target behavior symptoms or side effects for the psychotropic medications prescribed to these residents. This lack of monitoring could potentially place residents at risk for adverse consequences related to the use of these medications. Resident #1, a male with dementia, depression, and anxiety, was not monitored for side effects or behaviors related to his prescribed antidepressant and antianxiety medications. His care plan required monitoring for safety and documenting occurrences of target behavior symptoms, but no such orders were found. Similarly, Resident #2, with severe cognitive impairment and depression, was not monitored for side effects or effectiveness of his prescribed antianxiety, antidepressant, and anticonvulsant medications, despite care plan requirements. Other residents, including Resident #3 with mild cognitive impairment, Resident #4 with dementia and major depressive disorder, Resident #5 with expressive language disorder, and Resident #6 with major depressive disorder, were also not monitored for side effects or effectiveness of their psychotropic medications. Interviews with facility staff, including a Psych NP and an MD, revealed that while staff believed they were adequately monitoring residents, there were no specific orders or documentation to support this. The facility's policy on behavioral monitoring required compliance with regulatory requirements, but this was not reflected in the monitoring practices observed.
Failure to Report Resident's Suicide Attempt
Penalty
Summary
The facility failed to report an incident involving a resident's attempted suicide to the State Survey Agency within the required timeframe. The resident, a male with dementia, depression, and anxiety, was admitted to the facility and later discharged to an acute care hospital following the suicide attempt. The resident had a history of cognitive impairment and moderately severe depression, as indicated by his BIMS and PHQ9 scores. Despite these indicators, the facility did not report the incident as required by federal and state regulations. The incident occurred when the resident attempted suicide by using a shirt fashioned as a noose to cut off his airflow. This was documented in a progress note by an LVN, and the resident was subsequently admitted to a local hospital. Interviews with hospital staff confirmed the suicide attempt. However, the facility's administrator did not report the incident, believing it did not qualify as a reportable event based on her review of the reporting pathway and previous facility procedures. The facility's policies on abuse, neglect, and exploitation prevention, as well as recognizing signs of abuse or neglect, were not followed in this case. The policies clearly state that incidents involving suicidal ideation should be reported promptly. Additionally, guidance from the HHSC Long-Term Care Regulatory Provider Letter outlines the requirement to report such incidents immediately, but the facility failed to comply with these guidelines, resulting in a deficiency.
Failure to Investigate Resident's Suicide Attempt
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident involving a resident who attempted suicide. The resident, a male with dementia, depression, and anxiety, was admitted to the facility and later discharged to an acute care hospital. The resident had a history of moderately severe depression and expressed suicidal ideation. On the date of the incident, the resident attempted suicide by using a shirt fashioned as a noose. Despite this serious event, there was no evidence of a thorough investigation or documentation of the incident in the facility's records. Interviews with facility staff revealed inconsistencies in the reporting of the incident. The administrator was informed of the incident by a nurse, but discrepancies in the report led to the decision not to investigate further. The charge nurse who responded to the incident did not observe any physical signs of a suicide attempt on the resident, which contributed to the lack of investigation. However, the local hospital confirmed the resident's admission for a suicide attempt, and the resident himself confirmed the attempt. The facility's policies require the identification, investigation, and reporting of all possible incidents of abuse, neglect, or mistreatment. Despite these policies, the administrator chose not to report the incident, citing previous procedures followed before her employment. This decision was made without a thorough investigation, potentially placing residents at risk of incidents not being properly addressed.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 44% error rate based on 11 errors out of 25 opportunities. This deficiency involved a resident who did not receive their medications as scheduled. The medications, which included treatments for high blood pressure, mood disorders, and other conditions, were administered over an hour and a half late. This delay in administration could potentially affect the therapeutic outcomes for the resident. The resident involved was a male with a history of paranoid schizophrenia, atherosclerotic heart disease, peripheral vascular disease, localized edema, and constipation. He was cognitively intact, as indicated by a BIMS score of 15. The medications scheduled for 7:00 a.m. included Amlodipine, Buspirone, Calcium-Vitamin D, Clonidine, Docusate Sodium, Divalproex Sodium, Furosemide, Metoprolol Tartrate, a multivitamin, a sodium supplement, and Spironolactone. These medications were administered late, which was confirmed by the CMA responsible for the administration. The CMA reported starting her shift at 6:00 a.m. and began passing medications at 6:30 a.m. daily. Due to the number of residents and the schedule, she consistently administered medications late, particularly on F-hall. Although she reported the issue to shift nurses, she did not inform the ADONs, the prior DON, or the administrator. The facility's policies did not address timeliness in medication administration, and the MD consulted did not express concerns about the side effects or interactions due to the delay.
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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