San Antonio West Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 636 Cupples Rd, San Antonio, Texas 78237
- CMS Provider Number
- 675002
- Inspections on file
- 51
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 35 (1 serious)
Citation history
Health deficiencies cited at San Antonio West Nursing And Rehabilitation during CMS and state inspections, most recent first.
A CNA opened a room door during personal care, exposing a cognitively impaired, fully dependent resident who was lying in the bed closest to the door wearing only a brief and connected to a G-tube. The privacy curtain had been pulled but did not cover the foot of the bed, leaving the resident visible to anyone passing by while the CNA sought assistance with turning the resident, who was stiffer than usual and had hemiplegia. The DON confirmed staff are expected to ensure privacy during care and that exposing a resident in this manner violates privacy, contrary to facility policy requiring protection of bodily privacy during personal care and treatment.
A resident with paranoid schizophrenia and anxiety, who required substantial assistance with personal hygiene and had a physician’s order for podiatry care, was not placed on the facility’s podiatry schedule and had not seen a podiatrist since admission. Surveyors observed toenails about 1/2 inch past the nailbeds with very thick great toenails; the resident reported needing them cut and that a CNA had been unable to clip them due to thickness. An LVN acknowledged the long, thick toenails but had not previously noted or documented the need for referral, and the DON stated that long toenails were not documented on weekly skin sheets and that staff were expected to verbally notify the social worker instead. The social worker confirmed the resident was not on the recent podiatry list, despite a facility policy requiring staff to refer identified foot care needs so the social worker could arrange podiatry services.
A resident with severe cognitive impairment, hemiplegia, and a G-tube was on Enhanced Barrier Precautions (EBP) requiring staff to don gown and gloves for high-contact personal care. An observed CNA exited the resident’s room after providing peri-care without wearing a gown, mask, or gloves, despite an EBP sign on the door instructing use of PPE. The CNA reported there was no PPE in the room or nearby caddies and admitted she did not notify nursing staff or seek PPE from other areas. Subsequent observations showed PPE was available in the unit supply closet, and interviews with HR/central supply, the ADON (infection preventionist), and the DON confirmed that PPE was ordered weekly, stored on the hall, and that floor staff and resident ambassadors were responsible for restocking door caddies for residents on EBP, in accordance with the facility’s written EBP policy.
A resident with psychiatric diagnoses but intact cognition, who had been evaluated as safe to smoke independently and educated on the facility smoking policy, was observed smoking in a front patio area instead of the designated smoking area. Staff were seen entering and exiting without intervening, despite a care plan goal to prevent smoking-related accidents and observe for unsafe smoking behaviors. The DON acknowledged prior awareness that this resident did not always follow the smoking policy and confirmed that smoking was permitted only in the designated outdoor area equipped with safety devices.
The facility failed to develop and update comprehensive, person-centered care plans after multiple resident-to-resident physical altercations. In several cases, a resident physically assaulted a roommate or another resident, or a resident experienced physical aggression from another resident, as documented in progress notes and incident reports. Although IDT meetings were held and new behavioral interventions such as frequent checks and psych referrals were identified, these behaviors and interventions were not incorporated into the affected residents’ care plans. The SW and MDS LVN confirmed that behavior-related care plans were missing, contrary to facility policy requiring care plans to include identified problems, risk factors, measurable objectives, and timeframes.
A resident with severe cognitive impairment and multiple medical conditions had dementia with anxiety documented as an active problem in a physician progress note, but this diagnosis was not included on the resident’s electronic medical diagnosis list. The resident was unable to report his own medical problems due to low cognitive function. The DON confirmed that both she and the primary care physician recognized dementia with anxiety as an active diagnosis, acknowledged that the electronic list was inaccurate, and stated she was responsible for ensuring accurate diagnosis lists, despite facility policy requiring complete documentation of changes in medical condition.
A resident who was readmitted with a Foley catheter did not have corresponding catheter care orders in the administration record, despite receiving care such as cleaning and bag changes. Staff interviews and record reviews confirmed that while care was provided, the lack of proper orders prevented accurate documentation in the medical record, resulting in incomplete clinical records.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room after damaging a privacy curtain, but the guardian was not notified in writing or given the reason for the change. Staff believed the move was temporary and did not follow facility policy requiring notification and consent from the resident's representative.
A resident with severe cognitive impairment and a history of wandering exited the facility, resulting in police intervention. Staff were unable to redirect the resident, and emergency contacts were not notified of the incident until days later, learning about it through social media instead of from the facility. Facility policy required prompt notification of significant changes, but this was not followed, and there was no documentation of timely communication.
Two residents' care plans were not updated by the interdisciplinary team after significant behavioral changes, including repeated safety-impacting behaviors and an episode of suicidal ideation. Staff and administrative interviews confirmed that these behaviors were known but not reflected in the care plans, contrary to facility policy.
A resident with complex medical needs, including dysphagia and reliance on G-tube feedings, was repeatedly served regular textured foods instead of the prescribed pureed diet with thickened liquids. Staff interviews and documentation revealed confusion about dietary orders, lack of supervision during meals, and failure to follow care plans, resulting in the resident receiving food inconsistent with her assessed needs.
A resident with multiple pressure ulcers and a history of refusing wound care was found with live maggots in a stage 3 heel wound after refusing care for at least a day. Staff observed that the resident often spent time outdoors and that a window screen in the room was not fully adjusted, potentially allowing flies to enter. Housekeeping did not clean the room or change linens the night the maggots were discovered, and pest control logs showed no prior issues. The facility's pest control policy was not effectively implemented, leading to this deficiency.
A resident with multiple pressure ulcers did not receive timely wound care for several wounds due to missing treatment orders and incomplete documentation. The resident, who was cognitively intact but frequently refused care and spent extended periods outside, had maggots develop in a wound after wound care was missed. Staff interviews and record reviews confirmed that wound assessments and documentation were not consistently completed as required by facility policy.
A resident with a below-the-knee amputation and multiple health conditions did not have wound care treatments properly documented in the medical record on several occasions, despite physician orders. Staff interviews revealed that wound care was sometimes performed by different nurses, and documentation was missed, making it unclear if care was provided as required.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
The facility failed to maintain complete food temperature logs for multiple meals over several days, with missing documentation for breakfast, lunch, and dinner. The Food Service Supervisor could not explain the missing records, and the Dietician noted the deficiency in the Sanitation Report, resulting in an unsatisfactory rating. The facility also lacked a policy requiring daily documentation of food temperatures for each meal prepared.
The facility failed to keep the kitchen steam table in safe working order, resulting in hot foods being served at unsafe temperatures and, at times, cold to residents. Staff attempted to compensate by using hot water and holding food on the stove, but the steam table remained non-operational for several days. The facility lacked a policy for maintaining essential equipment, and no foodborne illnesses were reported during this period.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
Surveyors found that the kitchen had two overhead ceiling light covers with dead brown insects and a dishwashing area vent covered in a black substance. Staff interviews confirmed awareness of these sanitation issues, and facility policies requiring cleanliness were not followed.
A resident with significant medical needs did not have working bedside or overhead lights in their room for at least 30 days, despite multiple complaints to staff. The issue persisted due to the absence of a maintenance director, lack of effective communication, and missing work order documentation. Staff confirmed the lights were necessary for safe care and resident comfort, and the deficiency led to a diminished quality of life for the resident.
In a memory care unit, inadequate supervision led to repeated incidents of resident-to-resident aggression. A resident with severe cognitive impairment and a history of wandering was physically abused by two other residents with known aggressive behaviors. The unit was often staffed by only one CNA, with the nurse assigned to multiple units, leaving residents unsupervised at times.
The facility failed to treat residents with respect and dignity during meal service. One resident consistently received her meal after her tablemate, causing dissatisfaction. Another resident received a burnt chicken patty instead of the fried chicken listed on the menu, without a substitution log. The absence of knives made it difficult for residents to eat comfortably, highlighting a lack of consideration for their dining experience.
The facility failed to provide a structured activity program tailored to residents' needs and preferences, as several residents were observed without engagement in activities despite their care plans. A resident with cognitive impairment organized some activities due to the absence of a full-time Activity Director. The activity calendar did not match actual activities, and a resident was unable to watch TV due to a non-functioning remote.
The facility failed to maintain a full-time Activity Director since November 2024, resulting in unstructured and inconsistent activities for residents. A PRN Activity Director managed activities sporadically, leading residents to organize their own activities. The Operations Manager acknowledged the absence and was in the process of hiring a new director.
The facility failed to provide necessary treatment for residents with pressure ulcers. A resident with a heel ulcer was not observed with offloading boots, despite orders for their use. Another resident at risk for ulcers was found without heel protectors, and a third resident requiring repositioning every two hours was not repositioned as needed. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to care plans and facility policies.
A facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate for a resident. Medications crucial for managing high blood pressure and swelling were administered late by Medication Aide E, who did not report the delays to the DON. The facility lacked a policy for timely medication administration.
A facility failed to properly label and store medications, leaving a medication cart unlocked and unsupervised, and storing expired insulins for three residents. An LVN left the cart unattended, and expired insulins were found in the cart, compromising resident safety and medication efficacy.
The facility failed to maintain food safety standards, with unlabeled food items lacking discard dates, missing entries in temperature and dishwashing logs, and a dietary aide not adhering to dress code policies. These deficiencies could lead to food-borne illnesses, as acknowledged by the CDM and RD.
The facility failed to adhere to infection prevention protocols, as evidenced by staff not using appropriate PPE for residents requiring Enhanced Barrier Precautions. A resident with a UTI and another with a gastric tube were involved in incidents where staff either wore insufficient PPE or none at all, despite clear signage and available supplies.
The facility's secured backyard and smoking patio area had deficiencies, including a detached chain link fence and improper use of trash cans, posing risks for resident elopement and fire hazards. Residents with cognitive impairments and behavioral issues were observed in the area. Staff interviews revealed a lack of awareness and oversight regarding these issues, and the facility failed to adhere to its smoking policy.
A facility failed to provide adequate pharmaceutical services, resulting in late medication administration and expired insulin storage. Medications were administered late to several residents with various conditions, and expired insulins were found unrefrigerated and unlabeled. The facility's policies on medication administration and storage were not followed, leading to these deficiencies.
The facility failed to maintain resident privacy and confidentiality due to two incidents involving LVNs. One LVN entered residents' rooms without knocking, while another left a computer screen open with a resident's personal information visible. These actions violated the facility's policies on privacy and confidentiality.
The facility failed to maintain adequate lighting in the dining room, affecting two residents with complex medical conditions. The malfunctioning fluorescent lamps resulted in dim lighting, causing discomfort and dissatisfaction. Despite attempts to fix the issue, the problem persisted over several days, impacting the residents' ability to see their food and contributing to feelings of isolation and depression.
A facility failed to ensure a comprehensive person-centered care plan for a resident, resulting in a discrepancy between the resident's documented DNR status and their expressed wish to be a Full Code. The inconsistency was confirmed by the social worker, who noted the need to verify and update the resident's code status during assessments.
A resident with a history of cognitive deficits and elopement risk was able to exit through a door without triggering the wander guard alarm, as the device was not functioning properly. Despite staff presence, the malfunction went unnoticed until the survey. The wander guard was supposed to be checked daily, but it was not functioning during the survey period, and the exact date of failure was unknown.
A facility failed to maintain a resident's nutritional status, resulting in significant weight loss. Despite the care plan requiring weekly weights and nutritional assessments, these were not conducted, leading to a 10-pound weight loss over one month. Interviews revealed that staff were aware of the weight loss but did not implement timely interventions, contrary to facility policy.
The facility failed to follow prescribed dietary menus for residents on soft bite-sized and minced moist diets, serving a full pimento cheese sandwich and non-pureed tomato basil soup instead of the required textures. Staff interviews revealed a lack of adherence to dietary guidelines and insufficient knowledge of diet preparation, posing a choking hazard to residents.
Two residents identified as elopement risks managed to leave the facility despite interventions such as wander guards and structured activities. One resident, with vascular dementia, was found at a bus station, while another, with Alzheimer's, was found at a church suffering from heat exhaustion. The facility's policies on monitoring and responding to alarms were not effectively implemented, leading to these incidents.
The facility failed to appoint a licensed administrator within the required timeframe after terminating the previous administrator. Employee B, who was not licensed, served as the administrator for 39 days. Although she was in the process of obtaining her NHA license, she was not yet licensed at the time of her appointment. Administrator C, a licensed administrator from another facility, provided oversight only once or twice a week. This situation could potentially decrease the quality of care provided to residents.
A facility failed to document a thorough investigation of a resident-to-resident altercation where a resident with a history of behavioral issues threw a cup at another resident during an argument. The incident was not properly investigated by the former administrator, and the current AIT could not locate the necessary report. This lack of documentation and investigation could place residents at risk for further abuse.
A facility failed to conduct proper pre- and post-dialysis assessments for a resident, as required by professional standards. The resident did not receive complete vital sign assessments before leaving for dialysis on eight occasions and after returning on nine occasions. Interviews with the DON and an RN highlighted the importance of these assessments to ensure resident stability, but the DON was unaware that previous dates' assessments were used. Attempts to interview the responsible LVN were unsuccessful.
The facility failed to maintain proper infection control practices, as observed during skin assessments and wound care for multiple residents. An LPN consistently washed hands for less than the recommended duration and did not allow alcohol-based hand rub to dry before donning gloves, increasing the risk of infection transmission. Interviews with staff revealed a misunderstanding of proper hand hygiene procedures, despite existing guidelines.
A resident with diabetes and end-stage renal disease developed an unstageable pressure ulcer due to the facility's failure to notify the wound care physician and family of significant changes in the wound. Despite having a care plan, the facility did not adhere to interventions, resulting in the wound progressing to a severe state. Interviews revealed a lack of documentation and communication, with the wound care physician unaware of the wound's deterioration until the resident was hospitalized.
A resident with multiple medical conditions developed an unstageable pressure ulcer due to inadequate care and communication failures at the facility. Despite having a care plan, the facility did not consistently implement interventions or notify physicians of significant wound changes. The resident's condition worsened, leading to hospitalization with severe wound complications.
A facility failed to follow a doctor's orders for a resident with a feeding tube, as an LPN did not administer the prescribed 100 mL water flush before a bolus feeding. The resident, with a history of dysphagia and dementia, was at risk of not receiving proper hydration. The LPN admitted to the oversight, which was against the facility's policy requiring water flushes to maintain tube patency.
An LPN failed to administer a prescribed 100ml water flush before giving a bolus feeding to a resident with dysphagia and dementia, as observed during an interview and observation session. The resident's medical records indicated a need for enteral feeding, and the facility's policy required flushing the tube with water before feeding, which was not followed.
A resident with severe cognitive impairment and multiple medical conditions developed a hematoma on the back of the head, which was not promptly reported to the physician. The bump was discovered by rehabilitation staff and reported to the assigned nurse, who did not notify the physician, believing it was related to a previous injury. The physician was not informed until the following day, leading to a delay in medical treatment.
A facility failed to administer Keppra, a seizure medication, to a resident in a timely manner, exceeding the medication window by 1 hour and 31 minutes. The resident, with a history of epilepsy, had previously complained about not receiving his medication on time. The DON confirmed the delay was caused by an agency nurse and acknowledged the importance of timely administration. The facility had not been actively monitoring medication timeliness prior to the surveyor's intervention.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain personal privacy during personal care for one resident when a CNA opened the resident’s door while he was lying in bed wearing only a brief. The resident had been admitted with malnutrition, cerebral infarction due to small artery occlusion or stenosis, dysphagia following cerebral infarction, a gastrostomy for enteral feeding, and a cognitive communication deficit. His admission MDS showed he was severely cognitively impaired, totally dependent for all ADLs including toileting and personal hygiene, and had a feeding tube. His care plan documented impaired communication related to CVA with aphasia, cognitive communication deficit, impaired physical functioning, debility/weakness, hemiplegia/hemiparesis, neurological disease, prolonged hospitalization, lack of coordination, and abnormalities of gait and mobility, and that he required one to two persons for toileting and hygiene, as well as enteral tube feeding for oropharyngeal dysphagia and failure to thrive. During observation, the CNA exited the resident’s room and opened the door, exposing the resident in bed closest to the door. Although the privacy curtain was pulled, it did not extend around the foot of the bed, leaving the resident visible while wearing only a brief and connected to a G-tube. The CNA reported she opened the door to get help from another CNA because the resident, normally a one-person assist, was stiffer than usual and had paralysis on his left side, and she needed assistance to turn him to secure his brief. She stated she typically pulled the privacy curtain to the edge of the bed and never all the way around because it was not long enough, and in this instance did not draw it to cover the foot of the bed closest to the door to avoid exposing the resident to his roommate. The resident did not engage in conversation during an attempted interview and did not speak. The DON stated staff should ensure privacy during care and that exposing a resident during care would be a violation of privacy and could cause embarrassment. Facility policy on Quality of Life – Dignity required staff to promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Provide Ordered Podiatry Care and Foot Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and podiatry services in accordance with professional standards and its own policy for a resident who required assistance with personal hygiene. The resident was admitted with paranoid schizophrenia and generalized anxiety and had a quarterly MDS showing a BIMS score of 13/15, indicating no cognitive impairment, but a need for substantial to maximum assistance with personal hygiene. The resident had a physician’s order for podiatry care, and a local podiatry group was providing services to multiple residents in the facility; however, the resident’s name did not appear on the podiatry schedule. On observation, the resident’s toenails were approximately 1/2 inch past the nailbeds, with very thick great toenails, and the resident reported needing them cut, stating that a CNA had tried to clip them but they were too thick and that he preferred podiatry to do it. He also stated he had not seen a podiatrist since admission. The charge nurse (LVN) acknowledged during observation that the resident’s toenails were long and needed cutting and that the great toenails were very thick, but she stated she had not noticed the length of his toenails before that day and that there was nothing in the progress notes indicating a need for podiatry referral. The DON stated that staff would not document the condition of long toenails on weekly skin sheets and that she did not necessarily require staff to document the need for podiatry care in a progress note, instead expecting staff to verbally inform the social worker so a referral could be made. The social worker reported that any staff could notify her of the need for podiatry care and that review of the last podiatry list showed the resident had not been seen. The facility’s undated “Podiatry Services” policy stated that residents requiring foot care with complicating conditions would be referred to qualified professionals and that employees should refer identified foot care needs to the social worker, who would assist with appointments and transportation. Despite these orders and policies, there was no documented or acted-upon referral for this resident’s podiatry care, resulting in prolonged overgrown and thick toenails.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP). The resident was admitted with multiple diagnoses including malnutrition, cerebral infarction with resulting dysphagia, cognitive communication deficit, hemiplegia/hemiparesis, and required a feeding tube. The admission MDS showed the resident was severely cognitively impaired and totally dependent for all ADLs, including toileting and personal hygiene. The care plan documented that the resident had impaired communication related to CVA and other neurological and functional deficits, required one to two persons for toileting and hygiene, and was on EBP due to an indwelling medical device, with an intervention directing staff to don gown and gloves during high-contact personal care activities. On the survey date, a CNA exited the resident’s room after providing peri-care and was observed not wearing gloves, a mask, or a gown, despite an EBP sign posted at the door instructing staff to wear gloves, gown, and mask for high-contact personal care. The resident was observed in bed wearing a brief and connected to a G-tube. In interview, the CNA stated she had been changing the resident and acknowledged she was not wearing PPE. She reported there was no PPE in the room, in the caddy on the door, or in nearby door caddies, and admitted she did not inform any nurse or look for PPE on other halls or in the storage closet. She further stated she should have been wearing PPE while providing direct care and because the resident had a PEG-tube. Additional interviews and observations showed that HR/Central Supply staff had been ordering PPE weekly for about two years, with deliveries the next day, and that there was no central storage room but supply closets on three halls, including the resident’s hall. Observation of the supply closet on that hall revealed available PPE, including gowns, masks, and gloves. HR staff stated that floor staff and resident ambassadors were responsible for restocking PPE caddies on doors of residents on EBP. The ADON, who served as the infection preventionist, reported she had recently restocked PPE caddies after the DON noted they were low, and she acknowledged some caddies had been empty or had only a few gowns. The DON stated that residents were placed on EBP for indwelling medical devices or open wounds, that signs and PPE caddies were placed at their doors, and that staff were expected to wear gloves and gowns to minimize infection spread. The facility’s written EBP policy required gowns and gloves to be made available immediately near or outside the resident’s room for residents with wounds or indwelling medical devices, such as feeding tubes.
Failure to Enforce Designated Smoking Area Policy
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible by not enforcing its smoking policy for one resident. The resident had a history of bipolar disorder, depression, anxiety, schizophrenia, and post-traumatic stress disorder, but a BIMS score of 15/15 indicating no cognitive impairment. Her initial smoking evaluation documented no deficits preventing her from smoking independently and unsupervised, and staff had reviewed the smoking policy with her, with documentation that she verbalized understanding. Her care plan, revised on 6/16/25, identified her as a smoker with a goal to prevent accidents while smoking and to observe her for unsafe smoking behaviors or attempts to obtain smoking materials from outside sources. On observation, the resident was seen sitting in a wheelchair and smoking a cigarette in the front patio area, which was not the designated resident smoking area. When asked if she was allowed to smoke in the patio, she stated she was allowed to sign out and could smoke when she left the premises, and did not answer when asked again if she could smoke in the patio. Staff were observed entering and exiting the facility during this time, and none approached the resident. The DON reported awareness that the resident did not always follow the smoking policy and stated she had previously seen the resident smoking in the front patio. The DON confirmed that per policy the resident was only allowed to smoke in the designated smoking area at the back of the facility, where metal ashtrays, a fire blanket, and a fire extinguisher were located, and stated that all staff were responsible for monitoring and reporting residents who smoked outside designated areas because the resident could start a fire and other residents could get hurt.
Failure to Care Plan Resident-to-Resident Physical Altercations and Behavioral Risks
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents who were involved in resident-to-resident physical altercations. For one resident with schizophrenia, anxiety disorder, and mild cognitive impairment, progress notes documented that staff heard yelling and found him standing over his roommate with his fist raised, and the resident stated he had punched the roommate because of how the roommate spoke to him. Despite this documented incident of physical aggression, the resident’s care plan, with a target date of 01/07/2026, did not include any problem, goal, or interventions addressing his physical aggression toward another resident. Subsequent observations showed the resident interacting with others without aggressive behavior, and he denied the incident during interview, but the absence of a behavior-related care plan remained. Another resident with schizoaffective disorder, anxiety disorder, and paraplegia had a Significant Change MDS showing intact cognition and behavioral symptoms not directed toward others. A progress note documented that staff heard yelling, entered the room, and found this resident lying in bed with his roommate standing over him with a balled fist above his head; the resident reported being hit in the head, after which he was removed and assessed. His care plan, with a target date of 02/02/2026, did not include any care plan entry reflecting that he had experienced physical aggression from another resident. During interviews, the resident reported only one such incident, stated staff had moved him from the room, and denied having exhibited behaviors himself. The social worker and the MDS LVN both reviewed the care plans and confirmed they could not locate behavior-related care plan entries for either resident, despite stating that such incidents were typically care planned to provide interventions and alert staff to behaviors and safety concerns. Two additional residents with significant cognitive impairment and behavioral histories were also involved in resident-to-resident altercations without corresponding updates to their care plans. One resident with Alzheimer’s disease, diabetes, and depression had an incident report documenting that she hit another resident in a secure unit; staff separated them and assessed both residents with no injuries noted, and an IDT meeting the next day identified new interventions such as 15-minute checks and referral to psychiatric services. However, her comprehensive care plan did not reflect the altercation or the new interventions. Another resident with dementia, psychotic disorder, depression, and hallucinations had an incident report indicating he pulled another resident out of bed because the other resident was sleeping in his bed; staff separated and assessed them with no injuries noted, and an IDT meeting identified new interventions including 15-minute checks and psychiatric referral. His comprehensive care plan likewise did not include the altercation or the new interventions. The social worker acknowledged forgetting to create behavior care plans for these residents after the IDT meetings, despite facility policy requiring comprehensive, person-centered care plans that incorporate identified problem areas, risk factors, measurable objectives, and timeframes.
Inaccurate Electronic Diagnosis List for Resident With Dementia and Anxiety
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of complete and accurate medical records for one resident. The resident’s face sheet listed multiple diagnoses, including hyperlipidemia, cerebral infarction, encephalopathy, and hypertension. The admission MDS documented a BIMS score of 7/15, indicating severe cognitive impairment, and showed the resident required substantial/maximal assistance with most ADLs such as sit-to-stand, chair-to-bed, and toilet transfers. A physician progress note dated 12/01/2025 identified dementia with anxiety as one of the resident’s active medical problems. However, review of the resident’s electronic medical diagnoses list on 01/06/2026 showed that dementia with anxiety was not included as an active diagnosis. During observation, the resident was seen sitting in a wheelchair near the nursing station and was unable to state his medical problems due to low cognitive function. In an interview, the DON confirmed that the resident had dementia with anxiety, that the primary care physician had documented this diagnosis, and that the diagnosis was missing from the electronic medical diagnosis list. The DON acknowledged the inaccuracy and stated she was responsible for ensuring residents had accurate medical diagnosis lists. The facility’s “Charting and Documentation” policy required that all services and changes in a resident’s medical condition be documented in the medical record.
Failure to Maintain Accurate Foley Catheter Orders and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident who was readmitted from the hospital with a Foley catheter. Upon review, it was found that the resident's November administration orders did not include any orders for Foley catheter care, despite the resident having an indwelling catheter in place. The resident's care plan and physician order summary indicated the presence of a Foley catheter and outlined care interventions, but these were not reflected in the administration record, which is used by nursing staff to document care provided. Interviews with staff confirmed that the resident returned from the hospital with a Foley catheter and that care, such as cleaning the insertion site and changing the drainage bag, was being provided. However, staff also stated that there should have been specific orders for Foley catheter care in the administration record to ensure proper documentation and completion of required tasks. The Director of Nursing acknowledged that the Foley catheter order was entered into the electronic medical record but was not activated on the administration record, resulting in a lack of documentation for the care provided. Record reviews further showed that the facility had a policy requiring catheter care every shift and as needed, and that staff had received in-service training on Foley catheter care. Despite this, the absence of Foley catheter care orders in the administration record meant that the care provided was not properly documented, which could affect the accuracy and completeness of the resident's clinical records.
Failure to Notify Guardian of Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to a resident's guardian prior to moving the resident to a different room. The resident, an elderly male with diagnoses including vascular dementia, chronic obstructive pulmonary disease, and interstitial pulmonary disease, was rarely or never understood, had significant memory problems, and was severely impaired in daily decision making. The resident was at risk for injury due to wandering and resided in a secure unit. On the day of the room change, there was no documentation or notification to the resident's guardian regarding the reason for the move, nor was there any evidence of consent or the right to refuse being offered. Staff interviews revealed that the room change occurred after the resident pulled down a privacy curtain, damaging the curtain rail. Staff, including an LPN, HR, and the DON, believed the move was temporary and did not notify the guardian, as required by facility policy. The DON later confirmed that there was no documentation of guardian notification, and the guardian stated he did not recall being informed of the room change. Facility policy required prompt notification of the resident's representative when a room assignment change was needed, but this was not followed in this instance.
Failure to Notify Resident Representatives After Significant Behavioral Incident
Penalty
Summary
The facility failed to notify a resident's physician and representatives following a significant change in the resident's behavior, specifically an increase in exit-seeking behavior that resulted in police intervention. The resident, a male with diagnoses including schizoaffective disorder, type 2 diabetes mellitus, and dementia, had a documented history of wandering and was assessed as being at risk for elopement. On the night of the incident, the resident left the facility through a secured door, setting off an alarm, and was pursued by staff who were unable to redirect him. The situation escalated to the point where police were called, and the resident was physically restrained and returned to the facility by law enforcement. Despite the seriousness of the event, there was no documentation that the resident's emergency contacts were notified of the incident until several days later. Both emergency contacts reported learning about the incident through a family member who saw it on social media, rather than from the facility itself. Interviews with staff and administration confirmed that there was no immediate notification to the resident's representatives, and the facility's electronic medical record did not show any timely communication regarding the police intervention or the resident's attempted elopement. The facility's policy required prompt notification of the resident, physician, and representative in the event of significant changes in condition or incidents involving the resident. However, the Director of Nursing stated that the incident was not considered a change of condition due to the resident's history, and therefore, notification was not deemed necessary at the time. This lack of timely communication was confirmed by both the DON and the administrator, as well as by the absence of documentation in the resident's records.
Failure to Update Care Plans Following Behavioral Changes
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident with vascular dementia and severe cognitive impairment, the care plan did not address known behaviors such as stripping the bed and pulling down the privacy curtain, despite multiple incidents and staff awareness of these behaviors. Staff interviews confirmed that these behaviors had occurred more than once, and that the care plan had not been updated to reflect these safety-impacting actions. Another resident, diagnosed with schizoaffective disorder and major depressive disorder, experienced an episode of suicidal ideation, which resulted in her being sent to the emergency room for evaluation. Documentation and staff interviews revealed that this was the first such incident for this resident, and although she was receiving psychological services, her care plan was not updated to reflect the new behavior of suicidal ideation. The facility's policy required that such behavioral changes be care-planned, but this was not done following the incident. Record reviews and staff interviews indicated that the interdisciplinary team did not consistently update care plans to reflect significant changes in residents' behaviors or conditions. This lack of timely care plan revision could result in staff not having the necessary information to provide appropriate interventions, as documented in the facility's own policy and as acknowledged by administrative staff during interviews.
Failure to Provide Prescribed Therapeutic Diet and Food Texture
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's Disease, dysphagia, chronic respiratory failure, diabetes, and legal blindness, did not receive food prepared in accordance with her prescribed therapeutic diet. The resident's care plan and physician orders specified a mechanically altered, pureed diet with mildly thick liquids, and most of her nutrition was to be provided via G-tube feedings. Despite these orders, the resident was observed receiving regular textured foods, such as scrambled eggs, refried beans, and bread, on her breakfast tray. Staff interviews confirmed that the resident routinely received pleasure trays with regular textured foods, and there was confusion among dietary and nursing staff regarding the existence and appropriateness of orders for these pleasure trays. The facility failed to ensure that food was prepared and served in a form that met the resident's individual needs as outlined in her comprehensive assessment and care plan. Multiple staff members, including CNAs, LVNs, and the dietary manager, acknowledged that the resident required assistance to eat, could not use utensils independently, and should not have been given regular textured foods due to her swallowing difficulties and lack of dentures. The dietary manager and registered dietitian were unaware of any physician order for pleasure trays, and the registered dietitian minimized concerns about the risk of aspiration from the foods provided. Additionally, the resident's responsible representative and several staff members reported that the resident was not consistently supervised during meals, despite her need for assistance and risk of choking or aspiration. Documentation and interviews revealed ongoing issues with communication and adherence to dietary orders. The facility's policy required that diets be served according to physician orders and that staff check meal trays for compliance with diet cards, but this was not consistently followed. A grievance had previously been filed regarding the resident receiving non-compliant foods, and staff interviews indicated that concerns about the resident's diet and supervision during meals had been raised multiple times without resolution. The administrator confirmed there was no facility policy specifically addressing therapeutic diets, and was unaware that the resident was receiving pleasure trays at every meal.
Failure to Maintain Effective Pest Control Program Resulting in Maggot Infestation in Wound
Penalty
Summary
A deficiency occurred when the facility failed to maintain an effective pest control program, resulting in a resident being found with live maggots in a stage 3 pressure ulcer on the right heel. The resident, a 32-year-old male with multiple pressure ulcers, paraplegia, and a history of refusing wound care, was admitted with several wounds but no maggots present at admission. Over the course of his stay, the resident intermittently refused wound care, and on the day maggots were discovered, he had refused care for at least one day. Nursing staff observed maggots in the wound dressing and notified the physician, but the resident initially refused to be sent to the emergency room. Observations and interviews revealed that the resident often spent extended periods outdoors and sometimes refused wound care, which contributed to the wound's condition. Staff noted that the dressing was sometimes moist and that the resident's room had a window screen that was not fully adjusted, potentially allowing flies or gnats to enter, although no flies or gnats were observed at the time of inspection. Additionally, flies were observed in another resident's room, and staff reported that food debris sometimes attracted flies, but no infestation was documented. The facility's pest control logs indicated regular pest control visits, but no issues were noted prior to the incident. Housekeeping practices were found to be inconsistent, as the resident's room and linens were not cleaned or changed on the night the maggots were discovered due to the absence of housekeeping staff. Nursing staff did not recall whether the room was cleaned or linens changed that night. The Housekeeping Manager confirmed that deep cleaning and linen changes did not occur until the following afternoon. The facility's pest control policy required the building to be kept free of insects and rodents, but the lack of timely cleaning and environmental controls contributed to the deficiency.
Removal Plan
- Resident #1's wound was cleansed per wound protocol when maggots were discovered.
- Resident #1's room was cleaned and sanitized in accordance with the facility's cleaning and disinfection policy.
- A facility-wide environmental inspection was completed by the Maintenance Director to ensure all windows, screens, and entry points were intact and secure.
- Three additional fly zap lights were ordered and installed in B Hall Dining Room, C Hall Dining Room, and E Hall dining room.
- The effectiveness of the newly installed Zap Lights will be monitored utilizing the environmental checklist by the Housekeeping Supervisor and Maintenance Director or designee.
- The Pest Prevention Technician assisted the facility with the wipe down method in rooms of residents with treatment orders, entailing wiping down surfaces and walls.
- A comprehensive skin and wound audit was completed for all residents with pressure injuries to ensure no other residents were affected.
- All staff were in-serviced on the facility's Pest Control Program, including pest prevention, environmental inspection, and staff reporting.
- Training provided to all staff on the cleanliness of resident rooms to ensure rooms remain as free as possible of items that may attract pests, and on cleaning procedures in the event pests are identified.
- Housekeeping cart is available in E hall housekeeping closet for after-hour use.
- Pest control vendor visits increased and three additional fly lights installed in key areas.
- Maintenance initiated an environmental inspection log for all window seals, screens, and potential pest entry points.
- Environmental Services implemented a cleaning checklist focusing on food debris and sanitation in resident rooms and dining areas.
- Nurses received re-education on wound care refusal documentation, physician notification, and resident education procedures.
- The Quality Assessment and Assurance Committee will review the pest control log for any pest control issues, and the Admin/DON/designee will complete 5 observations.
- If any pest control issues or deficient practices are discovered, the Admin/DON/designee will provide additional training for staff, including pretest, inservice, post-test, and return demonstration.
- The results of the Admin/Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations.
- The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received necessary treatment and services consistent with professional standards of practice. Upon admission, the resident had nine wounds, including several stage 3 and stage 4 pressure ulcers and a deep tissue injury. Treatment orders for five of these wounds were not implemented for 12 to 13 days, and there was no documentation on the Treatment Administration Record (TAR) indicating whether wound care was provided to these wounds during that period. Additionally, weekly wound assessments were not completed for five of the nine wounds on a specified date, as required by the resident's care plan and facility policy. The resident was cognitively intact and frequently refused care, preferring to spend extended periods outside and declining to return indoors for wound care and medication administration. Nursing notes documented repeated refusals of wound care and medication, as well as the resident's noncompliance with recommended treatment. Despite these refusals, there was a lack of consistent documentation regarding whether wound care was attempted or provided, and treatment orders for several wounds were delayed. The facility's staff, including the treatment nurse and DON, acknowledged that the absence of timely treatment orders and incomplete documentation could result in wounds not being treated as required. The situation escalated when maggots were discovered in one of the resident's wounds, specifically the right heel, after a period of missed wound care. Interviews with staff confirmed that the resident's wounds were not always assessed or treated due to both the resident's refusals and lapses in staff follow-through with documentation and order entry. The facility's own wound care policy required verification of physician orders and documentation of wound care provided, which was not consistently followed in this case. The deficiency was further substantiated by the lack of admission treatment orders for several wounds and incomplete weekly wound assessments.
Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically by not documenting the completion of wound care treatments as ordered. The resident, a female with a below-the-knee amputation and multiple comorbidities including osteonecrosis, diabetes, atrial fibrillation, cirrhosis, and chronic kidney disease, was readmitted to the facility and required surgical wound care four times weekly. Observations and interviews revealed that the treatment administration record did not reflect completion of wound care on three specific dates, despite physician orders and the resident's care plan requiring these treatments. During interviews, staff indicated that wound care was typically performed by a designated wound care nurse, but on at least one occasion, another nurse provided the care and failed to document it. The Director of Nursing confirmed that the treatment administration record was not marked as completed on the specified dates and acknowledged that without this documentation, it could not be confirmed whether the care was provided. The resident herself reported that wound care was not always performed daily as expected.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Incomplete Food Temperature Documentation in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by incomplete food temperature logs for multiple meals over several days. Specifically, documentation was missing for lunch meals from 7/9/25 to 7/21/25 and 7/23/25 to 7/31/25, breakfast meals from 7/24/25 to 7/31/25, and dinner meals from 7/30/25 to 7/31/25. The Food Service Supervisor (FSS) confirmed the lack of documentation and was unable to provide an explanation for the missing records. The Dietician was also aware of the incomplete logs and noted the deficiency in the Sanitation Report, which resulted in an unsatisfactory rating for the facility's food service safety. Further review revealed that the facility did not have a policy on documenting food temperatures on a daily basis for each meal prepared. When requested by the surveyor, the Administrator was unable to provide such a policy during the survey period. The facility's existing Food Preparation and Service policy, dated 2001, referenced the 'danger zone' for food temperatures but did not address documentation requirements. These findings were based on observation, interview, and record review, and affected all residents who consumed meals from the kitchen during the period in question.
Failure to Maintain Safe Operation of Dietary Equipment
Penalty
Summary
The facility failed to maintain essential dietary equipment in safe operating condition, specifically the kitchen steam table, which was not functioning for several days. Staff attempted to compensate for the non-operational steam table by adding hot water to it and keeping food items in the oven or on the stove for longer periods. Despite these efforts, observations revealed that hot foods placed on the steam table quickly dropped to unsafe temperatures and were served cold to residents. Staff interviews confirmed that the steam table had been out of service since earlier in the week, and food was served cold as a result. The facility did not have a policy in place for maintaining essential equipment, including kitchen equipment, in operational condition, and no such policy was provided to the surveyor upon request. The dietician, upon learning of the equipment failure, recommended placing boiling water in the non-working steam table and holding hot foods on the stove or oven until serving. On subsequent observation, food was served directly from the stove top or placed in a roaster with hot water before plating, and food temperatures were within regulation at that time. Staff reported that if residents complained of cold food, a microwave was available for reheating. There were no reports of foodborne illness among residents during this period. The deficiency was identified through observation, staff and dietician interviews, and review of facility records and policies.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation and cleanliness in the kitchen area, as required by professional standards for food service safety. Specifically, two overhead ceiling light covers in the cooking area contained numerous dead brown insects, and the ceiling vent in the dishwashing area was covered with a black substance. These conditions were directly observed during a kitchen inspection. Interviews with facility staff, including the Administrator, DON (who also serves as the Infection Preventionist), Dietician, and Food Service Supervisor (FSS), confirmed awareness of the issues. The Administrator and DON acknowledged the presence of brown spots and a dirty vent, while the FSS admitted to not having checked the light fixtures prior to the survey but was aware of dust on the vent. The Dietician was not previously aware of these sanitation issues. Review of facility policies indicated that all food service areas should be kept clean, sanitary, and free from insects and debris, but these standards were not met at the time of the survey.
Failure to Maintain Functional Lighting in Resident Room
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not ensuring that the bedside and overhead lights in one resident's room were operational for at least 30 days. The affected resident, a 75-year-old male with peripheral vascular disease, chronic kidney disease, a left below-the-knee amputation, and diabetes, required total assistance for transfers and mobility and had moderate cognitive deficits. Observations confirmed that both the overhead and bedside lights in his room were not working, and the resident reported that the lights had been out for five months, impacting his ability to see at night and during care activities. He stated that he had complained to nursing staff but felt ignored. Interviews with staff, including the DON, Administrator, RN, and CNA, revealed that the issue had been reported but not addressed due to the absence of a maintenance director. The facility had been relying on maintenance support from a sister facility, and work orders were maintained manually, but the log could not be located. The interim Maintenance Director was unaware of the issue and had not received a work order. Staff acknowledged the importance of functional lighting for providing care and noted that the lack of lighting had not resulted in any reported negative outcomes, but it did diminish the resident's quality of life.
Inadequate Supervision Leads to Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically involving three residents in the Memory Care Unit (MCU). Resident #61, who has severe cognitive impairment and a history of wandering, was physically abused by Resident #83 and Resident #55 on multiple occasions. Resident #83, who also has severe cognitive impairment and a history of aggressive behavior, physically battered Resident #61 by punching him in the face, pulling his hair, and dragging him across the floor. This incident occurred when Resident #61 wandered into Resident #83's room. Additionally, Resident #61 was involved in altercations with Resident #55, who has severe cognitive impairment and a history of agitation and aggression. On separate occasions, Resident #61 was punched in the nose and face by Resident #55 after entering Resident #55's room. These incidents highlight the facility's failure to adequately supervise and separate residents with known aggressive behaviors and cognitive impairments. The facility's staffing practices contributed to the deficiency, as the MCU was often staffed by only one CNA, with the nurse assigned to multiple units, leaving residents unsupervised at times. This lack of adequate supervision and monitoring allowed for repeated incidents of resident-to-resident aggression, placing residents at risk for physical abuse.
Removal Plan
- Ensure a second team member is staffed in the memory care unit.
- Complete a 100% in-service for nursing staff on staffing requirements for the memory care unit and emergency procedures.
- Utilize walkie talkies for communication between the memory care unit and general population.
- Provide immediate education to all licensed/certified nursing staff on managing difficult behaviors, de-escalation strategies, and wandering/elopement.
- Educate all facility staff on the Abuse, Neglect, Exploitation or Misappropriation Prevention Program.
- Conduct all-staff meetings to address behavioral care, focusing on de-escalation, behavior management, wandering, dementia care, and activities.
- Evaluate the facility's staffing schedules and requirements for the memory care unit and general population.
- Provide access to behavioral health services for residents with increased behaviors.
- Complete Preferences for Activity and Leisure (PAL) Cards for all residents in the memory care unit.
- Develop and ensure an ongoing long-term monitoring and oversight system to review and address concerns related to deficient practices.
- Develop a short-term monitoring system for all areas of deficient practice identified.
- Monitor use of walkie talkies.
- Conduct monitoring to determine if compliance is being sustained.
- Ensure social services attend meetings to be aware of newly identified behaviors or concerns.
- Hold an Ad Hoc QAPI meeting to review and validate the plan of removal.
- Notify the facility's Medical Director of the Immediate Jeopardy tag.
- Ensure 2 CNAs are always staffed in the memory care unit.
- Actively hire and search for new staff members to be adequately staffed.
Failure to Ensure Dignified Meal Service
Penalty
Summary
The facility failed to ensure that all residents were treated with respect and dignity during meal service, as observed in the cases of two residents. One resident expressed frustration at consistently receiving her meal after her tablemate had finished eating, highlighting a lack of synchronized meal service at the table. This delay in serving meals at the same table led to feelings of dissatisfaction and disrespect. Additionally, the facility served a fried chicken patty instead of the fried chicken listed on the menu, without maintaining a substitution log or obtaining approval for the change, which further contributed to the residents' dissatisfaction. Another resident received a chicken patty that was burnt and difficult to cut, exacerbated by the absence of knives due to safety concerns. This resident struggled to cut the patty with a fork, and the lack of appropriate utensils made it challenging for residents to eat their meals comfortably. The facility's failure to provide the correct menu items and appropriate utensils, along with the lack of a substitution log, demonstrated a disregard for the residents' rights to a dignified dining experience.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs and preferences of its residents, as evidenced by the lack of an updated activity assessment and care plan for several residents. Resident #5, who was cognitively intact and expressed interest in various activities, was observed repeatedly lying in bed watching television without any engagement in other activities. Despite her care plan encouraging socialization and participation in activities, no staff were observed conducting in-room activities with her. Resident #22, who had mild cognitive impairment and a strong interest in group activities, reported that the facility had been without a full-time Activity Director for several months. She took it upon herself to organize some activities, such as calling bingo, but noted the lack of a structured program and limited vendor presence. Her care plan indicated a need for staff assistance in activities, yet the facility failed to provide a consistent and comprehensive activity program. Resident #45, who was severely cognitively impaired and dependent on staff for activities, was observed in bed without any music or television, contrary to her care plan which emphasized the importance of activities. Additionally, the activity calendar did not match the actual activities taking place, and Resident #79, who had moderate cognitive impairment, was unable to watch television due to a non-functioning remote, leaving him without his preferred activity. The facility's failure to maintain an updated activity program and assessments for these residents highlights a significant deficiency in meeting their psychosocial and recreational needs.
Lack of Full-Time Activity Director Leads to Unstructured Resident Activities
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. Since November 2024, the facility has not had a full-time Activity Director. The Operations Manager confirmed that they were in the process of hiring a new Activity Director, but in the meantime, the activities program was being managed by a PRN Activity Director who only came in as needed. This PRN Activity Director attempted to organize activities by calling vendors from home and visiting the facility when possible. However, this arrangement led to a lack of structured activities for the residents. Interviews with residents and staff revealed that the absence of a full-time Activity Director resulted in residents having to organize their own activities, such as bingo and watching TV, with occasional visits from vendors and church groups. The Resident Council expressed that they felt left in limbo without a dedicated Activity Director, and residents reported that the activities were not consistent or structured. The facility's job description for the Director of Activities outlined responsibilities that were not being fulfilled, such as planning, organizing, and directing a comprehensive program of activities to meet the residents' needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as observed in three cases. Resident #67, who had a pressure ulcer on her heel, was not observed with offloading boots during multiple observations, despite physician orders and care plans indicating their necessity for wound healing. The wound care nurse acknowledged the absence of the boots and emphasized their importance in preventing infection and worsening of the wound. Similarly, Resident #5, who was at risk for pressure ulcers and had a history of skin integrity issues, was found without heel protectors while in bed. A CNA admitted to not putting the heel protectors on after changing the resident, and the facility's administration recognized the need for staff education on the importance of such treatments. Resident #45, who required repositioning every two hours due to immobility and risk of pressure ulcers, was observed not being repositioned as per her care plan. Staff interviews confirmed the failure to reposition the resident, with the LVN expressing uncertainty about why the CNAs had not performed the task. The facility's policy on repositioning and pressure injury prevention was not adhered to, as evidenced by the observations and staff interviews.
Medication Administration Delays Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate for one resident. Medication Aide E administered medications to a resident with a significant delay. Specifically, the resident's doxazosin was administered 1 hour and 28 minutes late, while hydralazine, carvedilol, and furosemide were administered 58 minutes late. These medications were crucial for managing the resident's high blood pressure and swelling due to heart failure. The resident, who had a history of hypertensive chronic kidney disease with end-stage kidney disease, required timely medication administration to manage his condition effectively. During an observation, Medication Aide E acknowledged being late in administering medications and had not reported this to her direct supervisor, the Director of Nursing (DON). The DON stated that the expectation was for medications to be administered within 1 hour of the prescribed time and that any potential late administration should have been reported. However, Medication Aide E did not report the late administration. Additionally, the facility did not provide a policy for timely medication administration, only a policy titled Documentation of Medication Administration, which did not address the timeliness of medication administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a survey. On one occasion, a Licensed Vocational Nurse (LVN) left a medication cart unsupervised and unlocked for seven minutes while attending to a resident, leaving the cart out of her line of sight. This lapse in security could potentially allow unauthorized access to medications, posing a risk to resident safety. Additionally, the facility was found to have expired insulins stored in the medication cart for three residents. Resident #5's liraglutide pen was expired by 19 days and stored unrefrigerated. Resident #81 had three vials of insulin lispro, which were unlabeled with expiration dates and expired by up to 59 days. Resident #85's insulin lispro vial was expired by 45 days. These expired medications were available for administration, which could compromise the therapeutic effects intended for the residents. The facility's policy on medication labeling and storage was not adhered to, as evidenced by the improper storage and labeling of medications. The Director of Nursing (DON) confirmed that the expectation was for medication carts to be locked when unattended, and it was the responsibility of individual nurses to ensure this. The facility's policy also required medications to be stored under proper temperature controls and labeled with necessary information, including expiration dates, which was not followed in these instances.
Food Safety and Documentation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was found that two bags of salad and a bag of ham in the refrigerator were not properly labeled with discard dates. The Certified Dietary Manager (CDM) admitted to being unaware of who was responsible for this oversight and subsequently discarded the items to ensure food safety. This lack of proper labeling could potentially lead to food-borne illnesses among residents consuming meals prepared in the facility. Additionally, the facility's documentation for the Three Compartment Sink Log and Milk Refrigerator Temperature Log showed no recorded entries for several days in January. The CDM acknowledged the importance of these logs in maintaining food safety and expressed concern over the missing entries, which could compromise the effectiveness of dishwashing and temperature control processes. The absence of these records indicates a failure to consistently monitor and document critical food safety measures. Furthermore, a dietary aide was observed with a facial piercing and improperly covered hair while working in the kitchen, which violates the facility's dress code policy. The CDM recognized the need for staff training on dress code compliance to prevent contamination risks. The Registered Dietitian (RD) emphasized the importance of labeling and dating food products and maintaining accurate logs to prevent food-borne illnesses, aligning with the facility's policies and the U.S. Food and Drug Administration's Food Code.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with Enhanced Barrier Precautions (EBP) for residents requiring such measures. Resident #69, diagnosed with a urinary tract infection (UTI) and assessed with the need for EBP, was involved in two separate incidents. On one occasion, the Director of Nursing (DON) attempted to administer intravenous access while wearing only one glove as personal protective equipment (PPE), despite the presence of EBP signage and PPE supplies at the room entry. In another instance, Medication Aide E administered medication to Resident #69 without wearing any PPE, acknowledging the oversight despite the clear requirement for EBP. Additionally, Resident #45, who was prescribed a gastric tube and assessed with a need for EBP, was involved in an incident where Licensed Vocational Nurse J administered medications via the g-tube while wearing gloves but not a gown, contrary to the EBP protocol. The room had appropriate EBP signage and PPE supplies, yet the nurse admitted to forgetting to wear the gown. These failures in adhering to infection control protocols could potentially lead to cross-contamination and infections among residents.
Deficiencies in Secured Backyard and Smoking Patio Area
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the secured backyard and smoking patio area. Observations from January 26 to January 30, 2025, revealed a section of chain link fencing was detached from the top rail and leaning down, posing a potential risk for resident elopement. Additionally, several red fire-rated trash cans designated for cigarette butts were filled with non-cigarette butt trash, and a regular trash can contained both trash and cigarette butts, creating a potential fire hazard. Resident #24, who was assessed as an elopement and wander risk, was observed in the smoking patio area. This resident had a history of tobacco use, lack of coordination, and muscle weakness, and was supported for safety with a wander guard anklet. The care plan for Resident #24 included monitoring for elopement and smoking-related injuries. Resident #55, with severe cognitive impairment and a history of behavioral disturbances, was also present in the area. Resident #83, with severely impaired cognition and a history of behavioral symptoms, was another resident observed in the smoking patio. Interviews with facility staff, including the Admissions Coordinator and the Operations Manager, revealed a lack of awareness and oversight regarding the condition of the secured backyard and smoking patio. The facility's smoking policy required metal containers with self-closing covers in smoking areas and specified that ashtrays should be emptied only into designated receptacles. However, the facility failed to adhere to these policies, as evidenced by the improper use of trash cans and the detached fencing, which were not addressed by the staff.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by the late administration of medications to several residents. Medication Aide E was observed administering medications late to multiple residents, including those with conditions such as vascular dementia, seizures, hypertension, schizophrenia, epilepsy, GERD, constipation, muscle weakness, diabetes, and urinary tract infections. The medications were administered beyond the prescribed time window, with delays ranging from 20 minutes to nearly two hours. This failure to administer medications on time was acknowledged by Medication Aide E, who did not report the delays to her direct supervisor, the Director of Nursing (DON). Additionally, the facility was found to have expired insulins stored in the medication cart, which were available for administration to residents. Insulin vials and pen injectors for residents with diabetes were stored unrefrigerated and were past their expiration dates, with some being expired by as much as 59 days. The insulins were not labeled with expiration dates, and the staff could not confirm the intended recipients or the dates the vials were unrefrigerated. This practice placed residents at risk of not receiving the therapeutic effects of their prescribed medications. The facility's policies on medication administration and storage were not adequately followed, as evidenced by the lack of timely administration and improper storage of medications. The DON stated that medications should be administered within one hour of the prescribed time and that expired or unlabeled insulins should be discarded. However, the facility did not provide a policy for timely medication administration, and the existing policies on medication labeling and storage were not adhered to, leading to the deficiencies observed.
Privacy and Confidentiality Breach by LVNs
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as evidenced by two specific incidents involving Licensed Vocational Nurses (LVNs). In the first incident, LVN J was observed entering two different residents' rooms without knocking, which is a violation of the facility's policy that requires staff to knock and request permission before entering a resident's room. During an interview, LVN J acknowledged the oversight and admitted to not knocking on the doors before entering. In the second incident, LVN Z left a computer screen open, displaying a resident's personal information, including their picture, name, vitals, age, ID number, and medications. This occurred while LVN Z was busy checking resident lunch trays, and she admitted to forgetting to turn off the monitor. The facility's policy on confidentiality mandates that access to resident personal and medical records be limited to authorized staff, and this incident represents a breach of that policy.
Inadequate Lighting in Dining Room Affects Residents' Well-being
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, specifically in the dining room area where adequate lighting was not maintained. Observations revealed that several fluorescent lamps and fixtures were malfunctioning, resulting in dim lighting conditions. This issue persisted over several days, from January 26 to January 30, 2025, despite attempts by staff to rectify the situation. The malfunctioning lights were noted to flicker and intermittently fail, causing discomfort and dissatisfaction among the residents. Two residents, both with intact cognition and complex medical conditions, expressed their dissatisfaction with the lighting conditions. One resident, who had a history of dysphagia, anxiety, and bipolar disorder, reported feeling lonely and isolated, while the other resident, diagnosed with bilateral cataracts and depression, expressed feelings of being down due to the dim lighting. Both residents indicated that the poor lighting affected their ability to see their food during meals, which could potentially impact their nutritional intake and overall well-being.
Discrepancy in Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which is consistent with the resident's rights and includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, there was a discrepancy between the resident's code status as documented in the care plan and the resident's wishes. The resident's care plan indicated a Do Not Resuscitate (DNR) status, while the resident expressed a desire to be a Full Code, and the physician orders also reflected a Full Code status. The deficiency was identified through interviews and record reviews, revealing that the resident's care plan did not match the physician orders or the resident's stated wishes. The social worker confirmed the inconsistency and acknowledged the need to verify and update the resident's code status upon admission and during quarterly assessments. This failure could potentially affect the resident by not having their end-of-life preferences met, as the care plan did not accurately reflect the resident's current wishes and medical orders.
Failure to Ensure Functioning Wander Guard for Resident
Penalty
Summary
The facility failed to ensure that Resident #84's wander guard was functioning properly, which is a device intended to prevent elopement. The resident, who has a history of falling, cognitive communication deficit, and is considered an elopement risk, was observed exiting through a door without triggering the alarm. This incident occurred despite the presence of staff members both inside and outside the exit door. The wander guard was supposed to be checked daily, but it was found not to be working during the survey period. Interviews with staff, including the Director of Nursing (DON) and a Certified Nursing Assistant (CNA), revealed that the wander guard was not functioning between specific dates, but the exact date it stopped working was unknown. The DON admitted that the wander guard might have stopped working overnight and emphasized the importance of these devices in keeping residents safe. The CNA confirmed that the wander guard was not checked properly, as it was not functioning when tested at multiple doors. The facility's documentation indicated that wander guards should be checked for proper function and documented in the electronic medical administration record (eMAR).
Failure to Maintain Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to a significant weight loss. The resident, who had a history of depression, vitamin deficiencies, dysphagia, and a stage 3 pressure ulcer, experienced a weight loss of 11.9 pounds in six days and 10 pounds over one month. Despite the care plan indicating the need for weekly weights and nutritional assessments, the facility did not conduct these assessments in December 2024 or January 2025. The resident expressed a desire to maintain a weight of 205 pounds, but the facility did not follow through with the necessary interventions to address the weight loss. Interviews revealed that the facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Dietitian (RD), were aware of the resident's weight loss but did not implement timely nutritional interventions. The RD acknowledged the significant weight loss and the need for extra protein and calories for wound healing but admitted that no significant weight note was made. The facility's policy required weight assessments and interventions for significant weight loss, but these were not adequately followed, resulting in a lack of appropriate care planning and intervention for the resident's nutritional needs.
Failure to Follow Prescribed Diet Textures
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents on soft bite-sized and minced moist diets during a dinner meal. Specifically, the menu for the dinner included Tomato Basil Soup and Pimento Cheese Sandwich, which required specific preparation methods to meet the dietary needs of residents. However, the facility served a full pimento cheese sandwich and non-pureed tomato basil soup, contrary to the required minced and moist and soft bite-sized textures. This discrepancy was observed during a meal tray inspection, and it was confirmed that the recipes were not followed as per the dietary requirements. Interviews with staff revealed a lack of adherence to the dietary guidelines and a gap in knowledge regarding the preparation of these specific diet textures. The RN overseeing meal trays acknowledged the oversight, and the CDM admitted to not pureeing the soup or grinding the sandwich as required. The RD highlighted the risk of choking hazards if residents received incorrect diet textures and noted that training on these textures had been conducted six months prior, but acknowledged the need for further in-service training due to staff turnover. The DON emphasized the importance of serving diets as prescribed to prevent choking hazards, but could not recall the timing of the last training session.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for two residents identified as elopement risks. One resident, diagnosed with vascular dementia, epilepsy, and other cognitive impairments, was supposed to be monitored with a wander guard and regular checks. However, on one occasion, the resident removed the wander guard and eloped from the facility, reaching a bus station before being found and returned by staff. The resident's care plan included interventions such as visual checks and electronic monitoring of the wander guard, but these measures were insufficient to prevent the elopement. Another resident, with a history of Alzheimer's disease and dementia, was also identified as an elopement risk and was supposed to be engaged in structured activities to distract from wandering. Despite these interventions, the resident eloped from the facility and was found down the street in front of a church. The resident was exposed to high temperatures and was later diagnosed with heat exhaustion. The care plan for this resident included wearing a wander guard and participating in structured activities, but these interventions failed to prevent the elopement. The facility's policy on wandering and elopement required staff to monitor residents at risk and respond promptly to alarms. However, the incidents indicate a failure in implementing these policies effectively. Staff interviews revealed uncertainty about how the residents managed to elope, suggesting lapses in supervision and monitoring. The facility's inability to prevent these elopements placed the residents at risk of harm, highlighting deficiencies in the facility's safety protocols and supervision measures.
Unlicensed Administrator Appointment
Penalty
Summary
The facility's governing body failed to designate a person to exercise the administrator's authority when the facility did not have a licensed administrator. The facility terminated Licensed Administrator A on November 8, 2024, and subsequently hired Employee B, who was not a licensed administrator, 24 days later. Employee B served in the capacity of the administrator for 39 days without the necessary licensure. During this period, Employee B was listed as the Administrator in the facility's records, despite not having a Nursing Home Administrator (NHA) license, which was a requirement for the position. Employee B had previously worked as an Administrator in Training (AIT) and was in the process of obtaining her NHA license, with authorization to register for the exam received on December 11, 2024. However, she was not yet licensed at the time of her appointment. Administrator C, who was licensed but affiliated with another facility, was present only once or twice a week to oversee Employee B's activities. The South Texas President acknowledged the 30-day grace period to fill the administrator position and was aware of Employee B's unlicensed status, but believed she was a suitable fit for the facility. This oversight could potentially result in a decrease in the quality of care provided to the residents, although no immediate harm was reported.
Failure to Investigate Resident Altercation
Penalty
Summary
The facility failed to maintain documentation of a thorough investigation into an alleged violation involving a resident-to-resident altercation. The incident involved a 56-year-old male resident with a history of epilepsy, encephalopathy, opioid abuse, bipolar disorder, alcohol abuse, and blindness in one eye, who threw a cup at a 64-year-old male resident with diagnoses including diabetes with neuropathy, bipolar disorder, major depressive disorder, and hypertension. The altercation occurred when the first resident felt threatened during an argument with his roommate over cleanliness, leading to the cup being thrown. Despite staff intervention and the subsequent relocation of the resident, the facility did not document a proper investigation into the incident. The former administrator failed to investigate the altercation, and the current administrator in training (AIT) was unable to locate the required Potential Incident Report (PIR) for the incident. The AIT, who joined the facility after the incident, made several attempts to contact the former administrator for information but received no response. The facility's policy requires all possible incidents of abuse, neglect, or mistreatment to be identified and investigated, but this was not adhered to in this case. The lack of documentation and investigation could place residents at risk for further abuse from altercations.
Failure to Conduct Proper Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate pre- and post-dialysis assessments, consistent with professional standards of practice. Specifically, the resident did not have a complete set of vital signs assessed prior to leaving for dialysis on eight occasions and upon returning from dialysis on nine occasions. The resident's care plan indicated the need for dialysis and the importance of assessing the dialysis access site for any redness, swelling, or pain. However, the facility's records showed that the necessary pre- and post-dialysis evaluations were not completed on multiple dates, with vital signs from previous dates being documented instead. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the facility's protocol required residents to be assessed on the same day of dialysis, both before leaving for and after returning from the dialysis center. These assessments were crucial to determine the resident's stability and included checking vital signs and the dialysis access site. The DON was unaware that assessments from previous dates were used, as she only reviewed assessments triggered by abnormal results. Attempts to interview the Licensed Vocational Nurse (LVN) responsible for the assessments were unsuccessful.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during skin assessments and wound care for several residents. Observations revealed that LVN G did not adhere to the recommended handwashing duration, washing hands for significantly less than the required 20 seconds. Additionally, LVN G did not allow alcohol-based hand rub (ABHR) to dry before donning gloves, which is crucial for effective infection control. Resident #2, who had cellulitis and open lesions, was subjected to wound care where LVN G washed her hands for only 9 seconds before and 7 seconds after the procedure. During the wound care, LVN G also failed to allow the ABHR to dry before putting on new gloves, increasing the risk of infection transmission. Similar lapses were observed during skin assessments for Residents #5, #6, #8, #10, and #11, where handwashing durations were consistently below the recommended time. Resident #15, who had a pressure ulcer, also received wound care under similar conditions where LVN G did not allow the ABHR to dry before donning gloves. Interviews with staff, including LVN G, RN H, and the DON, highlighted a misunderstanding of the correct hand hygiene procedures, despite the facility's policy and CDC guidelines emphasizing the importance of proper hand hygiene to prevent infection. The facility's failure to ensure adherence to these guidelines compromised the safety and health of the residents.
Failure to Notify of Wound Changes Leads to Unstageable Pressure Ulcer
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative when there was a significant change in the resident's condition. This deficiency was identified in the case of a resident who experienced a change in the condition of a wound, which progressed to an unstageable pressure ulcer. The facility did not notify the wound care physician, primary care physician, or the resident's representative about the changes in the wound, which included the development of slough and eschar. The resident, who had a history of diabetes mellitus, end-stage renal disease, and hypertension, was at risk for developing pressure ulcers. Despite having a care plan in place to monitor and manage skin integrity, the facility failed to adhere to the plan's interventions, such as notifying the physician of significant findings and changes in the wound. The wound care physician was not informed of the necrotic tissue and slough, which were significant changes that required immediate attention and possible debridement. Interviews with facility staff revealed a lack of documentation and communication regarding the resident's wound changes. The treatment nurse admitted to not documenting notifications to the wound care physician and failing to notify the primary physician of the wound's progression. The wound care physician confirmed that they were not informed of the wound's deterioration, which was evident upon the resident's admission to the hospital, where the wound was found to be unstageable with necrotic tissue and infection.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident, leading to the development of an unstageable pressure ulcer. The resident, who had multiple medical conditions including diabetes, end-stage renal disease, and hypertension, was at risk for pressure ulcers due to her limited mobility and frequent incontinence. Despite having a care plan in place that required regular repositioning and skin assessments, the facility did not consistently implement these interventions, resulting in the deterioration of the resident's skin condition. The facility also failed to notify the wound care physician or primary care physician of significant changes in the resident's wound condition. The resident's sacral wound, initially identified as moisture-associated skin damage, progressed to an unstageable pressure ulcer with slough and eschar. The wound care physician was not informed of these changes, which prevented timely intervention and appropriate treatment adjustments. The lack of communication and documentation regarding the wound's progression contributed to the resident's condition worsening. Additionally, the facility did not ensure consistent wound assessments and documentation. The treatment nurse and other staff members failed to document wound care treatments and changes in the resident's condition accurately. The wound care physician was unable to assess the resident regularly due to scheduling conflicts with the resident's dialysis appointments, further complicating the situation. This lack of coordination and oversight resulted in the resident being transferred to the hospital with severe wound complications, including infection and necrotic tissue.
Failure to Administer Prescribed Water Flush Before Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding. Specifically, the facility did not follow the doctor's orders for administering water before initiating feeding for a resident with a feeding tube. The resident, a female with a history of dysphagia following a stroke and dementia, was prescribed an enteral feed order that included a water flush of 100 mL before and after medication administration to maintain tube patency. However, during an observation, an LPN did not administer the prescribed water flush before giving a bolus feeding, which could potentially affect the resident's hydration status. The LPN admitted to not following the prescribed procedure due to nervousness, despite acknowledging the importance of administering water to ensure the feeding tube was clear. The facility's policy on enteral tube feeding, revised in November 2018, requires flushing the tubing with at least 30 mL of warm water or the prescribed amount before feeding. The failure to adhere to these procedures was confirmed through interviews and record reviews, highlighting a lapse in following the established protocol for enteral nutrition management.
LPN Fails to Administer Prescribed Water Flush Before Enteral Feeding
Penalty
Summary
The facility failed to ensure that a nurse demonstrated competency in providing nursing services for a resident requiring enteral nutrition. Specifically, an LPN did not administer the prescribed 100ml water flush before giving a bolus feeding to a resident with dysphagia and dementia, who was dependent on a feeding tube. This oversight was observed during an interview and observation session, where the LPN admitted to being nervous and acknowledged the importance of flushing the tube to ensure it was clear. The resident's medical records indicated a history of dysphagia following a stroke and dementia, necessitating enteral feeding. The facility's policy required flushing the tube with at least 30ml of water or the prescribed amount before feeding, which was not adhered to in this instance. The Director of Nursing (DON) confirmed the LPN's failure to follow the doctor's orders and noted the absence of completed competency paperwork for the LPN, despite the facility's policy and training protocols.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, specifically the development of a hematoma on the back of the resident's head. This incident involved a resident with severe cognitive impairment and multiple medical conditions, including type 2 diabetes mellitus and non-Alzheimer's dementia. The resident had a history of falls and was at risk for complications related to anticoagulant medication. On the day of the incident, the resident was found with a laceration above the left eye, and later, a bump on the back of the head was discovered. The bump was first noted by a member of the rehabilitation staff, who informed the nurse assigned to the area. However, the nurse did not report this change in condition to the physician, believing it was related to the previous injury. The nurse attempted to contact the on-call physician but did not receive a response before the end of the shift. The bump was not documented in the 24-Hour Report/Change of Condition Report, and the physician was not notified until the following day when the resident was sent to the hospital for further evaluation. Interviews with facility staff revealed a lack of timely communication and documentation regarding the resident's change in condition. The Director of Nursing and the Administrator were not informed of the bump until the morning meeting the next day. The facility's policy required immediate notification of the physician for significant changes in condition, which was not followed in this case. This failure placed the resident at risk for delayed medical treatment.
Failure to Administer Seizure Medication Timely
Penalty
Summary
The facility failed to administer Keppra, a medication used to treat seizures, to a resident in a timely manner on 5/10/2024. The medication was scheduled to be given at 7:00 p.m., but it was administered at 9:31 p.m., exceeding the facility's medication window by 1 hour and 31 minutes. The resident, who has a history of epilepsy and seizures, expressed concerns about not receiving his medication on time and reported feeling an aura that he might have a seizure when his medication is delayed. The resident's care plan emphasized the importance of administering medications as ordered, and the facility's policy required medications to be administered within one hour of their prescribed time. Interviews with the resident and staff revealed that the resident had previously complained about not receiving his Keppra on time and had been educated on the facility's medication administration window. The Director of Nursing (DON) confirmed that the medication was administered late by an agency nurse and acknowledged the importance of timely administration for this particular resident. The DON also stated that the facility had not been actively monitoring the timeliness of medication administration prior to the surveyor's intervention. The facility's policy on administering medications, last revised in April 2019, required medications to be administered in a safe and timely manner, as prescribed, and within one hour of their scheduled time. The DON admitted that neither she nor the Assistant Director of Nursing (ADON) had been monitoring the timeliness of medication administration, as there had been no recent complaints. The resident had not experienced any seizures in 2024, but the delay in administering Keppra on 5/10/2024 was a clear deviation from the facility's policy and the resident's care plan.
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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