San Gabriel Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Round Rock, Texas.
- Location
- 4100 College Park Dr, Round Rock, Texas 78665
- CMS Provider Number
- 676308
- Inspections on file
- 41
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 11 (2 serious)
Citation history
Health deficiencies cited at San Gabriel Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions did not receive a physician-ordered medication for tardive dyskinesia as scheduled due to delays in obtaining a signed order and the medication not being in stock at the pharmacy. The DON initially placed a verbal order, but the pharmacy required a written, signed order, which was sent several days later. The medication was then found to be out of stock and had to be ordered from the manufacturer, resulting in missed doses.
A resident with multiple comorbidities and dependent on staff for toileting reported being physically abused by a CNA during incontinent care, experiencing pain and fear when a dry towel was used on a healing skin tear. Despite reporting the incident to staff, there was no documentation of her complaints, no evidence of a thorough investigation, and the CNA continued to provide care to the resident. Staff interviews revealed inconsistent awareness and response, and the administrator did not document or investigate the allegation, resulting in an Immediate Jeopardy finding.
A resident with multiple medical conditions, including incontinence and dependence on staff for toileting, reported experiencing pain and fear after a CNA provided rough pericare using a dry towel. Despite the resident reporting the incident to several staff members, there was no documentation of a thorough investigation, no immediate assessment, and the CNA continued to provide care. The facility failed to follow its own policies for reporting, investigating, and protecting the resident during the process, resulting in a deficiency and Immediate Jeopardy.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident was subjected to physical restraints that were not required for medical treatment, in violation of regulations that mandate residents remain free from unnecessary restraints.
The facility did not provide adequate nursing staff to meet all resident needs and failed to have a licensed nurse in charge on every shift, as observed through staffing records and facility review.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this finding.
A resident with a diagnosis of psychotic disorder and depression was admitted with a negative PASRR Level 1 screening, despite clear indications of mental illness. Facility staff later confirmed that the resident's diagnoses should have triggered a positive Level 1 PASRR and subsequent Level 2 evaluation, but this was not completed, resulting in the resident not being properly assessed for specialized services.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
A box of Novolin 70/30 insulin prescribed to a resident with diabetes was found on a medication cart after its expiration date, despite facility policy requiring timely removal of expired medications. Both the RN and DON acknowledged awareness of the policy, and the expired medication remained accessible even though non-expired insulin was available.
The facility did not establish or maintain an infection prevention and control program as required, as identified by surveyors through observation and review of facility practices.
Three residents with cognitive impairment, mobility issues, and incontinence were found with their call lights out of reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed awareness of the requirement, but observations showed call lights on the ground or under beds, preventing residents from requesting assistance.
A resident with dementia and a history of exit-seeking behaviors was able to leave the facility unsupervised by following visitors out the front door. Staff interviews revealed inconsistent knowledge of elopement protocols, incomplete training, and poor communication regarding sign-out procedures. The resident was found in the street by visitors, highlighting failures in supervision and adherence to established elopement prevention policies.
An RN left a treatment cart unlocked and unattended, contrary to facility policy requiring secure storage of drugs and biologicals. The ADON and DON acknowledged the risk of unauthorized access to medicated creams and cleansers, which could be harmful if misused.
A resident with a history of liver cirrhosis and chronic pain was harmed during a Hoyer lift transfer when CNA B failed to follow proper procedures, resulting in the resident being hit in the head and foot. Despite the resident's cries of pain, CNA B did not stop the transfer or seek assistance, leading to physical harm and emotional distress. CNA C, who was present, confirmed the rough handling and lack of adherence to transfer protocols.
Two residents experienced accidents due to improper transfer techniques by CNAs. One resident, requiring extensive assistance, was transferred without a Hoyer lift or a two-person assist, resulting in a fall and injury. Another resident was roughly handled during a Hoyer lift transfer, causing their head and foot to hit the wall. These incidents highlight failures in adhering to transfer protocols and ensuring resident safety.
A CNA in an LTC facility failed to follow proper hand hygiene procedures while caring for residents, despite being trained on infection control. The CNA was observed handling items and assisting residents without washing or sanitizing her hands, posing a risk of contamination and infection. Other staff members confirmed their training in hand hygiene, and facility policies emphasized its importance, yet the CNA's actions did not align with these standards.
The facility failed to ensure that two residents had their call lights within reach, as required by their care plans. One resident, severely cognitively impaired and at risk of falling, had her call light tucked under the mattress, while another resident with impaired mobility found her call light on the floor. Staff interviews confirmed the expectation for call lights to be accessible, highlighting a lapse in adherence to facility policy.
A resident with severe cognitive impairment and mobility issues was found with bed rails in place without a physician's order or proper documentation. The facility failed to ensure the resident's freedom from unnecessary physical restraints, as the bed rails were not required to treat medical symptoms. Staff interviews revealed a lack of awareness and proper documentation regarding the use of side rails, leading to the deficiency.
A facility failed to ensure accurate assessments for two residents, leading to potential risks for inadequate care. One resident's MDS did not reflect the use of bed rails, while another's dementia diagnosis was inaccurately coded as a psychotic disorder. Staff interviews revealed inconsistencies in assessment and documentation processes, contributing to these deficiencies.
Two residents were admitted to the facility without baseline care plans being completed within the required 48-hour timeframe, potentially risking their care. One resident had acute kidney failure and other conditions, while the other had cellulitis and paraplegia. Despite having comprehensive care plans from prior stays, the absence of timely baseline care plans meant their immediate needs were not formally documented. Interviews revealed that charge nurses were responsible for this task, but a breakdown in the process occurred, possibly due to new staff.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident's care plan did not include side rails despite a history of falls, while another resident, who was non-verbal, lacked a functioning communication system to call for assistance. These deficiencies placed the residents at risk of not having their care needs adequately assessed and met.
A resident with severe cognitive and physical impairments was not provided with a functional communication system to call for assistance. The standard call light system was ineffective due to the resident's inability to use her arms or hands, and the care plan did not address alternative communication methods. Despite staff efforts to replace the call button with a paddle, the resident's needs remained unmet, highlighting a deficiency in the facility's care planning.
The facility failed to ensure that residents had access to a functioning call light system, affecting two residents with significant medical conditions and fall risks. Both residents reported issues with the call lights, and observations confirmed the malfunction. Staff and administration were unaware of the problems, despite maintenance logs indicating previous notifications.
Failure to Provide Timely Pharmaceutical Services for Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the timely acquisition and administration of a physician-ordered medication, Ingrezza 80 mg, prescribed for tardive dyskinesia. The resident, a 68-year-old female with multiple diagnoses including pneumonia, acute respiratory failure, anxiety disorder, and schizoaffective disorder, was dependent, non-verbal, and received medications via a feeding tube. Despite a physician's order for Ingrezza with a specified start date, the medication was not administered as scheduled on several occasions because it was not available in the facility. The delay in medication administration was due to a series of procedural lapses: the DON initially placed a verbal order with the pharmacy, but the pharmacy required a signed order before filling the prescription. The signed order was not sent until several days later, and upon receipt, the pharmacy reported the medication was not in stock and had to be ordered from the manufacturer. The DON was unaware of the stock issue until after the order was submitted, and the resident did not receive the medication as prescribed. Interviews with the family, pharmacy staff, and physician confirmed the medication was not provided as ordered, and there were no alternative medications suitable for administration via feeding tube.
Failure to Protect Resident from Physical Abuse and Inadequate Investigation
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for toileting hygiene and had a history of cerebral infarction, sepsis, diabetes, depression, anxiety, and osteomyelitis, reported being physically abused by a CNA during incontinent care. The resident described experiencing pain and fear after the CNA used a dry towel roughly on a healing labial skin tear, despite her requests to use wet wipes and to stop due to pain. The resident reported the incident to multiple staff members, including a nurse and the social worker, but there was no documentation of her complaints or of a head-to-toe assessment being completed in response. The facility failed to implement protective measures, as the CNA continued to provide care to the resident after the initial complaint. There was no evidence that the CNA was suspended during the investigation period, and documentation in the CNA's personnel file did not reflect any suspension or disciplinary action related to the abuse allegation. Additionally, the care plan and physician orders did not address the labial skin tear, and there was a lack of documentation regarding the resident's complaints of rough treatment or any follow-up assessments. Interviews with facility staff revealed inconsistent awareness and response to the abuse allegation. The administrator did not investigate further, believing the incident did not constitute abuse, and did not document the allegation or conversations with the resident or CNA. Other staff members were either unaware of the complaint or could not recall details of the investigation or protective actions taken. The lack of prompt, thorough investigation and failure to remove the alleged perpetrator from resident care led to the identification of Immediate Jeopardy by surveyors.
Failure to Investigate and Protect Resident Following Allegation of Rough Care
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that measures were taken to prevent further incidents while an investigation was in progress. Specifically, a female resident with a history of cerebral infarction, sepsis, diabetes, depression, anxiety, and sacral osteomyelitis, who was dependent on staff for toileting and incontinent of bowel and bladder, reported experiencing pain and fear after receiving rough incontinent care from a male CNA. The resident described the CNA using a dry towel during pericare, causing her significant pain and distress, and stated that her requests for gentler care were ignored. She reported the incident to multiple staff members, including a nurse and the social worker, but there was no documentation of a thorough investigation or immediate protective measures, such as suspension of the alleged perpetrator. The resident's care plan and physician orders did not address the labial skin tear that was identified, and there was no documentation of a head-to-toe assessment or follow-up regarding her complaints of rough treatment. Progress notes and incident reports lacked any mention of the resident's report of rough care or the labial tear, and the CNA continued to provide care to the resident after the initial complaint. Interviews with facility staff revealed inconsistent awareness of the incident, lack of documentation, and failure to follow facility policy, which required immediate reporting, assessment, and suspension of the alleged perpetrator during an investigation. The administrator, who was the designated abuse coordinator, did not document the allegation or her conversations with the resident and CNA, and did not initiate a formal investigation, stating she did not consider the incident to be abuse. The resident later recounted ongoing fear and distress, stating that the CNA continued to provide care after the initial incident and that she felt unsafe and traumatized. Interviews with the medical director and other staff confirmed that the use of a dry towel for pericare was not standard practice and that any complaint of rough treatment should have been documented and investigated. The facility's failure to document, investigate, and report the allegation, as well as to protect the resident during the investigation, constituted a deficiency and resulted in the identification of Immediate Jeopardy.
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 residents did not consistently receive treatment and supports for daily living in a manner that ensured 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 at the time, are not provided in the report.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these fundamental resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency, nor does it mention any particular residents or circumstances involved.
Failure to Complete Accurate PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to provide an accurate PASRR Level 1 screening for a resident who was admitted with a diagnosis of psychotic disorder with hallucinations and depression. Despite these diagnoses, the resident's PASRR Level 1 screening, completed by the hospital doctor prior to admission, was marked negative for mental illness, intellectual disability, and developmental disability. Upon review, facility staff including the administrator, MDS coordinator, and DON all acknowledged that the resident's diagnoses should have resulted in a positive Level 1 PASRR screening, which would have triggered a Level 2 evaluation. The resident's care plan indicated the use of antipsychotic medication for the treatment of her psychotic disorder, and her MDS assessment showed intact cognitive function. The facility's PASRR policy required that any indication of mental illness, intellectual disability, or developmental disability in the Level 1 screening should prompt a Level 2 evaluation, following state-specific procedures. The failure to identify the resident's mental illness in the PASRR Level 1 screening resulted in the resident not being properly evaluated for specialized services she may have been eligible to receive.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Expired Insulin Found on Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and disposed of in accordance with professional standards, specifically regarding expiration dates. During an observation of a medication cart, a box of Novolin 70/30 insulin prescribed to a male resident with type 2 diabetes was found to have been opened on 05/29/25 and remained on the cart past its 42-day expiration period, which should have been on or before 07/10/25. The expired medication was still present on the cart during the survey, despite the resident having non-expired medication available for administration. Interviews with the RN responsible for administering medications and the DON revealed that both were aware of the policy requiring regular checks for expired medications. The RN acknowledged the expired medication should have been removed, and the DON stated that both the charge nurse and the pharmacist are responsible for ensuring expired medications are not present on the carts. Review of facility policy and the medication's prescribing information confirmed the requirement for proper labeling and timely disposal of opened medications.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as expected. The report specifically notes the absence or inadequacy of a program designed to prevent, identify, investigate, and control infections within the facility. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents who were at risk for falls, incontinence, and other health concerns. Observations on the specified date revealed that the call lights for all three residents were found on the ground or under the bed, making them inaccessible. One resident, who was in a wheelchair, attempted to reach the call light on the ground but was unable to do so. The other two residents were observed in bed with their call lights similarly out of reach, and both declined to answer questions during the surveyor's visit. Each of the affected residents had significant medical histories, including dementia, unsteadiness, muscle weakness, incontinence, and a history of falls. Their care plans specifically required that call lights be kept within reach at all times due to their risk factors. Documentation showed that staff had checked on these residents earlier in the day, but the call lights were still not accessible at the time of observation. Staff interviews confirmed that they had been in-serviced on the importance of call light placement and were aware of the policy requiring call lights to be within reach whenever care was provided or when leaving a resident's room. Despite staff training and facility policies, the deficiency occurred because staff did not consistently ensure that call lights were accessible to residents. The facility's own policies and the Guardian Angel Program emphasized the importance of call light accessibility for resident safety and communication. However, the observations and interviews demonstrated a lapse in following these procedures, resulting in residents being unable to summon assistance when needed.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Protocol Adherence
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, altered mental status, psychotic disorder with delusions, and anxiety disorder was able to leave the facility unsupervised and without staff knowledge. The resident had a documented history of wandering, confusion, and exit-seeking behaviors, and was identified as an elopement risk on multiple assessments. Care plans and progress notes indicated that the resident was rarely understood, had impaired cognition, and required redirection when entering unsafe areas. Despite these documented risks, the resident was able to follow visitors out the front door and was later found in the street by facility visitors. Interviews with staff revealed inconsistencies and gaps in the implementation of elopement prevention protocols. Some staff members were unaware of the existence or location of the elopement risk binder, and not all staff had received training on elopement procedures. The receptionist on duty at the time of the incident did not recognize the resident as an elopement risk and assumed the resident was leaving with family, failing to verify sign-out procedures. Additionally, there was confusion among staff regarding the process for signing residents out for leave of absence, and communication between nursing staff and reception was inconsistent. The facility's policies required that residents at risk for elopement be identified and monitored, and that residents leaving the facility have written physician permission and be properly signed out. However, these procedures were not consistently followed, as evidenced by the resident's ability to exit the building unsupervised. The lack of staff awareness, incomplete training, and failure to adhere to established protocols directly contributed to the resident's elopement and the resulting deficiency.
Removal Plan
- Resident #1 no longer resides at the facility.
- Elopement Risk evaluations done on current residents inhouse will be reviewed by Director of Nursing/Designee for accuracy. Residents identified at risk will be reviewed for appropriate interventions including placement in the Elopement Binder and validated care plans have interventions listed.
- The Director of Nursing was reeducated by the Clinical Consultant on Accidents and Incidents including: elopement risk and the elopement binder; when a resident is identified as an elopement risk, education will be provided to facility staff to alert them of a new resident listed in the elopement binder; validating that when a resident is leaving the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence; elopement risk assessment process and putting interventions in place based on risks identified.
- All Facility Staff will be reeducated by the Director of Nursing/Designee on Accidents and Incidents including: elopement risk and the elopement binder; when a resident is identified as an elopement risk, education will be provided to facility staff to alert them of a new resident listed in the elopement binder; validating that when a resident is leaving the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence.
- Licensed Nurses will be reeducated by the Director of Nursing on the elopement risk assessment process and putting interventions in place based on risks identified.
- Any staff not receiving this education will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation.
- The Director of Nursing will randomly interview a minimum of 2 staff daily to validate understanding of elopement risk and elopement binder.
- The Director of Nursing/Designee will review the facility activity report in clinical morning meeting to identify documentation and/or elopement risk assessments that may suggest a resident is exit seeking. If identified, the Director of Nursing/Designee will validate interventions are appropriate and care plan is updated.
- The Director of Nursing/Designee will review new admission elopement risk assessments in Clinical Morning Meeting for accuracy and interventions validated if indicated, including placement in the elopement binder and education to staff of new resident listed in the binder.
- The Medical Director was notified of the Immediate Jeopardy.
- An Ad Hoc Quality Assurance and Performance Improvement Meeting was held to discuss contents of this plan.
- Administrator will oversee compliance of this plan.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with a treatment cart that was left unlocked and unattended by an RN. This incident occurred outside of a resident's room, where the door was closed, indicating that the cart was not within the RN's line of sight. The RN acknowledged the oversight, admitting that the cart should have been locked when unattended, as it allowed potential access to residents or unauthorized individuals. Interviews with the ADON and DON revealed that the facility's policy required medication and treatment carts to be locked when not in use to prevent unauthorized access. The ADON expressed concern that residents or unauthorized staff could access the cart, which contained medicated creams and cleansers that could be harmful if misused. The DON expressed disappointment upon learning of the incident, as it did not align with her expectations for medication storage practices. The facility's policy, revised in April 2024, mandates that all drugs and biologicals be stored securely in locked compartments, accessible only to authorized personnel.
Resident Harmed During Improper Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure the safety and well-being of a resident during a Hoyer lift transfer, resulting in the resident being hit in the head by the lift and having his right foot hit against the wall. The incident occurred when CNA B was transferring the resident from his bed to his wheelchair. Despite the resident expressing pain by crying out, CNA B did not stop the transfer or request an assessment, which made the resident feel neglected and uncared for. The resident involved was a male with a history of alcoholic cirrhosis of the liver with ascites, chronic pain syndrome, anorexia, and altered mental status. His cognitive abilities were intact, as indicated by a BIMS score of 14. The resident was dependent on mechanical lift transfers, as outlined in his care plan. During the transfer, CNA B did not follow proper procedures and ignored the resident's expressions of pain, leading to physical harm and emotional distress. CNA C, who was present during the transfer, confirmed that CNA B was rough and did not listen to his directions. CNA C witnessed the resident being hit in the head and his foot being struck against the wall. Despite being trained on abuse, neglect, and transfer techniques, CNA B's actions during the transfer were inappropriate and did not align with the facility's standards of care.
Improper Transfer Techniques Lead to Resident Accidents
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices during resident transfers, leading to accidents involving two residents. In the first incident, a resident with moderate cognitive impairment and extensive assistance needs was improperly transferred by a CNA. The CNA did not use a two-person transfer or a Hoyer lift as required by the resident's care plan. Additionally, the CNA failed to lock the wheelchair brakes, resulting in the resident falling and sustaining a bruised and swollen knee. In the second incident, another resident, who was dependent on transfers, experienced rough handling during a Hoyer lift transfer. The CNA involved did not seek assistance and mishandled the resident, causing the resident's head and foot to hit the wall. This incident was witnessed by another CNA, who confirmed the rough handling and lack of communication during the transfer. Both incidents highlight the facility's failure to adhere to established transfer protocols and ensure the safety and dignity of residents during transfers. The lack of proper technique and communication among staff contributed to the accidents, putting residents at risk of harm and neglect.
Inadequate Hand Hygiene Practices by CNA
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the actions of a Certified Nursing Assistant (CNA) who did not follow proper hand hygiene procedures while providing care to four residents. The CNA was observed feeding one resident and then adjusting another resident's bib without washing or sanitizing her hands. She continued to handle items and assist other residents without performing hand hygiene, despite being trained on the importance of handwashing to prevent contamination and infection spread. The residents involved in this incident had various medical conditions that made them vulnerable to infections. For instance, one resident had a pressure ulcer and elevated white blood cell count, while another had dementia and difficulty swallowing. These conditions necessitate strict adherence to infection control practices to prevent further health complications. The CNA's failure to sanitize her hands after touching potentially contaminated items posed a risk of food contamination and infection to these residents. Interviews with other staff members, including a Medication Aide (MA), a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), confirmed that they were all trained in hand hygiene and infection control. They acknowledged the importance of washing hands before and after resident contact and the potential consequences of not doing so. The facility's policies and procedures emphasized hand hygiene as a critical component of infection prevention, yet the observed practices did not align with these standards.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which is a necessary accommodation for their needs. Resident #8, a severely cognitively impaired female with a history of stroke, muscle weakness, and a risk of falling, was found with her call light tucked under the mattress, making it inaccessible. Her care plan specifically required the call light to be within reach due to her impaired mobility and risk of injury. During an observation, her bed was in the highest position with side rails raised, further complicating her ability to access the call light. Similarly, Resident #38, who is cognitively impaired and requires moderate assistance with activities of daily living, was found with her call light tied to the bed rail and lying on the floor, out of her reach. Despite her care plan also mandating the call light to be within reach due to her impaired mobility and cognition, she reported having to yell for help. Staff interviews confirmed that call lights should always be within reach, and it is everyone's responsibility to ensure this. However, the failure to do so was observed, indicating a lapse in the facility's adherence to its policy and care plans.
Failure to Ensure Resident Freedom from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically bed rails, which were not required to treat the resident's medical symptoms. The resident, an elderly female with a history of cerebral infarction, muscle weakness, moderate protein-calorie malnutrition, history of falling, and chronic pain, was found to have bed rails in place without a physician's order or proper documentation. The resident's MDS assessment did not reflect the use of bed rails, and there was no care plan addressing their use, despite the resident's severe cognitive impairment and substantial assistance needs for activities of daily living. During an observation, the resident was found in bed with the side rails fully raised, and the call light was out of reach, tucked under the mattress. Interviews with facility staff revealed a lack of awareness and proper documentation regarding the use of side rails. The LVN on duty was unaware of the bed's elevated position and the call light's inaccessibility. The MDS nurse acknowledged the absence of a care plan and order for the side rails, attributing it to a recent audit that led to the discontinuation of side rails for the resident. The facility's policy on restraints clearly states that side rails should only be used when necessary to treat medical symptoms and must be documented with a physician's order. The DON and ADM both acknowledged the oversight, with the ADM suggesting that the resident may have been overlooked during the facility's efforts to minimize the use of side rails. The facility's failure to adhere to its policy and ensure proper documentation and assessment for the use of side rails resulted in the deficiency.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks for inadequate care. For one resident, the Minimum Data Set (MDS) assessment did not reflect the use of bed rails, despite observations showing that bed rails were in use. The resident was severely cognitively impaired and required substantial assistance with activities of daily living. The care plan did not include the use of side or bed rails, and there was no documented functional need for them. Interviews with staff revealed a lack of clarity and consistency in the assessment and documentation process regarding the use of bed rails. Another resident's MDS assessment inaccurately coded a diagnosis of dementia as a psychotic disorder. The resident had a primary diagnosis of dementia with psychotic features, but the MDS did not reflect this accurately. Interviews with staff, including the MDS Coordinator and the Regional MDS Consultant, showed differing opinions on the correct classification of the resident's condition. The facility's policy and guidelines for MDS assessments were not consistently followed, leading to discrepancies in the resident's assessment. The deficiencies in the assessment process for both residents were identified through observation, interviews, and record reviews. The facility's failure to accurately assess and document the residents' conditions could have led to inadequate care. Staff interviews highlighted a lack of understanding and consistency in following the facility's policies and guidelines for MDS assessments, contributing to the inaccuracies in the residents' assessments.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop baseline care plans within the required 48-hour timeframe for two residents, which could place them at risk for not receiving necessary care and services. Resident #88, a male with acute kidney failure, cerebral infarction, hypertension, and diabetes, was admitted without a baseline care plan being completed within the specified timeframe. His previous comprehensive care plan indicated unclear speech related to a CVA, requiring extra time to communicate needs, and a risk of being misunderstood. However, the absence of a timely baseline care plan meant that these needs were not formally documented for immediate care. Similarly, Resident #90, a male with cellulitis of the buttock, hypertension, congestive heart failure, and paraplegia, also did not have a baseline care plan completed within 48 hours of admission. His comprehensive care plan from a prior stay noted the need for assistance with ADLs to maintain dignity and hygiene. Despite having a BIMS score indicating no cognitive impairment, the lack of a baseline care plan could have led to gaps in addressing his immediate care needs. Interviews with facility staff, including the ADM, DON, and MDS nurses, revealed that the charge nurses were responsible for completing baseline care plans, but there was a breakdown in the process. The MDS nurses were tasked with checking new admissions to ensure baseline care plans were completed, but this did not occur for Residents #88 and #90. The facility's policy required baseline care plans to be developed within 48 hours, yet this was not adhered to, and the reasons for the oversight were unclear, with new nurses being cited as a possible factor.
Deficiencies in Care Planning and Communication Systems
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. For one resident, the care plan did not include the use of side rails, despite the resident having severe cognitive impairment and a history of falls. The resident was observed with side rails in place, but there was no care plan or physician's order for their use. Interviews with staff revealed that there was a lack of communication and documentation regarding the necessity and safety of side rails for this resident. Another resident, who was non-verbal and had severe cognitive impairment, was not provided with a functioning communication system to call for nursing assistance. The resident's care plan did not address her inability to use the facility's call light system due to her physical limitations. Observations showed that the call light system was not operational, and alternative methods of communication were not effectively implemented. Staff interviews indicated that the resident was checked every two hours, but there was no specific plan to address her communication needs. The deficiencies in care planning and implementation placed both residents at risk of not having their care and treatment needs adequately assessed and met. The facility's policies on care planning and communication systems were not effectively followed, leading to gaps in the residents' care. The lack of a comprehensive care plan for these residents highlights the need for better coordination and documentation of care needs and interventions.
Failure to Provide Functional Communication System for Resident with Disabilities
Penalty
Summary
The facility failed to provide a functioning communication system for Resident #60, who had severe cognitive and physical impairments, including aphasia, hemiplegia, and seizure disorder. The resident was non-verbal and unable to use her arms or hands, making it impossible for her to utilize the standard call light button designed to be activated with a thumb or finger. Despite these limitations, the resident's care plan did not address her inability to use the call light system or provide alternative methods for communication. During an observation, it was noted that the call light button clipped to Resident #60's bed did not illuminate when activated, indicating a malfunction. The facility's staff, including LVN B, attempted to rectify the issue by replacing the call button with a call light paddle, which also proved ineffective for the resident due to her physical limitations. The maintenance team confirmed the paddle was operational, but it was still not a viable solution for the resident's needs. Interviews with staff revealed that the facility had procedures in place, such as guardian angel rounds, to ensure call light systems were functioning. However, these procedures did not account for residents with specific disabilities that prevented them from using the standard communication systems. The comprehensive care plan for Resident #60 failed to include her communication limitations and did not provide alternative methods to ensure her needs were met, placing her at risk of unmet needs.
Failure to Ensure Functioning Call Light System
Penalty
Summary
The facility failed to ensure that residents had access to a functioning call light system, which is essential for requesting staff assistance. This deficiency was identified for two residents, both of whom had significant medical conditions and were at risk for falls. Resident #1, who had a diagnosis of infection, acute respiratory failure, and other conditions, reported that staff did not frequently respond to her call light, and she had to use her personal cell phone to contact the nurse's station. Observations confirmed that the call light in her room was not functioning, and a staff member was unaware of any prior issues but promised to submit a maintenance request. Resident #2, who had severe cognitive impairment and a history of falls, also experienced issues with the call light system. She reported waiting over 30 minutes for assistance, and observations showed that her call light was broken and not functioning. A Licensed Vocational Nurse (LVN) attempted to fix the call light but was unsuccessful. The LVN stated she would submit a maintenance request and check other residents' rooms for similar issues. Interviews with the Director of Nursing (DON), the Administrator, and the Maintenance Director revealed that none were aware of the call light issues. The DON and Administrator both emphasized the importance of a functioning call light system for resident safety. Maintenance logs showed that the Maintenance Director had been notified of call light problems multiple times from January to March 2024, but the issues persisted. The facility's policy on call lights was requested but not provided by the exit interview.
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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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