Silver Tree Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Schertz, Texas.
- Location
- 930 Roy Richard Dr, Schertz, Texas 78154
- CMS Provider Number
- 676121
- Inspections on file
- 39
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Silver Tree Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that MDS assessments were inaccurate and not properly validated when one resident’s quarterly MDS omitted active, treated diagnoses of GERD and hypothyroidism and the care plan incorrectly listed hyperthyroidism, while another resident’s assessment lacked required RN review. In both cases, the LVN MDS Coordinator signed in the section designated for the RN Assessment Coordinator without an RN signature, despite facility policy requiring that assessments accurately reflect resident status and be conducted or coordinated by an RN.
A resident with documented hypothyroidism had a care plan that incorrectly listed hyperthyroidism and included interventions appropriate for hyperthyroidism rather than the resident’s actual condition. The MDS assessment did not list either thyroid diagnosis, and the resident had moderate cognitive impairment and required moderate ADL assistance. The MDS nurse and other team members were responsible for developing and reviewing care plans, but the incorrect diagnosis and related interventions, originally entered by an LVN who had left the facility, were not corrected during routine reviews. The DON reported that she did not review this resident’s MDS assessment, even though she stated that accurate care plans are important for accurate care.
The facility failed to maintain complete clinical records when physician progress notes for a resident with acute kidney failure, HTN, and rheumatoid arthritis were not obtained and uploaded into the EMR, despite existing paper notes. The DON confirmed that no physician notes were in the EMR and that the facility was behind on uploads. The Medical Records staff reported he was not on the physicians’ email group, only requested and uploaded documents when specifically asked, and had no defined timeframe or routine process. The DON and Administrator both acknowledged that physician offices were behind in sending documentation and that there was no established system or regular schedule for requesting and uploading physician progress notes, contrary to facility policy requiring notification of physicians when notes are due and use of routine chart audits.
A resident with significant medical and cognitive needs was transferred using a mechanical lift by a single CNA, despite the care plan and facility policy requiring two staff for such transfers. The CNA, new to the facility and not yet trained on the lift, acted alone because other staff were unavailable, and did not request help. No injury occurred, but the event was confirmed through observation, interviews, and record review, showing a failure to implement the resident's comprehensive care plan.
A resident with dementia and a history of falls, identified as an elopement risk, exited the facility unsupervised due to lack of care plan interventions and insufficient alarm volume. Staff did not recognize the resident as exit-seeking prior to the incident, resulting in the resident being found outside with injuries.
The facility did not ensure that care plans for two residents reflected their specific needs and behaviors, including one resident's repeated refusal of wound care and another resident's ongoing behavioral issues involving allegations against staff. Staff interviews and records confirmed these issues were known and addressed in practice, but the care plans were not updated to include measurable objectives, timeframes, or interventions as required.
A resident with severe cognitive impairment and a history of wound care refusal did not have wound treatment or refusals documented in the medical record for several days, despite daily wound care orders. Nursing staff confirmed the resident often refused care and that these refusals were not recorded as required by facility policy.
A nurse failed to immediately notify a physician and a resident's representative after a resident was found injured and confused on the floor, resulting in delayed medical intervention. The resident, who had a complex medical history and recent changes in mental status, was later hospitalized with multiple injuries. The nurse did not recognize the incident as a fall and did not follow required notification protocols.
A resident with multiple complex medical conditions experienced an unwitnessed fall with injuries. Two CNAs repositioned the resident without a nurse's assessment, and the LPN on duty failed to initiate required neuro checks or promptly notify the physician and the resident's representative. Documentation was inaccurate regarding notifications, and the resident was later found to have additional injuries and confusion, leading to hospital transfer. The facility's protocols for post-fall assessment and notification were not followed, resulting in a deficiency.
Surveyors found that the medication room was left unlocked and unattended, with medications accessible, and a syringe of normal saline for flushing a resident's PICC line was left unattended on the resident's nightstand. Both the DON and an LVN confirmed these items should have been secured in locked storage or a nursing cart, as required by facility policy.
Surveyors identified that dietary staff failed to use facial hair restraints properly, did not follow correct hand hygiene, and handled food contact surfaces inappropriately during meal preparation and service. The Dietary Manager and another staff member were observed not adhering to facility policy and professional standards, leading to potential cross contamination and infection control issues, as confirmed by interviews with the DON and Administrator.
Staff failed to follow infection control protocols during incontinence and colostomy care for two residents with severe cognitive impairment and complex medical needs. In both cases, staff did not perform required hand hygiene between glove changes after contact with contaminated materials. Additionally, staff did not use appropriate PPE, including N95 masks and eye protection, when entering the room of a resident on aerosol isolation for COVID-19 exposure, and improperly handled contaminated trash and PPE. These actions did not comply with the facility's infection control policies.
The facility did not ensure that several staff members, including a CNA, dietary aide, medication aide, dietary manager, and ADON, received and documented all required annual trainings in areas such as communication, ethics, resident rights, and behavioral health. Personnel records lacked evidence of completed trainings, and the facility could not provide a policy outlining these requirements when requested.
Three staff members, including a Dietary Aide, Dietary Manager, and ADON, did not receive required annual ethics training as documented in their personnel records. Despite the facility's use of a computer-based training system and notification procedures, the mandatory training was not completed for these employees, as confirmed by staff interviews and review of the employee handbook.
A nurse left a computer open and unattended on a hallway cart, displaying a resident's personal and medical information, including photo, name, date of birth, room number, age, and medications. The DON confirmed this was a privacy violation, and the nurse admitted to forgetting to lock the screen, resulting in a breach of confidentiality for a resident with multiple medical conditions.
A resident with an indwelling urinary catheter was incorrectly coded as "Always urinary incontinent" on the admission MDS, rather than "Not rated" as required. This error was confirmed by both the MDS nurse and DON, and was identified through record review, staff interviews, and observation.
A resident admitted with multiple complex medical conditions did not have a baseline care plan developed or implemented within 48 hours of admission, as required by facility policy. The responsible nurse did not initiate the care plan, and the DON confirmed the omission, resulting in the resident and their representative not receiving a copy of the plan.
A resident with cancer and on hospice had a documented DNR order, but the facility failed to update the care plan to reflect this code status. Staff interviews revealed confusion about responsibility for care plan updates, and the interdisciplinary team did not ensure the care plan included all necessary information.
A disposable razor was found unattended and dirty on the sink in a resident's restroom. The resident had severe cognitive impairment and required substantial assistance with personal hygiene, including shaving. Facility policy prohibited razors in resident rooms, and staff confirmed that razors should be discarded in a sharps container after use to prevent harm.
A CNA failed to properly separate and clean the labia area while providing incontinence care to a female resident with severe cognitive impairment and chronic incontinence. Despite recent peri-care training and a passed skill checkoff, the CNA omitted this step, which was required by the resident's care plan and facility policy. The DON confirmed the correct procedure was not followed.
A resident with a gastrostomy tube was flushed with 250 ml of water by an RN using a syringe plunger instead of gravity, contrary to facility policy. The resident had severe cognitive impairment and multiple medical conditions, and the care plan required monitoring for tube-related complications. The DON confirmed that gravity should have been used for flushing, as outlined in the facility's enteral medication administration policy.
A nurse failed to flush both lumens of a resident's PICC line as ordered by the physician during IV antibiotic administration, flushing only the medication port and omitting the blood port. The resident had multiple medical conditions requiring strict adherence to IV protocols, and the facility's policy and care plan specified that both lumens should be flushed according to orders.
Two residents did not receive respiratory care in accordance with professional standards: one had a nebulizer mask left uncovered when not in use, and another received oxygen therapy at 4 L/min via nasal cannula without a physician order. Staff acknowledged these lapses, and facility policy requires physician orders for oxygen administration.
Two staff members did not receive required annual communication training, as shown by a lack of documentation in their personnel files. Despite the facility's use of an online training system and stated procedures for assigning and tracking mandatory trainings, there was no evidence that these employees completed communication training during the review period. Facility leadership could not provide a policy outlining required annual training, including communication training, when requested by surveyors.
The facility did not provide or document required annual resident rights training for the Dietary Manager, as confirmed by personnel record review and staff interviews. The HR Coordinator, Administrator, and DON were unable to produce a policy on required annual training, and the training was not completed or documented in the facility's system.
A CNA did not receive the required 12 hours of annual in-service training, including communication training, as confirmed by personnel record review and staff interviews. The facility used a computer-based training system and email notifications, but lacked documentation and oversight to ensure completion of mandatory CNA training.
The facility did not ensure that the Dietary Manager received required annual behavioral health training, as shown by a lack of documentation in personnel records and confirmation from leadership interviews. The system in place for assigning and tracking annual trainings did not result in completion or documentation of this training for the Dietary Manager, and no relevant policy was provided when requested.
Two residents were not given the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when their skilled services ended before their Medicare days were exhausted. Although both residents received and signed the Notice of Medicare Non-Coverage (NOMNC), the SNF ABN, which would have informed them about the option to continue services at a private pay rate, was not completed. Staff interviews revealed a lack of awareness about the requirement, and facility policy confirmed the need for this notification.
A CNA was overheard making derogatory remarks about a resident, referring to them as lazy and treating staff as maids, within earshot of other residents. The resident, who was not present, has a history of cerebral infarction, diabetes, hemiplegia, and depression, and relies on staff for daily activities. The facility's policy prohibits such verbal abuse, indicating a failure to maintain an abuse-free environment.
A resident's bank card was stolen and used by facility staff, specifically two CNAs, at the facility's vending machines and local businesses. The resident's family member reported the unauthorized use, and the facility's investigation identified the CNAs as suspects. The facility contacted law enforcement but was unable to gather additional evidence from local businesses.
A nursing cart on the 400-hall was found unlocked and unattended, exposing medications and scissors, which could pose a risk to residents, visitors, and staff. LVN-A admitted to leaving the cart unsecured, and the DON confirmed the importance of keeping it locked to prevent unauthorized access, especially by residents with dementia.
A wound care nurse in an LTC facility failed to adhere to Enhanced Barrier Precautions by not wearing a gown during wound care for a resident with multiple health conditions, including Parkinson's disease and diabetes. Despite being trained, the nurse admitted to forgetting the gown due to nervousness, which was confirmed by the DON. The facility's policy mandates gown use during high-contact activities to prevent infection.
A resident's medical records inaccurately documented the administration of oxycodone, a pain relief medication, which was not given as scheduled. The error was discovered during a narcotic count, revealing only two doses were dispensed instead of three. RN B admitted to the mistake but did not report it to the DON or physician. The resident, with a history of multiple health issues, could not recall receiving the dose, and the family member was also unsure.
Inaccurate MDS Diagnoses and Lack of RN Validation for Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ diagnoses and were properly reviewed and signed by a Registered Nurse (RN). For one resident, the face sheet listed diagnoses including cerebral infarction, gastro-esophageal reflux disease (GERD), and hypothyroidism, while the care plan incorrectly documented hyperthyroidism instead of hypothyroidism. The quarterly MDS assessment for this resident showed a BIMS score of 10, indicating moderate cognitive impairment, but did not list either hypo- or hyperthyroidism or GERD as diagnoses, despite the resident being treated with protonix for GERD and levothyroxine for hypothyroidism. The facility’s own policy required that assessments accurately reflect the resident’s status. The same quarterly MDS assessment for this resident was signed in section Z0500 by the MDS Coordinator, who is an LVN, under the field designated for the RN Assessment Coordinator verifying assessment completion, and there was no RN signature. A second resident’s face sheet listed diagnoses including acute kidney failure, essential hypertension, and rheumatoid arthritis, and her quarterly MDS assessment showed a BIMS score of 13 with total functional dependence for movement. That assessment was also signed in section Z0500 by the LVN MDS Coordinator as the RN Assessment Coordinator, with no RN signature present. Facility policy stated that a registered nurse must conduct or coordinate each assessment. In interviews, the LVN MDS Coordinator stated he was responsible for MDS assessments and care plans and confirmed that GERD and hypothyroidism were active, treated diagnoses for the first resident that were not included on the MDS. He explained that active diagnoses usually auto-populate into the MDS and that he did not see a button to add GERD or hypothyroidism, and acknowledged he should have written them in under “other,” describing the omission as an oversight. He also confirmed he was aware that MDS assessments required RN review and signature, and suggested that he may have signed assessments as completed to check for errors and failed to unmark them as incomplete. The DON stated that all active diagnoses should be included for accuracy, that an RN must sign and validate MDS assessments, and that an LVN could not sign them, but she could not explain why the two residents’ assessments lacked RN signatures or why the first resident’s GERD and hypothyroidism diagnoses were missing from the MDS.
Inaccurate Care Plan Diagnosis and Interventions for Thyroid Condition
Penalty
Summary
The facility failed to develop and implement an accurate, comprehensive person-centered care plan for a resident by listing an incorrect diagnosis and related interventions. The resident, an older female admitted with conditions including cerebral infarction, GERD, and hypothyroidism, had a face sheet and provider note documenting a diagnosis of hypothyroidism. However, the resident’s care plan dated 3/13/2025 incorrectly identified hyperthyroidism instead of hypothyroidism and included interventions tailored to hyperthyroidism, such as adjustment of lighting to prevent eye irritation, safety for altered mental status and altered muscle coordination, and encouraging periods of rest to reduce energy needs. The quarterly MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment and a need for moderate assistance with ADLs, and did not list either hypo- or hyperthyroidism as a diagnosis. Interviews with staff revealed gaps in the care planning and review process that contributed to the deficiency. The MDS Coordinator, responsible for MDS assessments and care plans, stated that any licensed charge nurse or management team member could change a care plan and that care plans were discussed in morning meetings and reviewed with quarterly assessments. He acknowledged that the resident’s care plan incorrectly listed hyperthyroidism and that the interventions were not all appropriate for hypothyroidism, explaining that the care plan had been created by an LVN who no longer worked at the facility and that the error was not identified during subsequent reviews, including the last review on 1/14/2026. The DON stated that important care plan items are added on admission by various team members and that active diagnoses are entered by the MDS nurse after the MDS assessment, which she is supposed to review for accuracy. She reported that she did not review this resident’s MDS assessment, despite recognizing that accurate care plans are important for accurate care.
Failure to Maintain Complete Physician Progress Notes in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records when physician progress notes for one resident were not obtained and uploaded into the electronic medical record. The resident was an older female admitted with acute kidney failure, essential hypertension, and rheumatoid arthritis, and a quarterly MDS showed she was cognitively intact with total functional dependence for movement. Record review on 1/28/2026 showed no physician notes in her electronic medical record. The DON confirmed that no physician progress notes had been uploaded and later produced paper physician notes dated 3/21/2025, 10/15/2025, and 11/17/2025, none of which were in the electronic record because the facility was behind with uploads. The Medical Records staff reported he was not on an email group with the facility physicians, had noticed physicians were behind in providing notes, and only requested and uploaded specific documents when someone asked for them, stating that physician notes were not coming to him unless specifically requested. He stated his role was to upload and scan documents and that he had no defined timeframe for doing so. The DON stated physician offices were behind in sending notes, that the Administrator was responsible for contacting physician offices, and that she was not providing medical record oversight, which was handled by an unspecified corporate person. The Administrator acknowledged awareness that some physician offices were behind in sending documentation, had no system for routinely requesting physician notes, and only requested what was needed at the time, despite a facility policy stating it was the facility’s responsibility to notify physicians when progress notes were due and that routine chart audits should identify which physicians needed to be notified.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including moderate cognitive impairment, was transferred using a mechanical lift by a single certified nursing assistant (CNA), contrary to the resident's care plan and facility policy. The care plan and recent assessments specified that transfers required the assistance of two staff members using a mechanical lift. Despite this, the CNA performed the transfer alone, removing the sling and completing the process without another staff member present. The CNA was new to the facility, on her first day of orientation, and had not yet received facility-specific training on mechanical lift transfers. The CNA stated she was aware that two people were required for mechanical lift transfers but proceeded alone because other staff were occupied and she did not request assistance. Interviews with other staff confirmed that the expectation was to use two people for such transfers, and that the CNA had been orienting with another aide who was temporarily unavailable. The resident involved did not sustain any injuries and reported not recalling how many staff usually assisted with transfers, but other residents and staff confirmed that two or more staff were typically used for mechanical lift transfers. Facility policies, as well as manufacturer and regulatory guidelines, require that mechanical lifts be operated by at least two trained staff members to ensure safety. The facility's care planning and hydraulic lift policies, as well as external guidelines from OSHA and the FDA, all support this standard. The incident was observed and confirmed through interviews and record review, demonstrating a failure to implement the comprehensive, person-centered care plan as required for the resident's identified needs.
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with dementia and a history of repeated falls. The resident, who had a moderately impaired cognitive status as indicated by a BIMS score of 7, was identified as an elopement risk based on a recent assessment. Despite this, there were no interventions in place on the care plan to address the risk of elopement prior to the incident. On the night of the incident, the resident was last seen in the hallway by staff at approximately 1:20 AM. Shortly after, the exit door alarm in the dining room sounded, but staff response was delayed and the alarm was reportedly not loud enough to be clearly heard by all staff. The resident was subsequently found outside the facility, face down in the parking lot, with a nosebleed and skin tears on her forehead and cheek. She was transported to the emergency department and returned a few hours later. Interviews with staff revealed that although the resident had been assessed as high risk for elopement, staff did not perceive her as exit-seeking prior to the event and interventions were not implemented until after the incident. The facility's policy required assessment and care plan modifications for residents at risk of elopement, but these steps were not taken in this case. The lack of timely and appropriate supervision, as well as insufficient alarm volume, contributed to the resident's unsupervised exit and subsequent injury.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulation. For one resident with severe cognitive impairment and a history of wound care refusal, the care plan did not reflect the resident's refusals of wound treatment prior to a certain date, despite documentation and staff interviews confirming repeated refusals and the need for daily education involving the resident and family. The wound administration record also showed gaps in documentation for several days, and the care plan was not updated to reflect the resident's right to refuse treatment or the interventions used to address this issue. For another resident with moderate cognitive impairment and a diagnosis of dementia, the care plan did not address the resident's behaviors of making allegations and accusations about care, even though staff interviews and social work documentation confirmed a pattern of such behaviors. Staff accommodated the resident's preferences and worked with psychiatric and psychological services to address these behaviors, but these interventions and the resident's behavioral history were not included in the care plan. The facility's own policy required care plans to describe services furnished to attain or maintain the resident's well-being and the right to refuse treatment, but these elements were missing for both residents.
Failure to Document Wound Care and Refusals in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was reviewed for clinical records. Specifically, the wound treatment administration record for a male resident with severe cognitive impairment and a history of wound care refusal did not contain any documentation of wound care from 10/01/25 to 10/06/25, despite orders for daily wound care. Interviews with nursing staff revealed that the resident frequently refused wound care, and staff had to involve the resident's family to encourage compliance. However, these refusals and the attempts to provide care were not documented in the treatment administration record as required by facility policy. The facility's own policies require that all treatments be documented on the Treatment Administration Record and that complete and accurate documentation be maintained for each resident. Both the administrator and the DON acknowledged during interviews that refusals of wound treatment should have been documented to ensure the accuracy of the resident's records. The lack of documentation for the specified period was confirmed through record review and staff interviews.
Failure to Immediately Notify Physician and Representative After Resident Injury
Penalty
Summary
A deficiency occurred when a nurse failed to immediately notify a resident's physician and representative after the resident was found injured and confused on the floor by her bedside. The nurse, LVN A, did not report the incident to the physician or the resident's representative at the time of the event, despite documenting that she intended to do so. The resident was later hospitalized and diagnosed with acute congestive heart failure with fluid overload and multiple right rib fractures. The incident was not recognized as a fall by LVN A, and she did not consider the need for immediate notification, even though the resident had visible injuries and a change in mental status. The resident involved had a complex medical history, including end-stage renal disease, hypertension, and metastatic pancreatic cancer. She had previously been assessed as cognitively intact, with minimal hearing and vision difficulties, and was independent in activities of daily living. Prior to the incident, the resident had experienced increased confusion, which had been reported to the physician and family. On the day of the event, the resident was found kneeling on the floor with abrasions to both knees, and was assisted back to bed by CNAs before being assessed by LVN A. Interviews and record reviews revealed that LVN A did not notify the physician or the resident's representative immediately after the incident, as required by facility policy. The resident's representative only learned of the fall and injuries upon arriving at the facility later that morning. The medical director confirmed that the expectation was for nursing staff to report unwitnessed falls with injuries to a physician within a reasonable time, such as within an hour. The deficiency was identified as past noncompliance, with the immediate jeopardy period beginning on the date of the incident and ending several days later.
Failure to Follow Fall Protocols and Timely Notification After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with complex medical conditions, including end stage renal disease, hypertension, and metastatic cancer, experienced an unwitnessed fall with injuries. The resident was found on the floor by her bedside by two CNAs, who repositioned her back into bed without first notifying a nurse or having the nurse assess her for injuries. The nurse on duty, LVN A, subsequently assessed the resident in bed, noted abrasions to her knees, and provided basic first aid. However, LVN A did not initiate neurological assessments as required for unwitnessed falls with injuries, nor did she promptly notify the physician or the resident's representative as per facility protocol and policy. LVN A documented that she had notified the nurse practitioner and the resident's representative, but later admitted she had not actually done so at the time of the incident, only intending to call the nurse practitioner during business hours and leaving a message for the representative. The resident's representative was not informed of the fall until arriving at the facility later that morning, at which point the resident was found to be confused and injured. After the representative alerted another nurse, the resident was assessed and subsequently transferred to the hospital, where additional injuries, including rib fractures and significant changes in mental status, were identified. Interviews and record reviews confirmed that the facility's protocols required immediate assessment by a nurse after a fall, prompt notification of the physician and family, and initiation of neurological checks for unwitnessed falls or head injuries. The failure to follow these protocols, including the lack of timely notification and assessment, constituted noncompliance with professional standards of practice and the facility's own policies. The deficiency was identified as past noncompliance, with the Immediate Jeopardy period beginning on the date of the incident and ending several days later.
Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored in locked compartments as required. The long-term care medication room was found unlocked and open without staff supervision, with both over-the-counter and prescribed medications accessible inside. The Director of Nursing (DON) confirmed that the medication room was supposed to be locked at all times, but acknowledged that nurses might not fully close the door, resulting in it being left open and unlocked. Facility policy requires all medications and treatment items to be stored in a locked cabinet or room, inaccessible to patients and visitors. Additionally, a 10 cc syringe of normal saline intended for flushing a resident's peripherally inserted central catheter (PICC) line was found unattended on the resident's nightstand while the resident was sleeping. The resident had been admitted with multiple diagnoses, including pneumonia, hypertension, lymphedema, respiratory failure, and pulmonary embolism, and had physician orders for intravenous antibiotics and saline flushes. Both the LVN and DON confirmed that the normal saline should have been stored in a nursing cart rather than left in the resident's room, in accordance with facility policy.
Improper Food Handling and Infection Control Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food safety and infection control practices. The Dietary Manager was seen wearing a facial hair restraint that only covered his chin and not his mustache while taking food temperatures and cooking, including stirring soup and onions. He continued to work in this manner until he later adjusted the restraint to cover his mustache after leaving and returning to the kitchen. The Dietary Manager acknowledged that the restraint was intended to prevent hair from contaminating food and that staff were required to wear hair restraints upon entering the kitchen. Further observations revealed that a dietary staff member, while wearing gloves, handled plates by touching the inner surfaces with her thumb and fingers, patted the plates, and moved tray racks without changing gloves or washing hands. She also used a towel to open the warmer doors and then continued to handle food and plates without performing hand hygiene or changing gloves. During an interview, the staff member recognized that she should have washed her hands and changed gloves after these activities to prevent cross contamination. Interviews with the Dietary Manager, DON, and Administrator confirmed that these actions were not in line with facility policy or professional standards. The facility's policy required proper use of hair restraints, avoidance of touching food contact surfaces, and appropriate glove use with hand hygiene after touching potentially contaminated surfaces. The Administrator and DON both identified these lapses as infection control issues that could lead to foodborne illness, and the Dietary Manager stated that improper hand hygiene and glove use could result in harm to residents.
Failure to Maintain Infection Control Practices and Proper PPE Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents, resulting in multiple observed deficiencies. In one instance, a CNA provided incontinence care to a female resident with severe cognitive impairment and chronic medical conditions, including COPD, diabetes, and hemiplegia. After removing a soiled brief and cleaning the resident's perineal and buttock areas, the CNA did not change gloves before placing a clean brief under the resident, despite handling contaminated materials. The CNA only removed gloves and washed hands after completing the care, which was confirmed during interviews with both the CNA and the DON. In another case, an LVN performed colostomy care for a female resident with severe cognitive impairment, dementia, and a history of COVID-19 and intestinal obstruction. After cleaning feces from the resident's stoma, the LVN changed gloves but did not sanitize or wash hands before donning new gloves and applying a new colostomy bag. The LVN acknowledged during interview that hand hygiene should have been performed between glove changes, and the DON confirmed this expectation. Additionally, the facility did not ensure that staff wore appropriate PPE when entering the room of a resident on aerosol isolation precautions due to COVID-19 exposure. Two staff members were observed entering the room wearing only regular face masks, gowns, and gloves, rather than the required N95 respirators and eye protection. They also improperly removed and transported contaminated PPE and trash out of the isolation room. Interviews with the staff, DON, and Administrator revealed confusion and lack of adherence to the facility's posted isolation protocols, which required specific PPE and disposal procedures to prevent cross-contamination.
Failure to Ensure Completion and Documentation of Required Annual Staff Trainings
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, as evidenced by the lack of required annual trainings for five employees, including a CNA, a dietary aide, a medication aide, the dietary manager, and the assistant director of nursing. Personnel records reviewed for these staff members showed missing documentation of annual trainings in key areas such as communication, ethics, resident rights, and behavioral health. The HR Coordinator confirmed that the facility used an online training platform (Relias) and that department heads were responsible for ensuring staff completed their assigned annual trainings, but records did not show completion of all required topics for the reviewed period. Interviews with the HR Coordinator, Administrator, and DON revealed that while the facility had processes in place for assigning and notifying staff of required trainings, there was a lack of oversight to ensure completion and documentation of all mandated annual trainings. Additionally, when requested, the facility was unable to provide a policy specifically addressing the required annual trainings in communication, resident rights, ethics, and behavioral health prior to the survey exit. The employee handbook referenced mandatory training but did not specify the required topics or provide evidence of compliance for the staff reviewed.
Failure to Provide Annual Ethics Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual ethics training to three employees: a Dietary Aide, the Dietary Manager, and the Assistant Director of Nursing (ADON). Personnel records for these staff members showed no evidence of ethics training being completed during the review period. The facility utilized Relias, a computer-based training program, to assign and track annual trainings, with notifications sent to both employees and their supervisors. However, despite these systems, the required ethics training was not documented as completed for the identified staff. Interviews with the HR Coordinator, Administrator, and DON confirmed that annual trainings were assigned and that department heads were responsible for ensuring completion. The HR Coordinator and Administrator both emphasized the importance of annual training for staff, noting that it is necessary to ensure resident safety and compliance with facility policy. Review of the facility's employee handbook also confirmed that all employees are required to complete mandatory training as defined by federal, state, and company policies.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A registered nurse (RN) failed to maintain the confidentiality of a resident's personal and medical records by leaving her computer open and unattended on a nursing cart in a hallway. The computer screen displayed the resident's picture, name, date of birth, room number, age, and medication information. This was observed for a period of five minutes without any staff present at the cart, making the information accessible to unauthorized individuals. The resident involved was an elderly female with diagnoses including nonalcoholic steatohepatitis, seizures, anemia, and type 2 diabetes mellitus. She was cognitively intact but required substantial to maximal assistance with mobility and transfers. The Director of Nursing (DON) confirmed the privacy violation upon observing the unattended computer, and the RN acknowledged forgetting to lock the computer screen, admitting it was a mistake.
Inaccurate MDS Coding for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident who had an indwelling urinary catheter. Specifically, the admission MDS for a female resident with chronic kidney disease, type 2 diabetes mellitus, fluid overload, dementia, and a urinary tract infection was coded as "Always urinary incontinent" in Section H (Bladder and Bowel), despite documentation and observation confirming the presence of an indwelling urinary catheter. According to MDS coding guidelines, the continence status should have been marked as "Not rated" when a urinary catheter is present. Interviews with the MDS nurse and the Director of Nursing confirmed that the incorrect coding was a mistake and acknowledged that it was the responsibility of the MDS nurse to ensure accurate assessments. The facility's policy on resident assessment requires that results be recorded to assure continued accuracy, which was not followed in this instance. The error was identified through record review, staff interviews, and direct observation of the resident and her catheter.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review showed that the resident was admitted with multiple diagnoses, including acute kidney failure, type 2 diabetes mellitus, hyperlipidemia, hypertension, peripheral vascular disease, gastro-esophageal reflux disease, and a history of pulmonary embolism. Despite these complex medical needs, there was no completed baseline care plan in the resident's electronic medical record, and the Admission MDS assessment did not identify a BIMS score. The resident and their representative confirmed that they had not received a copy of a baseline care plan. Interviews with facility staff revealed that the admitting nurse or charge nurse was responsible for initiating the baseline care plan upon admission. The DON stated that the nurse assigned to the resident's admission had recently given notice and had not been present since, which contributed to the failure to initiate the care plan. The DON acknowledged that, as a result, the resident was at risk for not receiving care that addressed their specific needs. Facility policy required that a baseline care plan be developed within 48 hours of admission, but this was not followed in this case.
Failure to Include DNR Status in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with multiple medical conditions, including cancer, shortness of breath, and pain, who was also receiving hospice services. Despite the resident having a documented out-of-hospital do not resuscitate (DNR) order and a physician's order for DNR, the care plan did not reflect the resident's code status. The care plan review did not include this critical information, and there was no evidence that the interdisciplinary team had reviewed or updated the care plan to include the DNR status. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating the care plan with code status changes. The social worker stated she would update the care plan when code status changed, but had not signed off on the relevant section. The MDS coordinator acknowledged the absence of a code status care plan and indicated that it should have been included, noting that care plans are interdisciplinary documents. The administrator confirmed that the care plan should be person-centered and complete to ensure staff have the necessary information to provide proper care.
Unattended Disposable Razor Found in Resident Restroom
Penalty
Summary
A deficiency was identified when a disposable razor was found unattended on the sink inside a resident's restroom. The resident in question was a male with severe cognitive impairment, as indicated by a BIMS score of 6 out of 15, and required substantial to maximal assistance with activities of daily living, including personal hygiene and shaving. Facility records and the resident's care plan specified that staff were to assist with personal hygiene and that razors were considered safety hazards not allowed in resident rooms. During observation, the disposable razor was noted to be dirty with old hairs, and staff interviews confirmed that the resident required assistance with shaving. Staff acknowledged that razors should be discarded in a sharps container after use to prevent harm and infection, and that it was the responsibility of all staff to ensure razors were not left accessible. The facility's policy also listed razors as items not permitted in resident rooms due to safety concerns.
Failure to Provide Proper Perineal Care for Incontinent Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was incontinent of bladder. During an observation, the CNA did not separate and clean the resident's labia area while providing incontinence care, despite removing the soiled brief and cleaning other areas. The CNA later acknowledged forgetting to perform this step due to nervousness, even though she had received peri-care training and had recently passed a skill checkoff for female perineal care. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 5 out of 15, and was always incontinent of both bowel and bladder. Her care plan required incontinence care at least every two hours and the application of a moisture barrier after each episode. Facility policy specified that perineal care for female residents should include separating and cleaning the labia majora from front to back. The Director of Nursing confirmed that the CNA should have separated and cleaned the labia area to prevent possible infection.
Improper Flushing Technique Used for Enteral Feeding Tube
Penalty
Summary
A deficiency occurred when a registered nurse (RN) flushed a resident's gastrostomy tube with 250 ml of water by pushing the water into the syringe barrel with a plunger, rather than allowing the water to flow by gravity. This action was observed during a medication administration for a female resident with severe cognitive impairment, a history of cerebrovascular accident, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hemiplegia, cerebral infarction, and hypertension. The resident's care plan specified tube feeding and required monitoring for complications such as aspiration, fever, tube dislodgement, and infection at the tube site. The RN acknowledged using the plunger to flush the tube and stated she believed it was acceptable because there was no residual, but typically used gravity for medication administration. The facility's Director of Nursing confirmed that facility policy requires gravity to be used for flushing gastrostomy tubes, with gentle plunger pressure only if gravity cannot be used due to blockage. The facility's policy explicitly states not to force fluids into the tube and to allow gravity to work, applying gentle pressure only if necessary after repositioning the resident.
Failure to Follow Physician Orders for PICC Line Flushing
Penalty
Summary
A registered nurse (RN) failed to follow physician orders for the administration of intravenous (IV) fluids for a male resident with a peripherally inserted central catheter (PICC) line. The resident, who had been admitted with diagnoses including pneumonia, hypertension, lymphedema, respiratory failure, and pulmonary embolism, had a physician order specifying that both lumens of the PICC line should be flushed with 10 cc normal saline—one before and after medication administration, and the blood port specifically every evening antibiotic dose. During an observed medication administration, the RN only flushed the medication port and did not flush the blood port as ordered. Upon interview, the RN acknowledged not flushing the blood port and admitted to not remembering the specific order to do so. The Director of Nursing (DON) confirmed that the nurse was responsible for flushing both lumens according to the physician's order and facility policy, which requires each lumen to be flushed with a separate syringe as ordered. Facility policy and the care plan both supported the need for flushing the ports as directed by the physician.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring such care, as evidenced by direct observations, interviews, and record reviews. One resident with severe cognitive impairment and chronic obstructive pulmonary disease had a nebulizer mask left uncovered on the nightstand when not in use, contrary to professional standards and staff acknowledgment that it should have been covered to prevent possible infection. The facility did not have a specific policy regarding covering respiratory equipment when not in use, and responsibility was left to the nursing staff. Another resident, admitted with pneumonia and respiratory failure, was observed receiving oxygen at 4 liters per minute via nasal cannula without a corresponding physician order. The care plan indicated oxygen therapy as ordered, but no physician order for oxygen was found in the resident's records. Facility staff confirmed that the resident was receiving oxygen without an order due to an oversight in entering the order into the system, which was acknowledged as a mistake and inconsistent with the facility's own policy requiring physician orders for oxygen administration.
Failure to Provide Annual Communication Training to Staff
Penalty
Summary
The facility failed to provide annual communication training to two employees, specifically a CNA and a medication aide, as evidenced by a review of their personnel records. The records showed no documentation of communication training for the period reviewed, despite the facility's use of an online training platform (Relias) for annual mandatory trainings. Interviews with the HR Coordinator, Administrator, and DON confirmed that annual trainings were assigned and tracked through Relias, with department heads responsible for ensuring completion. However, there was no evidence that the required communication training was completed by the two staff members in question. Additionally, when requested, neither the HR Coordinator, Administrator, nor DON were able to provide a policy specifically addressing required annual training, including communication training, prior to the survey exit. The facility's employee handbook did state that all employees are required to complete mandatory training as defined by federal, state, and company policies, but did not provide specific details about communication training. This lack of documentation and policy contributed to the deficiency cited by surveyors.
Failure to Provide Annual Resident Rights Training for Dietary Manager
Penalty
Summary
The facility failed to provide mandatory and effective annual training on resident rights for one of its employees, specifically the Dietary Manager. Review of the personnel records showed that the Dietary Manager, hired in April 2023, did not have documented evidence of completing resident rights training for the period reviewed. The HR Coordinator confirmed that the facility uses a computer-based training program (Relias) to assign and track annual trainings, and that both employees and their department heads receive email notifications when trainings are due. However, there was no record indicating that the Dietary Manager completed the required resident rights training during the specified timeframe. Interviews with the HR Coordinator, Administrator, and DON revealed that the responsibility for ensuring completion of annual trainings lies with both the employees and their supervisors. Despite this system, the required documentation for the Dietary Manager's resident rights training was missing. Additionally, when requested, neither the HR Coordinator, Administrator, nor DON could provide a policy specifically addressing the requirement for annual resident rights training prior to the survey exit.
Failure to Provide Required Annual In-Service Training to CNA
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) received the required minimum of 12 hours of annual in-service training. Review of personnel records for one CNA, who was hired on 07/31/2023, showed no evidence that the facility provided the mandated annual in-service trainings, including communication training, within the previous 12 months. The HR Coordinator confirmed that the facility used a computer-based training program (Relias) to assign and track annual trainings, and that both employees and department heads received email notifications regarding training assignments. However, it was the responsibility of department heads to ensure completion, and there was no documentation that the required training was completed for the CNA in question. Interviews with the HR Coordinator, Administrator, and DON revealed that while the facility had systems in place to assign and notify staff of required trainings, there was a lack of oversight to ensure completion. The DON, who was new to the facility, was not familiar with the process for assigning annual trainings. Additionally, when requested, neither the HR Coordinator, Administrator, nor DON could provide a policy specifically addressing the required minimum 12 hours of annual in-service training for CNAs prior to the survey exit.
Failure to Provide Annual Behavioral Health Training to Dietary Manager
Penalty
Summary
The facility failed to provide annual behavioral health training to the Dietary Manager, as required by federal regulations and the facility's own assessment. Review of the Dietary Manager's personnel records showed no evidence of behavioral health training being completed for the period reviewed. The HR Coordinator confirmed that the facility uses Relias, a computer-based training program, to assign and track annual trainings, and that both employees and department heads receive email notifications regarding required trainings. However, the Dietary Manager did not have documentation of completing the required behavioral health training for the specified timeframe. Interviews with the HR Coordinator, Administrator, and DON revealed that the responsibility for ensuring completion of annual trainings lies with both the employees and their supervisors or department heads. Despite this system, the required behavioral health training was not completed or documented for the Dietary Manager. Additionally, when requested, no policy specifically addressing required annual training, including behavioral health training, was provided by facility leadership prior to the survey exit.
Failure to Provide Required SNF ABN Notification for Discontinued Skilled Services
Penalty
Summary
The facility failed to provide required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS form 10055 to two residents when their skilled services were discontinued prior to exhausting their covered Medicare days, despite both residents receiving and signing the Notice of Medicare Non-Coverage (NOMNC). The SNF ABN would have informed the residents of their option to continue services at a private pay rate. Record reviews confirmed the absence of the SNF ABN forms for both residents, even though facility policy required this notification when a resident remains in the facility after skilled services end but before Medicare days are exhausted. Interviews with staff revealed a lack of awareness regarding the requirement to provide the SNF ABN in these circumstances. The MDS coordinator acknowledged not knowing that residents who remained in the facility after skilled services ended, but before exhausting their benefit period, needed to receive the SNF ABN. The administrator confirmed that the MDS coordinator was responsible for completing the SNF ABN forms and recognized that not providing them meant residents or families were not informed about the option to continue services privately or the associated costs.
Verbal Abuse Incident Involving Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as observed by a state surveyor. On the specified date, a CNA was overheard speaking negatively about a resident in a hallway, referring to the resident as lazy and suggesting that the resident treated the staff as maids. This conversation took place within earshot of open resident rooms, potentially exposing other residents to the derogatory remarks. The resident in question, who was not present during the conversation, has a history of cerebral infarction, type 2 diabetes, hemiplegia, and depression, and is dependent on staff for daily activities. Interviews conducted with the involved staff members revealed differing accounts of the conversation. The CNA admitted to discussing the resident's lack of cooperation but denied using derogatory terms. However, another staff member confirmed hearing the CNA make inappropriate comments about the resident's abilities and attitude. The facility's policy on abuse and neglect clearly prohibits such verbal abuse, which includes the use of disparaging language within the hearing distance of residents. The incident highlights a failure to maintain an environment free of abuse and neglect, as required by the facility's policies.
Misappropriation of Resident's Bank Card by Facility Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property, specifically her bank card, which was stolen and used without her consent. The resident, an elderly woman residing in the facility for long-term care, had her bank card used at the facility's vending machines and various local businesses. The resident's family member alerted the facility to the unauthorized transactions, as the resident herself was unable to use the card and did not have visitors who could have done so. The facility's investigation identified two CNAs, who were twins, as potential suspects, but it was unclear which one or if both were involved in the theft and misuse of the card. The facility contacted local law enforcement, provided them with relevant information, and attempted to gather additional evidence from local businesses, but these efforts were unsuccessful. The facility's policy on abuse and neglect, which includes misappropriation of resident property, was in place, but the incident still occurred, indicating a lapse in its enforcement or effectiveness at the time of the event.
Unattended and Unlocked Nursing Cart Poses Safety Risk
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an incident involving the 400-hall nursing cart. During an observation, the cart was found unlocked and unattended, allowing access to multiple medication blister packs, scissors, and bottles of medications. This oversight was confirmed by LVN-A, who admitted to leaving the cart unlocked and acknowledged the importance of keeping it secured to ensure the safety of residents, visitors, and staff. The Director of Nursing (DON) also confirmed that the nursing cart should not have been left unlocked, as it posed a safety risk, particularly to residents with dementia who might access the medications. The facility's policy on medication storage, which was reviewed, specifies that the medication supply should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications. The 400-hall nurse was identified as responsible for ensuring the cart was locked, although monitoring was only done sometimes.
Infection Control Deficiency Due to Non-Compliance with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a wound care nurse who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident. The resident, a male with a history of Parkinson's disease, dermatitis, type 2 diabetes mellitus, and hypertension, was on EBP due to a risk of developing pressure ulcers. During a wound care procedure, the nurse entered the resident's room, sanitized her hands, and donned gloves but failed to wear a gown as required by the facility's policy for high-contact activities such as wound care. The nurse's failure to wear a gown was confirmed through interviews with both the nurse and the Director of Nursing (DON). The nurse admitted to being nervous and forgetting to wear the gown, despite having been trained on EBP. The DON corroborated that the nurse should have worn a gown when providing wound care to the resident. The facility's policy, revised in April 2024, clearly states that gloves and gowns must be worn during high-contact care activities, including wound care, to prevent possible contamination and infection.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the administration of oxycodone, a medication prescribed for pain relief. On June 10, 2024, the resident was scheduled to receive oxycodone every 8 hours, but the 4:00 PM dose was not administered. Despite this, the medication administration record (MAR) inaccurately documented that the dose was given by RN B. This discrepancy was discovered during a narcotic reconciliation count, which showed that only two doses were dispensed that day instead of the prescribed three. Interviews with the nursing staff revealed that RN B did not administer the 4:00 PM dose because it was too close to the next scheduled dose at midnight. RN B admitted to the mistake but failed to notify the Director of Nursing (DON) or the physician about the missed dose. The DON confirmed that the error was not reported until the end of RN B's shift, and there was no explanation for the inaccurate documentation in the MAR. The resident, who has a history of end-stage renal disease, anxiety, metabolic encephalopathy, and hypertension, was unable to recall whether the dose was received. The family member also could not confirm the administration of the medication. The facility's policies on physician's orders and medication administration procedures emphasize the importance of accurate documentation and adherence to prescribed orders, which were not followed in this instance.
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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