Solera At West Houston
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 2101 Greenhouse Road, Houston, Texas 77084
- CMS Provider Number
- 676310
- Inspections on file
- 30
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Solera At West Houston during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including type 1 DM and ESRD, had an unstageable right hip pressure injury with physician orders to cleanse the wound, apply skin prep to the peri-wound edge, apply Santyl to the wound bed, then apply calcium alginate and a border dressing each shift. During an observed dressing change, an LVN performed hand hygiene and cleansing but did not apply the ordered skin prep or Santyl, instead placing calcium alginate directly on the wound bed and covering it with a border dressing. The LVN later stated that a wound specialist NP had verbally changed the treatment earlier in the day but that she had not yet transcribed the new order, while the DON and RN staff indicated that nurses are expected to follow the orders entered in the system and that wound care orders are normally updated promptly by the NP or nursing leadership.
A resident with multiple comorbidities and limited mobility was admitted with a documented pressure injury to the right heel, but the facility failed to identify and properly assess the wound upon admission. Despite ongoing complaints of foot pain, the wound was not promptly recognized or treated as a pressure ulcer, and wound care was inconsistently provided and documented. The wound progressed to a necrotic state, leading to hospitalization and eventual above-the-knee amputation due to infection.
A resident with multiple comorbidities, including a recent hip replacement and diabetes, was admitted with a documented right heel pressure injury that was not accurately reflected in the facility's initial assessments or weekly skin documentation. The wound care nurse inconsistently recorded the presence of the wound, and the resident's ongoing pain and wound progression were not properly addressed or documented. Inconsistent assessment and infrequent wound care led to the wound worsening, ultimately resulting in hospitalization and amputation.
A plan to meet a resident's most immediate needs within 48 hours of admission was not created or put into place, as required. The facility did not ensure that a process was followed to assess and address the immediate needs of newly admitted residents within the specified timeframe.
A deficiency was cited when a resident's care plan did not include all necessary interventions, lacked measurable timetables, and failed to specify actions to address the resident's needs, as evidenced by incomplete documentation in the resident's records.
Surveyors observed three medication carts left unlocked and unattended in areas accessible to residents, staff, and visitors. Staff members admitted to leaving the carts unsecured due to malfunctioning locks or while attending to residents, and the DON confirmed that carts should have been locked at all times when out of view, in accordance with facility policy.
Surveyors identified multiple deficiencies in food storage, preparation, and service, including unsealed and unlabeled foods, improper dish cleaning, and failure to maintain required food temperatures. Observations included open containers in storage, dirty kitchen equipment, and food items on the steam table not held at safe temperatures, all contrary to facility policy.
Staff failed to maintain privacy for three residents during personal care activities, including entering rooms without knocking, not closing blinds or doors, and leaving a resident uncovered while unattended. These actions resulted in residents being exposed during care, despite staff having received training on privacy and dignity protocols.
Two residents who were dependent on staff for ADLs did not receive timely incontinent care, resulting in them being left in soiled briefs for extended periods. Staff interviews and observations confirmed that required two-hour rounding and care protocols were not consistently followed, despite both residents having care plans specifying the need for assistance and staff being trained on these procedures.
Two female residents who were dependent on staff for ADLs did not receive proper incontinent care, as CNAs failed to separate the labia and clean the area thoroughly before applying clean briefs. Both CNAs only corrected their technique after surveyor intervention, despite being trained on the correct procedure. Nursing leadership confirmed the expected protocol for cleaning and infection control, but the facility's incontinent care policy was not provided to surveyors.
Surveyors found that kitchen staff failed to label and date frozen premade waffles stored in the facility freezer, contrary to facility policy requiring opened or prepared foods to be labeled and used within 2-3 days. The Dietary Manager and other staff confirmed shared responsibility for proper food storage, and training records indicated staff had been instructed on these procedures. The Director of Nursing stated that the Dietary Manager was responsible for ensuring compliance with food storage policies.
Several staff members failed to adhere to infection control and hand hygiene protocols during care, including not washing hands before or after glove use, using the same gloves for both clean and dirty tasks, and improper handling of soiled items and clean linens. These lapses occurred while providing care to residents with significant medical needs, such as cognitive impairment, Parkinson's disease, and diabetes.
Two residents with complex medical needs did not have comprehensive, person-centered care plans addressing critical areas such as code status, allergies, impaired thought processes, cellulitis, nutritional problems, and feeding tube use. Staff interviews and record reviews confirmed that these omissions were not in accordance with facility policy or regulatory requirements, and the care plans did not reflect current needs or physician orders.
A CNA did not use a gait belt when transferring a resident with Parkinson's disease and other conditions, instead using improper techniques that left the resident unsteady and at risk. Additionally, used food trays and cutlery were left unattended in a hallway after meals, contrary to facility expectations and infection control practices. Staff interviews confirmed both deficiencies and acknowledged the required procedures were not followed.
A food cart with nine used trays and cutlery was left unsealed outside the kitchen entrance in a resident hall, rather than being promptly returned to the kitchen. Staff interviews confirmed this was not in line with facility policy, and that the practice posed infection control concerns and risks of cross-contamination, especially for residents with impaired cognition.
A male resident in a LTC facility was found inappropriately touching a female resident, who has severe cognitive impairment and multiple medical conditions. The incident was observed by the female resident's RP via electronic monitoring, and staff intervened immediately. The male resident, who has dementia, was arrested by law enforcement. The facility's policies emphasize resident protection, but the incident revealed a lapse in ensuring resident safety.
A resident with a stage IV pressure ulcer did not receive proper wound care due to the facility's failure to implement a PRN order for changing soiled bandages. Despite the resident's ability to communicate her needs, staff did not address her concerns, leaving her bandages wet with urine and increasing the risk of infection. The facility's wound care nurse was unavailable, and floor nurses lacked the necessary orders to perform adequate wound care.
A resident with quadriplegia and a stage IV pressure ulcer experienced inadequate care due to urine leakage not being properly managed, leading to soaked bandages and discomfort. Despite having a nephrostomy bag, the resident leaked urine, which was mistaken for wound drainage by staff. The facility lacked PRN orders for changing soiled bandages, and the wound care nurse was unavailable, resulting in insufficient care and increased risk of infection.
A resident did not receive a prescribed multivitamin with folic acid for six days due to it being out of stock, despite the MAR being initialed as if administered. The MA failed to notify the charge nurse or DON about the unavailability, leading to a significant medication error.
The facility failed to follow professional standards for food safety, with several food items lacking proper labeling and use-by dates, and an ice scoop improperly stored inside the ice bin. These practices could lead to foodborne illness risks for residents.
The facility failed to maintain an effective infection prevention and control program, as LVN C did not clean the accu-check machine between residents, and a resident's external urinary catheter tubing was found on the floor. These lapses in protocol placed residents at risk for infection, despite existing policies requiring proper cleaning and handling of medical equipment.
A resident with an indwelling urinary catheter was found without a catheter leg strap, contrary to care plan and physician orders, leading to a deficiency in care. The resident's catheter tubing contained blood-stained urine, and the resident required antibiotics for a urinary tract infection. The DON confirmed the need for catheter security to prevent trauma and infection, but this protocol was not followed.
The facility failed to store and label medications properly, with opened and undated Azelastine Spray and Fluticasone Propionate found in Hall 100's medication cart, and expired medications and supplies in various halls. Staff interviews revealed inconsistent checks for expired items, with responsibilities not effectively carried out.
The facility failed to ensure proper disposal of garbage by not securing the lids and doors of dumpster A, which was observed to be three-quarters full with its door open. The Food Service Manager acknowledged the importance of keeping the dumpster closed to prevent pests and insects. Staff from dietary, nursing, and housekeeping are responsible for monitoring the dumpster doors, as outlined in the facility's waste disposal policies.
A facility failed to maintain an effective pest control program, resulting in sugar ants in a resident's room and a bathroom. The resident, with multiple medical conditions, reported ants, but staff initially did not observe them. The Maintenance Director addressed the issue informally without documentation, and the pest control service had not yet reached the resident's room. The facility's pest control policy and logs did not reflect the ant sightings, leading to a deficiency.
A resident with severe cognitive impairment and incontinence did not receive proper incontinent care, as observed when CNA A failed to clean the labia and buttocks correctly. This oversight, admitted by CNA A, posed a risk of urinary tract infections. The facility's perineal care checklist was not followed, highlighting a deficiency in care procedures.
A facility failed to maintain proper infection control practices during incontinent care for a resident with severe cognitive impairment and multiple medical conditions. CNA A did not wash hands or use hand sanitizer after changing gloves and applied antiseptic ointment without proper hygiene. The resident's care plan required diligent skin care to prevent breakdown, but CNA A missed critical steps, such as cleaning the labia and buttocks thoroughly. The facility's infection control policy lacked guidance on hand washing, contributing to the deficiency.
A resident with multiple medical conditions, including impaired cognition, experienced emotional distress when a CNA aggressively removed her blanket and used profanity in the presence of an LVN. The incident was reported, and the CNA was terminated for unprofessional behavior.
A resident was verbally abused by a CNA, who made inappropriate and racially charged comments. The incident was captured on camera, and the resident felt unsafe and disrespected. The facility failed to document and address the incident properly, despite having an abuse prevention policy in place.
A facility failed to provide adequate supervision during a resident transfer, as a CNA conducted a mechanical lift transfer alone despite the care plan requiring two-person assistance. The resident had multiple diagnoses and was dependent on assistance for transfers. Video evidence and interviews confirmed the one-person transfer, contrary to facility policy and training.
Failure to Follow Physician Wound Care Orders for Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a pressure ulcer received wound care treatment and services as ordered by the physician and consistent with professional standards of practice. The resident was an adult female with scoliosis, type 1 diabetes mellitus with hyperglycemia, end-stage renal disease on dialysis, and legal blindness, who was admitted with a pressure ulcer as documented on the admission MDS. Her comprehensive care plan for skin concerns, dated 12/29/25 and revised 01/02/26, included an intervention to provide treatment as ordered. Physician orders dated 01/30/26 for an unstageable pressure injury to the right hip directed staff to cleanse with normal saline or house wound cleanser, pat dry, apply skin prep to the peri-wound edge, apply Santyl to the wound bed, apply calcium alginate, and cover with border gauze every shift. The MAR/TAR for February 2026 reflected that the facility was following this prescribed order. On observation of wound care on 02/18/26 at 12:04 PM, LVN A prepared the bedside table with disinfectant wipes, performed hand hygiene, donned PPE, and set up wound supplies. LVN A removed the old dressing, changed gloves with hand hygiene between glove changes, and cleansed the right hip wound bed with wound cleanser using one wipe at a time. The wound bed was described as dry and pink with tiny black dots. After cleansing, LVN A again changed gloves and sanitized hands, but did not apply skin prep to the peri-wound edge and did not apply Santyl to the wound bed as required by the current physician order. Instead, LVN A applied calcium alginate directly to the wound bed and covered it with a border dressing. The resident tolerated the procedure without complaints of discomfort. In interviews, the DON confirmed that, after reviewing the resident’s orders, LVN A should have followed the physician’s wound care orders to apply skin prep to the wound edges and Santyl to the wound bed. LVN A reported that earlier that day, during rounds with the Wound Specialist NP, the NP had instructed her not to apply Santyl to the right hip wound, but she acknowledged that she had not yet transcribed this new order into the system. LVN A stated that until a new order is entered, staff must follow the existing order. The DON, when asked what order a nurse would follow if a new wound care order had not been updated in the system, stated that such a situation would not occur because she or the ADON would have transcribed the new treatment. RN B stated that if a wound dressing became soiled and needed changing, she would follow the order in the system and that the Wound Care NP typically entered new orders at the time of wound rounds using a laptop cart. Facility policies on Medication Administration and Provision of Quality of Care required that medications and treatments be administered as ordered by the physician and in accordance with professional standards of practice and the resident’s care plan.
Failure to Identify and Treat Pressure Ulcer Resulting in Amputation
Penalty
Summary
A seventy-six-year-old woman with multiple comorbidities, including Type 2 diabetes, metastatic cancer, and recent hip replacement, was admitted to the facility. Upon admission, her hospital records documented a pressure injury to the right heel, but the facility's admission assessment did not identify any wounds, and she was marked as bed bound. Weekly skin assessments were inconsistently documented, with some entries indicating existing skin alterations and others not specifying the location or using unclear abbreviations. The resident was dependent for mobility and at high risk for pressure ulcers, but the care plan interventions, such as floating heels and a pressure redistribution mattress, were not consistently implemented or documented. The resident began to complain of foot pain, which she reported to nurses, the NP, and PT staff over several weeks. Despite these complaints, the wound on her right heel was not promptly or accurately identified. When a blister on her heel burst during physical therapy, it was initially treated as a simple blister rather than a pressure ulcer. The wound care nurse (WCN) did not consult the wound care nurse practitioner (WCNP) immediately, and there was confusion and lack of documentation regarding the wound's assessment and treatment. The wound progressed to a necrotic state with signs of infection, including odor and increased size, but wound care was not provided daily as ordered, and documentation of care was inconsistent. The resident and her family reported that wound care was infrequent, and the mattress provided was uncomfortable and not replaced despite complaints. The wound continued to deteriorate, and the resident was eventually admitted to the hospital with a necrotic pressure ulcer requiring possible amputation. Hospital staff found the wound to be unstageable due to extensive slough and necrosis. Interviews with facility staff revealed lapses in communication, assessment, and documentation, including failure to complete required SBAR assessments and progress notes. The WCN and ADON acknowledged gaps in their documentation and assessment processes, and the WCNP confirmed that the wound was not seen promptly after it opened. Ultimately, the resident underwent an above-the-knee amputation due to the infected pressure ulcer.
Removal Plan
- Skin sweep of all residents to assess for any worsening or unidentified pressure ulcers to identify and provide treatment to all pressure ulcers. The skin sweep was completed by RDCS, DON, DON #2, UNIT MANAGER, and Treatment Nurse with no new findings or negative outcomes.
- Conduct Emergency QAPI meeting regarding pressure ulcers including notification to the medical director.
- RDCS/DON/Designee audit new admissions and readmissions to ensure any pressure injuries are identified appropriately, prevention measures in place, and treatment orders, as applicable.
- Complete in-services regarding pressure ulcers for all licensed nursing staff including head to toe skin assessments, newly identified wounds will be assessed and documented with notifications to RP and medical provider, skin assessment will be completed by charge nurse or treatment nurse for any new admission or readmission, and treatment orders will be obtained as applicable.
- Implement quick interventions to prevent further breakdown of identified pressure ulcers by providing air mattresses for residents as applicable.
- Each Licensed Nurse will complete a post-test after their education is completed to ensure staff comprehend in-services. If the employee does not pass the test with at least 90% correctly answered the staff member will be re-educated and re-tested until at least 90% pass rate is met.
- DON/Designee will utilize a staff roster to ensure 100% compliance with education. Licensed nurses will not be allowed to work until in-services are completed by DON/Designee.
- Head to toe skin assessments of all residents will be completed by the Director of Nursing (DON), Treatment Nurse, Assistant Director of Nursing (ADON), and Regional Compliance Nurse.
- All newly admitted residents will have a head-to-toe skin assessment completed by the licensed nurse or treatment nurse and verified by the DON/Designee to ensure all pressure ulcers are identified upon admission and readmission and ensure appropriate treatment.
- Nursing staff will be in-serviced by the RDCS, DON, ADON, UM and Treatment Nurse on these protocols.
- Clinical staff will not be allowed to work their scheduled shift until they have completed all education related to the IJ.
- The Treatment Nurse or Nurse Manager designee will complete a head-to-toe assessment and document in the EMR to validate the findings of the initial skin assessment.
- Head-to-toe assessments must be completed weekly.
- Any newly identified wounds will be addressed by the Treatment Nurse or Licensed Nurses to include assessment and documentation of the skin site and initiate appropriate clinical interventions.
- Notify the Patient's Representative and Medical Provider of any new or change in the existing wound(s) and document in EMR.
- A Wound Assessment will be completed by the Treatment Nurse or Licensed Charge Nurse and a narrative of each site will be documented weekly for any pressure injury.
- RDCS/DON will complete an audit of all findings to ensure implementation of skin system.
- Notify the Medical Director of the Immediate Jeopardy by Executive Director.
- Conduct emergency QAPI meeting.
- The Treatment Nurse will receive 1:1 education and counseling regarding identification of pressure ulcers including worsening of wounds and obtaining orders from the physician for appropriate treatments.
- The treatment nurse will present a clinical wound report every day during the Clinical Stand-Up Meeting.
- DON/Designee will monitor new admissions during daily clinical IDT Stand Up meeting to ensure skin assessments have been completed upon admission and interventions and treatment orders are in place, as applicable.
- RN Weekend Supervisor will monitor new admissions on the weekend to ensure skin assessments have been completed upon admission and interventions and treatment orders are in place, as applicable.
- Facility policies & procedures will be reviewed by the DON, RDCS, VP of Operations, VP of Clinical Services and Director of Education. The policies and procedures will be included in the staff in-servicing.
Failure to Accurately Document and Assess Resident Wound Status
Penalty
Summary
A deficiency occurred when the facility failed to ensure that assessments accurately reflected a resident's status, specifically regarding the presence and documentation of a wound. The wound care nurse (WCN) did not accurately document an existing wound on the resident's weekly skin assessments after a new skin issue developed. The initial Minimum Data Set (MDS) assessment also failed to record the presence of a skin issue, despite hospital records at admission noting a pressure injury to the right heel. The WCN's documentation on weekly assessments was inconsistent, with some entries marked as 'existing wound' and others using an unlisted abbreviation or indicating no skin issues, even when a wound was present. Additionally, the WCN did not document a progress note until several days after admission and could not explain the delay or the lack of documentation for certain dates when she was present at work. The resident involved was a seventy-six-year-old woman with multiple comorbidities, including a recent hip replacement, cancer, diabetes, and a history of pressure injury. Upon admission, her hospital records indicated a right heel pressure injury, but this was not reflected in the facility's admission assessment or initial MDS. Over the following weeks, the resident developed worsening foot pain and a blister on her right heel, which eventually burst and became a significant wound. Despite ongoing complaints of pain and visible changes to the wound, documentation and assessment by nursing staff remained inconsistent. The WCN and other staff members provided varying accounts of the wound's progression and care, with some confusion over the timing and nature of assessments and interventions. Interviews with the resident, her family, and facility staff revealed that the resident's pain complaints were not consistently addressed, and wound care was not provided as frequently as ordered. The resident and her family reported that wound care was only performed once a week, and the wound was not regularly assessed or treated. The wound ultimately deteriorated, leading to hospitalization and amputation. The facility's skin assessment policy required thorough and timely documentation of skin conditions, but this was not followed in the resident's case, resulting in inaccurate records and delayed recognition and treatment of the wound.
Failure to Develop and Implement 48-Hour Immediate Needs Plan for New Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. The deficiency occurred due to the facility's failure to ensure that a process was in place to assess and meet the immediate needs of newly admitted residents within the required timeframe. There is no mention of specific residents, their medical history, or their condition at the time of the deficiency in the report.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records, which did not contain comprehensive or measurable interventions to address the resident's identified needs.
Medication Carts Left Unlocked and Unattended in Accessible Areas
Penalty
Summary
Three medication carts were observed unlocked and unattended in common areas accessible to residents, staff, and visitors. On multiple occasions, medication aides and nurses left carts unsecured while attending to residents in nearby rooms. In one instance, a medication aide admitted she thought she had locked the cart, but was able to open it without a key, revealing multiple containers of over-the-counter medications. Another nurse stated she had to leave the cart unlocked because the keypad lock was inoperable and she did not have a key, while a medication aide held the key. The Director of Nursing (DON) was present during one of these observations and instructed the nurse that the cart could not be left unlocked and unattended. Facility policy requires that medication carts be secured during medication passes and locked at all times when out of the nurse's view. Interviews with staff and the DON confirmed that the carts should have been locked and that leaving them unsecured could allow unauthorized access to medications. The observations and staff statements indicate that the facility failed to ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel access, as required by policy.
Deficient Food Storage, Preparation, and Service Practices Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and service that did not meet professional standards for food safety. Specifically, foods were found unsealed, unlabeled, and undated in both the dry storage room and walk-in freezer, including open containers of chicken tenders, mixed vegetables, French toast, and pudding mixes. Additionally, a dented can of beans and an open, unsealed container of cereal were present in dry storage. Plates and bowls with dried food particles were stored alongside clean dishware, and the coffee machine had visible brown stains. The deep fat fryer contained very dark oil with burnt food particles, indicating inadequate cleaning frequency. Further observations revealed that food items on the steam table were not maintained at the required holding temperature, with baked fish measured at 76°F and cream pie at 42°F, both outside the facility's policy standards. Staff interviews confirmed that cleaning and food handling procedures were not consistently followed, such as ensuring dishes were free of food particles before storage and maintaining proper food temperatures during service. Review of facility policies indicated requirements for labeling, dating, and proper storage of food, as well as maintaining specific temperature ranges for hot and cold foods, which were not adhered to during the survey.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Multiple instances of failure to maintain resident privacy during personal care were observed among three residents. In one case, a CNA entered a resident's room without knocking and failed to close the window blind while providing incontinent care, exposing the resident to potential observation from outside. The resident had severe cognitive impairment and was dependent on staff for activities of daily living (ADL) care. The CNA acknowledged not following privacy protocols, despite having received in-service training on the subject. Another incident involved a CNA assisting a resident with toileting without knocking before entering the room and leaving the restroom door open. This resulted in the resident being exposed to two visitors present in the room. The resident had intact cognition and required moderate assistance with transfers. The CNA admitted to not providing adequate privacy and recognized it as a dignity issue, confirming prior training on privacy and dignity protocols. A third deficiency was observed when a CNA left a resident uncovered from the waist down while leaving the room to retrieve additional supplies during incontinent care. The resident, who was dependent on staff for ADL care and had intact cognition, was left exposed and unattended. The CNA acknowledged the lapse in privacy and stated awareness of the requirement to cover residents when unattended. Interviews with facility leadership and staff confirmed that privacy protocols, such as knocking before entering, closing doors, curtains, and blinds, and covering residents during care, were part of facility policy and staff training.
Failure to Provide Timely Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely and adequate assistance with activities of daily living (ADLs), specifically incontinent care, for two residents who were dependent on staff for these needs. One resident, a female with severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and hypertension, was observed to have a saturated incontinent brief that had not been changed for several hours. The certified nursing assistant (CNA) responsible admitted to not checking the resident's brief during her second round due to a high workload and acknowledged that she was trained to provide care every two hours. Both the Director of Nursing (DON) and the Unit Manager confirmed that staff are expected to check and change residents every two hours, and that failure to do so could result in skin breakdown. Another resident, a female with diagnoses including ovarian cancer, diabetes, and cystitis, and who was also dependent on staff for ADLs, was found with a soiled brief containing semi-dry feces and a stained draw sheet. The CNA assigned to her had not changed her for an extended period, stating she was working in another hall and had not yet reached the resident. The CNA and the licensed vocational nurse (LVN) both acknowledged that the resident's care was delayed and that such delays could lead to skin issues. The Assistant Director of Nursing (ADON) reiterated that staff are expected to round and provide care every two hours. Record reviews confirmed that both residents had care plans indicating the need for one or two staff to assist with toileting and ADLs, and that staff had been in-serviced on the requirement for two-hour rounding and care. However, observations and staff interviews revealed that these protocols were not consistently followed, resulting in residents being left in soiled briefs for extended periods. The facility's ADL policy was requested but not provided during the survey.
Failure to Provide Proper Incontinent Care and Prevent UTIs
Penalty
Summary
The facility failed to ensure that incontinent care was provided appropriately for two female residents who were dependent on staff for activities of daily living. In both cases, certified nursing assistants (CNAs) did not separate the residents' labia during incontinent care, which was observed by surveyors. For one resident, the CNA was about to apply a clean brief without properly cleaning the area until the surveyor intervened, at which point a brown substance was found on the wipes. The CNA acknowledged not following proper technique due to the resident's leg position and confirmed awareness of the correct procedure, which includes separating the labia and cleaning thoroughly. In the second instance, another CNA also failed to separate the labia during incontinent care for a different resident, again only correcting the technique after surveyor intervention. The CNA admitted to not following the correct procedure and recognized the importance of proper cleaning to prevent infection, rashes, and skin breakdown. Both residents were documented as requiring one or two staff for toileting assistance due to deficits in self-care performance related to medical conditions such as dementia, impaired balance, and activity intolerance. Interviews with nursing leadership, including the DON, ADON, and unit manager, confirmed that staff are trained and expected to clean female genitalia from front to back, separating the labia and using a new wipe for each area. Staff are also expected to have all necessary supplies before entering the room, change gloves as needed, and follow infection control protocols. The facility's incontinent care policy was requested by surveyors but was not provided prior to exit.
Failure to Label and Date Stored Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, label, and date food items in accordance with professional standards and facility policy. During a kitchen inspection, a 1-gallon ziplocked bag of frozen premade waffles and four individually wrapped waffles were found in the freezer without any labeling or dating. The Dietary Manager (DM) confirmed that the waffles had been served for breakfast two days prior and acknowledged that it was the responsibility of the kitchen staff to label and date food items before storage. The DM also stated the importance of labeling to track shelf life and prevent serving expired food. Staff interviews revealed confusion about who was responsible for the unlabeled waffles, with one staff member denying involvement and stating that all kitchen staff had access to the freezer and shared responsibility for proper food storage. The facility's policy requires that leftover and opened food items be labeled, dated, and used within 2-3 days or discarded. Review of in-service training records showed that staff, including the involved personnel, had received training on labeling and dating food. The Director of Nursing (DON) stated that the DM was responsible for ensuring food storage policies were communicated and followed, and emphasized the importance of labeling to prevent serving spoiled food. Despite these policies and training, the failure to label and date food items was observed, constituting a deficiency in food storage practices.
Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
Multiple staff members failed to follow established infection prevention and control protocols during the provision of care to several residents. In one instance, a certified nursing assistant (CNA) provided incontinent care to a resident with severe cognitive impairment without performing hand hygiene before donning gloves, used the same gloves throughout the care process—including when handling clean supplies—and did not change gloves when moving from dirty to clean tasks. The CNA also failed to wash or sanitize hands after removing gloves and leaving the resident's room. The resident was dependent on staff for activities of daily living due to diagnoses including metabolic encephalopathy and dementia. Another CNA assisted a resident with Parkinson's disease and diabetes in the restroom without washing hands before putting on gloves or after removing them, leaving the resident's room without performing hand hygiene. A third CNA, while providing incontinent care to a resident with a urinary tract infection and diabetes, used gloves taken from her uniform pocket, did not perform hand hygiene before or after care, and used the same gloves to both clean the resident and handle clean wipes. This CNA also left the resident's room to retrieve supplies without washing hands and continued care upon return without hand hygiene, further contributing to cross-contamination risks. Additional infection control lapses were observed, including staff leaving untied plastic bags containing soiled items and used gloves on the floor outside resident rooms, and transporting clean linens on a wheelchair without using protective bags. Staff interviews confirmed awareness of proper infection control procedures, such as hand hygiene before and after resident care, not using gloves from uniform pockets, and proper disposal of soiled items, but these protocols were not consistently followed during observed care activities.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in multiple areas of care not being addressed. For one resident, the care plan did not include focus areas or interventions for full code status, allergies, impaired thought processes, cellulitis, and nutritional problems, including the use of a feeding tube. This resident had a history of cellulitis in both lower limbs, bipolar disorder, mild protein-calorie malnutrition, and cognitive communication deficits, and was dependent on staff for most activities of daily living. Despite these complex needs, the care plan lacked measurable objectives and timeframes for these critical issues. Another resident, who had diagnoses including Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, metabolic disorder, dysphagia, and cognitive communication deficit, also did not have a care plan focus area for her feeding tube, despite physician orders for enteral feeding. This resident required total assistance for all activities of daily living and was observed with a feeding tube in use, but the care plan did not reflect this intervention or provide guidance for staff. Interviews with facility staff, including the DON and MDS nurses, confirmed that these omissions were not in line with facility policy or regulatory requirements. Staff acknowledged that the care plans should have included these areas and that the lack of comprehensive care planning could result in residents not receiving necessary care. Record reviews and staff statements indicated that the care plans were not updated to reflect the residents' current needs and physician orders.
Failure to Use Gait Belt During Transfer and Improper Food Tray Handling
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to use a gait belt while transferring a resident with Parkinson's disease, hypertension, and diabetes mellitus from bed to walker and while assisting the resident to the bathroom. The resident required moderate assistance with transfers and was care planned for one-person assist with a gait belt and adaptive devices as recommended by therapy or medical providers. During the observed transfer, the CNA used improper techniques, including pulling the resident by the arm and pants, and did not utilize a gait belt, resulting in the resident becoming unsteady and nearly losing balance. The CNA was unable to explain where to obtain a gait belt and did not confirm receiving training on its use. Additionally, surveyors observed a food cart with nine used food trays and cutlery left unattended in a resident hallway after meals. Staff interviews confirmed that trays were left out for residents who preferred later meals, but acknowledged that this practice posed risks, including the possibility of residents consuming food not intended for them and infection control concerns. Facility staff, including the DON, administrator, and unit manager, confirmed that food trays should be removed from hallways and placed in the kitchen after meals. Review of facility policy indicated that a gait belt should always be used when transferring residents, and staff should seek assistance if unsure of the transfer process. The facility did not have a specific policy on accidents and hazards. The failure to use proper transfer techniques and to promptly remove food trays from hallways were directly observed and confirmed by staff interviews and record review.
Improper Disposal of Food Trays and Refuse
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of garbage and refuse in one of eight resident halls. Specifically, a food cart containing nine used food trays with cutlery was left unsealed outside the kitchen entrance in a resident hall. Staff interviews confirmed that these trays were from residents who preferred later dinners and that the trays were not promptly returned to the kitchen after use. The LVN acknowledged that leaving trays out posed an infection control issue and created a risk that residents could access and eat leftover food. The Unit Manager and DON both stated that trays should be taken to the kitchen after meals, and the Administrator confirmed that the trays should not have been left in the hall. Record review showed that the facility's policy required all food waste to be kept in containers and stored in a manner inaccessible to pests. The observed practice of leaving used trays and cutlery in the hallway was inconsistent with this policy. Staff interviews further indicated that residents with impaired cognition could potentially access the trays, leading to cross-contamination or injury, and that staff could also be at risk of illness.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a male resident was found inappropriately touching a female resident. The incident occurred when the male resident entered the female resident's room and was observed by the female resident's responsible party (RP) via electronic monitoring. The RP contacted the Director of Nursing (DON) to report the incident, and staff were immediately dispatched to the room. Upon arrival, staff found the male resident standing over the female resident, with her breast exposed and her diaper open. The male resident was touching the female resident's breast and had his hand between her legs. The female resident, who has severe cognitive impairment and multiple medical conditions including dementia, was unable to communicate effectively and was not interviewable. The male resident, who has a diagnosis of dementia with agitation, was described as alert and oriented and had no prior history of inappropriate behaviors or wandering into other residents' rooms. Staff members, including Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs), were trained on abuse and neglect and were knowledgeable about the procedures to follow in cases of resident-on-resident abuse. The facility's failure to prevent the incident placed residents at risk of experiencing abuse and neglect. The incident was reported to law enforcement, and the male resident was arrested. The facility's policies on abuse and resident rights emphasize the importance of protecting residents from abuse, neglect, and exploitation, but the incident highlighted a lapse in ensuring the safety and security of residents within the facility.
Inadequate Wound Care for Resident with Stage IV Pressure Ulcer
Penalty
Summary
The facility staff failed to provide adequate wound care for a resident with a stage IV pressure ulcer on the sacral region, leading to a deficiency in care. The resident, who was admitted with multiple medical conditions including quadriplegia and a urinary tract infection, had a chronic sacral wound that required daily dressing changes. However, the facility did not have a PRN order to change the bandage if it became soiled, which resulted in the resident's bandages remaining wet with urine, increasing the risk of infection and deterioration of the wound. Interviews with staff revealed a lack of clarity and communication regarding the resident's care needs. The CNAs and LVNs were aware of the resident's condition but did not take appropriate action to change the soiled bandages, as they believed it was not within their scope of practice or due to the absence of a PRN order. The resident expressed discomfort and pain due to the wet bandages, and despite being able to communicate her needs, the staff did not adequately address her concerns. The facility's wound care nurse was unavailable, and the responsibility fell on the floor nurses, who did not have the necessary orders to perform the required wound care. The facility's policies and procedures for wound care were not followed, as evidenced by the lack of a PRN order and the failure to change the resident's bandages when they became soiled. The DON and other nursing staff acknowledged the potential harm of leaving a soiled bandage on a wound, yet the necessary steps to prevent this were not taken. This deficiency in care highlights a significant oversight in the facility's wound care management and communication among staff.
Inadequate Incontinence and Wound Care Management
Penalty
Summary
The facility staff failed to provide appropriate care for a resident who was incontinent of bladder, leading to a risk of urinary tract infections and deterioration of a stage IV pressure ulcer. The resident, a 40-year-old woman with quadriplegia, was admitted with a stage IV pressure ulcer on her sacrum and a nephrostomy bag for urine drainage. Despite this, she experienced urine leakage that was not adequately managed, resulting in her wound being frequently soaked and causing her significant discomfort. Interviews with staff revealed a lack of clarity and communication regarding the resident's care needs. CNA A and LVN A both noted that the resident was often wet, but attributed this to wound drainage rather than urine leakage. The resident herself reported that she could distinguish between wound drainage and urine by the smell, indicating that the leakage was indeed urine. The facility's wound care nurse was unavailable, and the floor nurses were not adequately addressing the resident's needs, as there were no PRN orders for changing soiled bandages. The facility's Director of Nursing (DON) and other staff members acknowledged the potential harm of leaving a soiled bandage on a wound, which could lead to infection. However, there was a lack of appropriate orders and follow-through to ensure the resident's bandages were changed when necessary. The facility's wound care policy required a physician's order for wound care, but the absence of PRN orders and the lack of a consistent wound care nurse contributed to the deficiency in care provided to the resident.
Medication Administration Error Due to Stock Unavailability
Penalty
Summary
The facility failed to ensure that a resident was free of significant medication errors, specifically regarding the administration of a multivitamin with folic acid. The resident, who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, did not receive the prescribed multivitamin with folic acid for six days because it was not available in stock. Despite this, the medication administration record (MAR) was initialed as if the medication had been given. During an interview, the medication aide (MA) admitted that the multivitamin with folic acid was not in stock and had been requested from the pharmacy but had not yet arrived. The MA did not notify the charge nurse or the Director of Nursing (DON) about the unavailability of the medication. The DON confirmed that the MA should have informed the charge nurse and stated that she was responsible for overseeing the training of staff administering medications.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Several food items were found without proper labeling or use-by dates, which is a critical aspect of food safety to prevent spoilage and bacterial growth. Specifically, rice, sliced cheese, sliced bologna, deli ham, and shredded cheese were either not labeled or lacked use-by dates, indicating a lapse in the facility's food storage practices. These deficiencies in labeling and dating could lead to the use of expired or spoiled food, posing a risk of foodborne illness to residents. Additionally, the ice scoop was improperly stored inside the ice bin, contrary to the facility's policy that requires scoops to be kept in a protected area outside of food containers. This improper storage practice could lead to contamination of the ice, further compromising food safety. The Dietary Food Service Manager acknowledged these issues, indicating a need for staff training on proper food handling and storage procedures to ensure compliance with safety standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper cleaning techniques and inadequate handling of medical equipment. Licensed Vocational Nurse (LVN) C did not follow proper protocol when cleaning the accu-check machine used for blood glucose monitoring between two residents. This oversight was acknowledged by LVN C, who admitted to forgetting to clean the machine between uses, despite having received in-service training on infection control. The Director of Nursing (DON) confirmed that the machine should have been cleaned between residents to prevent infection. Additionally, the facility did not ensure the proper handling of an external urinary catheter for a resident, whose catheter tubing was observed on the floor, potentially leading to contamination. The resident, who had a history of urinary tract infections (UTIs), was using the catheter at the request of their family to reduce the frequency of UTIs. The tubing was reportedly knocked off the bed rail by housekeeping, and the resident's representative had provided instructions for its use, which were taped to the wall. The Certified Nursing Assistant (CNA) acknowledged the risk of cross-contamination if the tubing was on the floor. The facility's Infection Control Program Policy and Procedures, revised in March 2019, require adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces and equipment. However, the observations and interviews indicate that these procedures were not consistently followed, placing residents at risk for the development and transmission of infectious diseases.
Failure to Secure Catheter Strap Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate care to prevent urinary tract infections and maintain catheter security. The resident, a female with a history of chronic kidney disease, multiple sclerosis, and dementia, was observed without a catheter leg strap, which is necessary to secure the catheter and prevent it from pulling. This oversight was noted during an observation where the resident's catheter tubing contained blood-stained urine, raising concerns from the resident's family member. The resident's care plan and physician orders specifically required the catheter to be secured with a strap every shift, but this was not adhered to, as confirmed by RN A, who was unaware of how long the strap had been missing. The Director of Nursing (DON) confirmed that the catheter should be secured at all times to prevent trauma and infection. The facility's policy on catheter care also emphasized the importance of keeping the catheter and tubing free of kinks and ensuring the resident is not lying on the catheter. Despite these guidelines, the failure to secure the catheter strap was observed, and the resident subsequently required antibiotic treatment for a urinary tract infection. This deficiency highlights a lapse in following established protocols for catheter care, potentially leading to adverse outcomes for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled according to professional principles. During observations, it was found that Azelastine Spray and Fluticasone Propionate were opened and not dated in the medication cart for Hall 100. Additionally, Humulin insulin was opened and not dated in the medication room for various halls. Expired medications, including a Daily Multivitamin formula with iron, were found in the medication carts for Halls 500 and 600. The medication aide acknowledged the oversight, stating that medications should be dated when opened and checked monthly. Further observations revealed expired medical supplies and medications in the medication room for halls 500 to 800. These included Evencare G2 glucose control solutions, Drug buster bottles, and various medical devices such as Shiley tracheostomy tubes and Foley catheters. Interviews with staff, including a medication aide and an LVN, indicated a lack of consistent checks for expired medications and supplies. The Visiting DON mentioned that central supply and nurses were responsible for checking and removing expired items, but this was not effectively carried out.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that the lids and doors of dumpster A were secured. During an observation, it was noted that the dumpster, located behind the dietary department, was three-quarters full of garbage with its door open. The Food Service Manager confirmed that the dumpster doors should always be closed to prevent vermin, pests, and insects from accessing the dumpster and potentially entering the facility. It was stated that staff from dietary, nursing, and housekeeping are responsible for ensuring the dumpster doors are kept closed, and these departments monitor the doors as they dispose of waste. A review of the facility's Policies and Procedures on waste disposal indicated that waste should be disposed of in a manner that prevents disease transmission and that dumpster lids and doors should remain closed at all times. The Director of Maintenance or a designee is tasked with making daily rounds to check for debris.
Pest Control Deficiency in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of sugar ants in a resident's room and a bathroom near the main entrance. The issue was identified in one of the six resident rooms, specifically affecting a resident with multiple medical conditions, including acute and chronic respiratory failure, deep vein thrombosis, acute kidney failure, and paranoid schizophrenia. The resident reported ants crawling on her bedside table and nightstand, and although staff initially did not observe ants, subsequent observations confirmed their presence. Interviews with staff revealed a lack of awareness and communication regarding the pest issue. The CNA assigned to the resident did not notice any ants and was not informed by the resident. The DON was unaware of any pest complaints from the resident or other residents, and the Maintenance Director admitted to addressing the ant issue informally without documentation or notifying the administration. The pest control company had recently increased its service frequency due to warmer weather, but the resident's room had not yet been serviced. The facility's pest control policy and maintenance logs did not reflect the ant sightings, and there was no documentation of the Maintenance Director's previous encounter with ants in the resident's room. The facility's pest control vendor service invoices did not specify targeted areas, and the facility's policy emphasized maintaining an ongoing pest control program. Despite the resident's complaints and the eventual confirmation of ants, the facility's response was inadequate, leading to the deficiency.
Inadequate Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care to a resident, leading to a potential risk of urinary tract infections. During an observation, CNA A did not properly clean the resident's labia and buttocks while performing incontinent care. The resident, who was severely impaired cognitively and dependent on staff for care, was always incontinent of bowel and bladder. The care plan for the resident included applying a moisture barrier to the buttocks and checking the skin for redness, but the observed care did not adhere to these guidelines. CNA A admitted to missing a step by not washing her hands after changing gloves and forgetting to open the labia and clean around the buttocks. The CNA had been employed for five months and had undergone skilled care checks. The Director of Nursing acknowledged that staff should perform incontinent care without risking infection and confirmed that the proper procedure was not followed. The perineal care skills checklist required cleaning from front to back using a separate wipe for each area, which was not done in this instance.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene practices during incontinent care for a resident. The resident, who was severely impaired cognitively and dependent on staff for care, was always incontinent of bowel and bladder. During an observation, CNA A was seen performing incontinent care without washing hands or using hand sanitizer after changing gloves. CNA A applied antiseptic ointment to the resident's buttocks without proper hand hygiene, which could potentially lead to infections. The resident's medical history included conditions such as cerebral infarction, hypertension, chronic pain, diabetes, bacterial pneumonia, seborrheic dermatitis, rash, and cellulitis of the abdominal wall. The care plan for the resident emphasized the need for proper skin care to prevent breakdown. Despite this, CNA A did not follow proper procedures, such as opening the labia to clean it and cleaning around the buttocks, which were acknowledged as missed steps by CNA A during an interview. The facility's infection control policy, dated November 2017, did not address hand washing, contributing to the deficiency.
Emotional Abuse Incident Involving CNA
Penalty
Summary
The facility failed to ensure that a resident was free from mental and emotional abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) identified as CNA A. The incident occurred when CNA A aggressively pulled the resident's blanket off and used profanity while interacting with a Licensed Vocational Nurse (LVN) outside the resident's room. This behavior was reported to have caused the resident emotional distress, although the resident later stated she did not feel abused. The resident involved was an elderly female with a history of multiple medical conditions, including Guillain-Barre syndrome, type 2 diabetes, and major depressive disorder. She had a moderately impaired cognition as indicated by her BIMS score. The resident's care plan highlighted her risk for psychosocial issues due to a history of conflicts and required staff to approach her with a warm, positive attitude. During the incident, the resident had requested assistance to remove a blanket from her legs due to neuropathy pain, but the interaction with CNA A escalated, leading to the resident feeling terrified. Interviews with staff and the resident's family revealed that CNA A's behavior was unprofessional and included yelling and using profanity in the presence of the resident. The facility's Director of Nursing (DON) and Executive Director (ED) were informed of the incident, and it was reported that CNA A was terminated for violating company policy. The incident was classified as past noncompliance, and the facility had addressed the issue before the investigation began.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to ensure the resident's right to be free from abuse for one resident, who was verbally abused by a CNA. The incident was captured on camera, showing the CNA making inappropriate and racially charged comments towards the resident. The resident, who has a history of anxiety disorder and other medical conditions, felt unsafe and disrespected as a result of the CNA's behavior. The resident's family member reported the incident to the facility, but there was no record of the grievance or incident in the facility's logs. The family member also mentioned previous grievances about staff behavior and care quality, which were inconsistently addressed by the facility. The Director of Nursing (DON) and the Administrator acknowledged the family member's frequent complaints but did not take adequate steps to prevent further abuse. Interviews with other staff members revealed that they had received abuse training and knew the reporting procedures. However, the facility's failure to document and address the incident properly indicates a lapse in their abuse prevention and reporting protocols. The facility's abuse prohibition policy emphasizes the right of residents to be free from abuse, but this incident shows a failure to uphold that standard.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure that residents received adequate supervision to prevent accidents, specifically for one resident who required a two-person assist for transfers using a mechanical lift. The report details that CNA F transferred the resident alone, despite the presence of another CNA in the room who did not assist. This action was contrary to the resident's care plan, which specified the need for extensive assistance and the use of two staff members for transfers. The resident in question had multiple diagnoses, including transverse myelitis, paraplegia, ocular hypertension, anxiety disorder, and hyperlipidemia. The resident's care plan and MDS indicated that he was dependent on assistance for transfers and required the help of two or more people. Despite this, video evidence and interviews confirmed that the transfer was conducted by a single CNA, putting the resident at risk for injury. Interviews with various staff members, including CNAs and the Administrator, revealed that the facility's policy and training mandated the use of two staff members for mechanical lift transfers. However, the incident on the evening in question showed a clear deviation from this policy. The resident and his family also confirmed the one-person transfer, further corroborating the deficiency in supervision and adherence to the care plan.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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