Solera At West Houston

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $69,735

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $69,735

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $8,827

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $8,824

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $8,824

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.