Sorrento
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 2739 Babcock, San Antonio, Texas 78229
- CMS Provider Number
- 676378
- Inspections on file
- 36
- Latest survey
- November 30, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Sorrento during CMS and state inspections, most recent first.
The facility did not address or document group grievances raised by the resident council, including concerns about missing clothing, food service, and facility services. Staff interviews revealed confusion about the process for handling group grievances, and there was no evidence of investigation or communication of outcomes to the resident council, contrary to facility policy.
The facility did not complete or transmit required discharge MDS assessments for five residents, as shown by missing documentation in their electronic health records. This failure was identified during a review of MDS accuracy and completion, and it was found that the necessary discharge data was not submitted to the CMS system as required by policy and federal regulations.
A resident who required dialysis did not receive safe and appropriate dialysis care and services, as the facility failed to ensure the necessary care was provided.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not fully support residents' highest practicable physical, mental, and psychosocial well-being.
The facility did not ensure all residents were routinely offered suitable and nourishing snacks outside of scheduled meal times. Two residents reported not receiving snacks at night and expressed a desire for them, while staff confirmed snacks were mainly given to diabetics per physician orders, with leftovers provided only to those who asked. Staff did not proactively offer snacks to all residents, and facility records showed less than half of the residents were listed for evening snacks.
A resident with moderate cognitive impairment and partial mobility required assistance to use the restroom but was told by a CNA to use her brief instead of being assisted to the toilet. The resident's care plan called for encouraging self-care participation, and facility leadership confirmed that the CNA's actions did not meet expectations for resident dignity and respect.
A resident with multiple medical conditions and intact cognition had an OOH-DNR form that was not properly completed, as required signatures from the resident and witnesses were missing in the final section. Only the physician's signature was present, making the form invalid. The Social Worker acknowledged the oversight and responsibility for ensuring correct execution of advance directives, and the Administrator confirmed the expectation for accurate completion.
A resident with multiple chronic conditions was found to have a recliner in her room with a broken footrest and an exposed metal piece, which had not been reported or addressed for several days. The issue was only discovered after observation and interviews, revealing a lapse in maintaining a safe and comfortable environment as required by facility policy.
The facility did not develop and implement complete care plans with measurable actions and timetables to address all identified needs for sampled residents.
A resident with multiple chronic conditions was administered Hydralazine HCl on several occasions by LVNs despite their diastolic blood pressure being below the physician-ordered threshold. The facility's policy lacked guidance on medication parameters, and the DON confirmed that medications are expected to be given within set parameters or clarified with a physician if unclear.
A medication cart on one hall was left unattended and unlocked by an LVN due to a malfunctioning lock, with multiple medications accessible. The nurse did not report the malfunction, and the ADON was unaware of the issue. The DON stated that medication carts are expected to be locked when unattended and that malfunctions should be reported immediately. The facility did not provide a policy on medication cart security when requested.
A resident admitted for Covid-19 recovery was placed under droplet isolation precautions, but staff and a private caregiver entered the room wearing only surgical masks instead of the required N95 FFR. The PPE cabinet lacked N95 FFRs, and signage did not specify Covid-19-specific PPE requirements, leading to non-compliance with infection control protocols.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with severe cognitive impairment, respiratory failure, and mobility limitations did not receive care as outlined in her care plan. Staff transferred her using a gait belt instead of a mechanical lift and did not ensure her oxygen therapy was administered as ordered. These actions were inconsistent with physician orders and the resident's care plan.
A resident with severe cognitive impairment and significant mobility limitations was transferred from bed to wheelchair by two CNAs using a gait belt instead of the care-planned mechanical lift, due to the unavailability of a mechanical lift sling. Staff interviews confirmed the deviation from the care plan, and the facility administrator acknowledged the lack of a related policy.
A resident with severe cognitive impairment and a history of acute respiratory failure was not wearing oxygen tubing as ordered, despite medical orders and care plan interventions requiring continuous oxygen therapy. Observations and staff interviews confirmed the resident was not receiving oxygen as prescribed, and the facility's policy on oxygen administration was not followed.
A resident who required special eating equipment and utensils did not receive them, and appropriate assistance during meals was not provided.
Staff failed to immediately report multiple allegations of abuse and improper restraint involving a cognitively impaired, chair-bound resident. Incidents included a CNA yanking the resident from bed and making threats, as well as the resident's wheelchair being tied with trash bags to restrict movement. Several staff members observed or were informed of these events but did not escalate them to the administrator or authorities as required, resulting in delayed investigation and notification.
A CNA physically restrained a cognitively impaired, wheelchair-bound male resident by tying trash bags around his wheelchair wheels to restrict his movement after he was observed entering other rooms and taking items. The restraint was not medically indicated, not part of the care plan, and was not the least restrictive intervention. Staff observed the resident distressed and unable to move, and the incident was reported to facility leadership. Facility policy prohibits such restraints, and the event was not immediately reported to the state or administrator.
A resident with multiple health conditions was found with several unconsumed medications, including hydrocodone-acetaminophen and tamsulosin, left in their room. Nursing staff did not consistently verify that medications were swallowed and left medications at the bedside, contrary to facility policy. Additionally, the resident was repeatedly given the incorrect dosage of hydrocodone-acetaminophen due to staff not verifying the medication received from the pharmacy against the physician's order. Multiple nurses administered the wrong dose, and the error was only identified after review and interviews.
Nursing staff failed to consistently document the administration of hydrocodone-acetaminophen in the electronic medical record for a resident with multiple diagnoses and a pain management care plan. Although the medication was administered and signed out on the controlled drug record, entries were missing from the MAR, and staff interviews confirmed lapses in documentation as required by facility policy.
The facility's Dietary Services failed to maintain food safety and sanitation standards, with issues such as unsealed frozen food, gnats in the dry storage area, and unclean ice machines. The Nutritional Services Director and Registered Dietician acknowledged that improper cleaning and maintenance could lead to foodborne illnesses. A review of policies showed a cleaning schedule was in place but not followed.
A resident with multiple health issues developed new pressure ulcers while in a facility, but the family was not informed of these changes. Despite documentation indicating notification, staff interviews revealed confusion over responsibility for communication. The family only learned of the condition after a friend's visit, leading to the resident's hospital transfer.
A facility failed to ensure an accurate MDS assessment for a resident, incorrectly documenting a therapeutic diet instead of a regular diet. Interviews and record reviews confirmed the discrepancy, with staff acknowledging the outdated order and the importance of accurate documentation to prevent missed care.
The facility failed to update care plans for two residents, one with a supra-pubic catheter and another with PASRR services and an intellectual disability. These omissions could lead to missed or inaccurate care, as confirmed by staff interviews.
The facility failed to update care plans for two residents after assessments, leading to discrepancies in diet orders. One resident's care plan was not revised to reflect a change from a therapeutic to a regular diet, while another's did not accurately show a therapeutic and mechanically altered diet. Interviews confirmed the inaccuracies, which could result in missed care.
A facility failed to secure and label medications properly when an RN pre-poured Eliquis 25 mg for a resident and stored it in a medication cart after the resident was found sleeping. The medication was unlabeled, and the RN admitted that pre-pouring was against policy, risking incorrect administration. The resident's MAR did not document the medication as given.
The facility failed to properly dispose of garbage, leading to debris, including used incontinent briefs, around the dumpsters. The NSD noticed the overflow but did not clean it to avoid being late for a meeting, acknowledging the risk of attracting pests. The RD confirmed the need for a debris-free area to prevent pest entry. The facility's policy requires daily checks and reporting of debris.
A facility failed to maintain accurate medical records for a resident with multiple health issues, including a stage 4 pressure ulcer. The facility documented that the family was notified about wound assessments when they were not, as confirmed by RN C. This discrepancy could lead to miscommunication among staff, as noted by the DON. The facility's policy required accurate documentation of family notifications, which was not followed in this instance.
The facility failed to maintain an effective pest control program, leading to the presence of gnats in the kitchen's dry storage area. The NSD acknowledged not requesting pest control services, and interviews indicated that improper cleaning might have attracted the pests. The facility's pest control policy was not followed, as the Maintenance Supervisor was unaware of the issue until later, delaying intervention.
A facility failed to honor a resident's DNR order due to inadequate documentation and communication. The resident, with severe cognitive impairment, was admitted without proper acknowledgment of her DNR status, despite being a DNR in the hospital. Interviews revealed that the responsible party was not consulted about the code status, and the social worker failed to run necessary reports or communicate with the responsible party. The facility's policy on advance directives was not followed, resulting in the deficiency.
A facility failed to implement its admission policy for a cognitively impaired resident, leading to a deficiency. The resident, with severe cognitive impairment, was admitted without proper admission documents provided to her responsible party (RP). The admission packet was signed by the resident herself, despite her impairment, and completed five days post-admission. Interviews revealed discrepancies in understanding the resident's decision-making ability, with the RP expressing confusion and a lack of communication from the facility.
A facility failed to incorporate PASRR recommendations into a resident's care plan and did not submit required paperwork for specialized services on time. The resident, with Down Syndrome and severe cognitive impairment, was supposed to receive an air mattress and a custom wheelchair through PASRR. Despite receiving reminders, the MDS Nurse did not meet the submission deadlines, potentially delaying necessary services.
A newly admitted resident with cognitive impairment was not provided with a proper baseline care plan, leading to an incorrect code status being recorded. The resident's representative was not consulted about the code status, and the social worker failed to complete necessary advance directive paperwork. The facility's policy requiring a baseline care plan within 48 hours was not followed, resulting in potential risk to the resident's care.
A facility failed to update a resident's emergency contact information, listing a deceased family member despite the resident's severe cognitive impairment and available information. The CRC used hospital paperwork for contact details and acknowledged the resident's mention of the deceased family member during admission. The facility could not provide a policy for maintaining accurate medical records.
A resident was discharged from a facility without proper notification to her representative or the State LTC Ombudsman. Despite being cognitively intact and having no prior psychiatric issues, the facility refused her readmission after a hospital stay for an alleged suicide attempt. The facility did not provide the required written discharge notice or involve the Ombudsman, violating policy and regulatory requirements.
A resident was not readmitted to the facility after hospitalization due to an alleged suicide attempt, despite being medically cleared. The facility cited undisclosed suicidal ideation as the reason, failing to provide required notifications to the resident's representative and LTC Ombudsman, contrary to their policy.
Two residents with cognitive impairments were found with unsupervised access to disposable razors in their restrooms, posing a risk of injury. Despite no history of self-harm or aggression, the facility's staff, including the ADON and DON, acknowledged that these items should not have been accessible, highlighting a lapse in maintaining a safe environment as per the facility's safety policy.
The facility failed to include required information in 30-day discharge notices for three residents, omitting details such as the name, address, and contact information of the State Long-Term Care Ombudsman and the entity that receives appeal requests. This led to residents not being informed of their right to appeal or how to obtain assistance with the appeal process.
The facility failed to develop and implement effective person-centered discharge plans for three residents, resulting in 30-day discharge notices for unpaid balances without documented discharge plans or goals. The residents were not provided with appropriate assistance or viable discharge options that met their needs and preferences.
The facility failed to ensure that an LVN renewed his nursing license before expiration, resulting in him working for five days with an expired license. The HR Coordinator did not notice the expired license and did not communicate this to the DON or other management members. The issue was only addressed after surveyor intervention.
A resident with a history of heart failure, type 2 diabetes, and generalized osteoarthritis was improperly transferred to another facility while his Medicaid application was pending. The discharge notice lacked necessary information, and staff failed to communicate the resident's rights to appeal. Interviews revealed a lack of understanding and communication regarding the Medicaid application process and medical necessity determinations.
Failure to Address and Document Resident Council Grievances
Penalty
Summary
The facility failed to consider and act upon the views, grievances, and recommendations of the resident council regarding issues of resident care and life in the facility. Review of resident council meeting minutes from September through November showed that concerns such as missing clothing, food preferences, transportation issues, and problems with room landlines were documented, but there was no evidence of investigation, follow-up, or communication of results or rationale back to the resident council. The facility did not document responses or actions taken to address these group grievances, nor did it provide written decisions or maintain records as required by policy. Interviews with facility staff, including the DON, ADON, AED, and nursing staff, revealed that while individual grievances were generally addressed and documented, there was confusion and lack of clarity regarding the process for handling and documenting group grievances raised by the resident council. Staff members acknowledged that grievances brought up in resident council meetings should be addressed, but several were unsure whether these group grievances were documented or how they were resolved. The DON and other administrators indicated that they were not aware of the status or location of group grievance documentation for the months in question, and there was no system in place for tracking or responding to these concerns as a group. Facility policy required prompt resolution of grievances, written decisions, and maintenance of evidence regarding the results of all grievances. However, the lack of documentation and follow-up for resident council group grievances demonstrated a failure to comply with these requirements. This deficiency was identified through interviews, record reviews, and policy examination, which collectively showed that the facility did not ensure resident council concerns were investigated, resolved, or communicated back to the group as required.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System for five residents who were reviewed for MDS accuracy and completion. Specifically, discharge MDS assessments were not completed for these residents, as confirmed by record reviews of their electronic health records, which did not show a completed discharge MDS at least 30 days after each resident's discharge. This was identified for five out of twenty-four residents reviewed. Further review of the facility's policy and the RAI Manual confirmed that all MDS assessments, including discharge and reentry records, are required to be completed and electronically transmitted to the CMS QIES Assessment Submission and Processing (ASAP) system in accordance with OBRA regulations. The RAI Manual specifies that discharge assessments must be completed within 14 days after the discharge date. The facility did not adhere to these requirements for the identified residents, resulting in incomplete and untransmitted discharge MDS data.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided to meet the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the highest practicable physical, mental, and psychosocial well-being of each resident, as required.
Failure to Provide Suitable and Nourishing Snacks Outside Scheduled Meal Times
Penalty
Summary
The facility failed to ensure that all residents had access to suitable and nourishing meals and snacks outside of scheduled meal service times. Record review showed that the facility's meal schedule included only breakfast, lunch, and dinner, with no designated snack time. Observations and interviews revealed that residents were not routinely offered snacks at bedtime, and some residents expressed a desire for snacks at night but were hesitant to request them directly. Specifically, two residents reported not receiving snacks at night and indicated they would like to be offered snacks when hungry outside of regular meal times. Interviews with facility staff, including the ADM, ADON, and Certified Dietary Manager, confirmed that snacks were primarily distributed to diabetic residents based on physician orders, with any remaining snacks given to those who requested them. Staff did not proactively offer snacks to all residents or visit each room to ensure residents had the opportunity to receive a snack. The facility's records indicated that only 39 out of 96 residents were listed for an evening snack, and the policy for snack distribution was requested but not provided at the time of the survey.
Resident Denied Dignified Toileting Assistance by CNA
Penalty
Summary
A certified nursing assistant (CNA) failed to honor a resident's request to be taken to the restroom, instead instructing the resident to use her brief and stating she would return later to change her. This occurred despite the resident having no impairment in her upper or lower extremities, using a walker for mobility, and requiring only partial to moderate assistance for sit-to-stand transfers. The resident's care plan included encouraging participation in self-care to the fullest extent possible. The resident was observed vocalizing in her room with her call light on when the CNA responded and gave the instruction to use the brief. Interviews with the CNA, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that the expectation was to assist residents to the restroom if they requested and were able to transfer safely. The ADON and DON both acknowledged that telling a resident to use their brief instead of assisting them to the restroom was a dignity concern and not acceptable. Facility policy required all employees to treat residents with kindness, respect, and dignity.
Failure to Ensure Valid Completion of OOH-DNR Form
Penalty
Summary
A deficiency occurred when a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was found to be incomplete and therefore invalid. The resident, who had diagnoses including paraplegia, cirrhosis of the liver, and sepsis, was documented as having intact cognition and had requested a DNR status. The resident's care plan and face sheet both indicated a DNR order, and the OOH-DNR form was present in the record. However, upon review, it was discovered that the required signatures in the final section of the OOH-DNR form were missing for the resident and the witnesses, with only the physician's signature present. The form's instructions specified that all parties who signed above must also sign below to acknowledge proper completion. During interviews, the Social Worker confirmed that the missing signatures rendered the OOH-DNR form invalid and acknowledged responsibility for ensuring the correct execution of such forms. The Administrator also confirmed the expectation that all OOH-DNR forms be fully and accurately completed. Facility policy required verification of advance directive documentation for accuracy, and state guidance indicated that improperly completed forms may not be honored by health professionals.
Broken Recliner with Exposed Metal Piece in Resident Room
Penalty
Summary
A deficiency was identified when a resident's recliner was found to have a broken footrest with a metal piece protruding from it, which is part of the mechanical system that supports the footrest. The resident, who had diagnoses including muscle wasting and atrophy, COPD, type 2 diabetes, and hypothyroidism, and who was cognitively intact, reported that the recliner had been broken since being moved into the room several days prior. The resident had not reported the issue to staff and stated that she had not been injured because she was careful to avoid the exposed metal. Observation and interviews confirmed that the broken recliner was present in the resident's room until it was discovered by staff. The facility's policy requires a clean, sanitary, and orderly environment, but the broken recliner with an exposed metal piece was not identified or addressed by staff until it was brought to their attention. This failure resulted in the resident being exposed to an environment that was not safe, functional, or comfortable, as required by facility policy.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
A deficiency was identified regarding the development and implementation of a complete care plan that meets all the resident's needs, including measurable timetables and actions. The report indicates that the facility failed to ensure that care plans were comprehensive and addressed all identified needs for the residents sampled. Specific details about the number of residents sampled and cited are not provided in the excerpt, nor are individual resident conditions or medical histories described.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors. The resident, who had diagnoses including muscle wasting and atrophy, COPD, type 2 diabetes, hypothyroidism, and hypertension, was prescribed Hydralazine HCl with specific parameters: the medication was to be held if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was under 60 beats per minute. Despite these parameters, the medication was administered on four occasions when the resident's diastolic blood pressure was below 60. Record review showed that the medication was given outside of the prescribed parameters by two LVNs on multiple dates. The facility's medication administration policy did not include guidance regarding medication parameters. During an interview, the DON stated that medications should be given within parameters and that staff should contact the physician if parameters are unclear.
Unattended and Unlocked Medication Cart Due to Malfunctioning Lock
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all drugs and biologicals were stored securely and locked in accordance with professional standards. During an observation, a medication cart assigned to the 800 hall was found unattended and unlocked in a hallway, with drawers containing various medications such as acetaminophen, aspirin, docusate, and vitamin C accessible. The nurse assigned to the cart, an LVN, stated that the lock on the cart had malfunctioned and had not reported the issue since the start of her shift, assuming the facility was already aware of the problem. The cart remained unsecured and unattended, out of the nurse's line of sight, allowing potential unauthorized access to medications. Interviews with facility staff revealed that the ADON was not aware of the malfunctioning lock, and the DON confirmed that the expectation is for medication carts to be locked whenever unattended, with immediate reporting required for any malfunctions. Despite a request, the facility did not provide a policy regarding medication cart security by the time of the report. The failure to secure the medication cart and promptly report the malfunction led to a lapse in the safe storage of drugs and biologicals.
Failure to Provide Required PPE for Covid-19 Isolation Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident who was admitted with a diagnosis of Covid-19 and placed under droplet isolation precautions per physician order. Observations revealed that housekeeping staff entered the resident's room wearing a surgical mask, gown, gloves, and face shield, but not the required N95 filtering facepiece respirator (FFR) as specified for Covid-19 precautions. The signage outside the resident's room indicated droplet precautions but did not specify the need for N95 FFR for Covid-19, and the PPE storage cabinet outside the room did not contain any N95 FFRs. The private caregiver present in the room was also observed wearing only a surgical mask and reported not being trained on appropriate PPE use for the situation. Interviews with facility staff, including the ADON, LVN, and DON, confirmed that the resident was under Covid-19 isolation precautions and that all staff entering the room should have worn an N95 FFR. Staff acknowledged the absence of N95 FFRs in the designated PPE cabinet and the lack of clear signage specifying Covid-19-specific PPE requirements. The facility's failure to provide appropriate PPE and clear instructions for staff and visitors resulted in non-compliance with CDC infection control guidance for Covid-19.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or record review, indicating that the required protocols for protecting confidential information or properly maintaining medical records were not followed as expected. No additional details regarding specific residents, staff actions, or the exact nature of the records involved are provided in the report.
Failure to Implement Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs, including acute respiratory failure with hypoxia, dementia, and significant mobility limitations. The care plan specified that the resident required oxygen therapy at 2-4 liters per nasal cannula and mechanical lift transfers with two-person staff assistance. However, staff did not follow the care plan during observed care. On one occasion, two CNAs transferred the resident from bed to wheelchair using a gait belt instead of the required mechanical lift, citing the unavailability of a mechanical lift sling. Both CNAs acknowledged that the resident typically required a mechanical lift and that the deviation from the care plan was reported to the charge nurse. Additionally, the resident was observed on multiple occasions without her oxygen tubing in place, despite physician orders and care plan directives for continuous oxygen therapy. The oxygen tubing was found lying across the bed or not on the resident's nasal area while she was in her wheelchair and eating lunch. The resident stated she only wore the oxygen at night, and the ADON confirmed the resident was not wearing the oxygen as ordered, with no documented response to the risk. The facility's policy required care plans to be updated to reflect oxygen use, but there was no evidence this was consistently implemented.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including acute respiratory failure, dementia, and muscle weakness, was not transferred according to her care plan. The care plan specified that the resident required a mechanical lift with two-person staff assistance for transfers due to her mobility limitations and dependence on assistive devices. However, during an observed transfer, two CNAs used a gait belt instead of the mechanical lift because a mechanical lift sling could not be located. The mechanical lift was present in the room, but the necessary sling was missing, leading staff to proceed with a manual transfer using a gait belt. Interviews with the involved CNAs confirmed that the resident was typically transferred with a mechanical lift, but due to the unavailability of a sling, they used a gait belt for the transfer. One CNA reported the deviation from the care plan to the charge nurse. The physical therapist noted that the resident's ability to transfer could vary depending on her anxiety or pain levels, but at the time of the incident, the care plan still required a mechanical lift. The facility administrator and DON acknowledged the risk associated with not following the care plan and stated there was no policy in place regarding this situation.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure with hypoxia, pneumonia, cognitive impairment, and dependence on oxygen therapy was not provided oxygen as ordered. The resident's medical orders specified oxygen at 2-4 liters per nasal cannula every shift, and the care plan included interventions to provide oxygen as ordered. Observations revealed that the resident was not wearing her oxygen tubing on two separate occasions, with the tubing found lying across her bed and not in use while she was eating lunch. Interviews confirmed that the resident only wore her oxygen tubing at night, and staff acknowledged that the oxygen tubing was not in place as ordered. Further interviews with the ADON and DON confirmed the lack of adherence to the oxygen order, with the DON updating the care plan to note the resident's tendency to remove the tubing. The facility's policy required care plans to reflect oxygen use and proper storage of cannulas when not in use. The failure to ensure the resident received oxygen therapy as ordered was identified through observations, interviews, and record reviews.
Failure to Provide Special Eating Equipment and Assistance
Penalty
Summary
A deficiency was identified when the facility failed to provide special eating equipment and utensils for residents who required them, as well as appropriate assistance during meals. This inaction resulted in residents not receiving the necessary support to eat safely and effectively, as directly observed by surveyors.
Failure to Timely Report Alleged Abuse and Improper Restraint
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—were reported immediately to the administrator and appropriate authorities as required. Multiple staff members observed or were informed of incidents involving a resident with severe cognitive impairment, hemiplegia, and a history of falls, but did not report these allegations in a timely manner or to the correct individuals. Specifically, a CNA witnessed another CNA yanking the resident out of bed and threatening to kill him in Spanish, but did not report this to the administrator and delayed reporting to other supervisors. Another CNA observed the resident's wheelchair wheels tied together with plastic bags, restricting mobility, but did not escalate the incident to the DON or administrator, relying instead on the assumption that another nurse had reported it. Further, the DON and UM were notified by an LVN that the resident had been restrained with trash bags on his wheelchair, but neither reported the allegation to the administrator as required by facility policy and federal regulations. Interviews revealed confusion and lack of clarity among staff regarding reporting protocols, with some staff unsure of who the administrator was or how to contact them. Documentation confirmed that staff had received training on abuse prevention and reporting, and had signed policies outlining their responsibilities, yet failed to act according to these protocols when faced with actual incidents. The resident involved was highly vulnerable due to severe cognitive impairment, hemiplegia, and a high risk of falls, requiring substantial assistance for daily activities. Despite this, staff failed to report and escalate serious allegations of abuse and improper restraint, including physical handling and threats, as well as the use of makeshift restraints that restricted the resident's primary mode of mobility. These failures resulted in a lack of timely investigation and notification to state authorities, as required by both facility policy and federal regulations.
Resident Restrained with Trash Bags on Wheelchair Wheels
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically restrained a male resident with severe cognitive impairment, hemiplegia, and a history of falls by tying trash bags around the wheels of his wheelchair. This action was taken to restrict the resident's independent mobility after he was observed roaming the halls, entering other residents' rooms, and taking items from the nurse's station. The restraint was not ordered for medical treatment, was not documented in the care plan, and was not the least restrictive intervention. Multiple staff members observed the resident unable to move his wheelchair, appearing distressed and agitated, and attempting to reach for items while restrained. The incident was witnessed by a licensed vocational nurse (LVN), who intervened by cutting the trash bags off the wheelchair and reported the event to facility leadership. Other staff members also became aware of the restraint, with some expressing concern that it constituted abuse and should have been reported immediately. The CNA involved admitted to placing the trash bags on the wheelchair wheels to slow the resident down, acknowledging prior training on restraints and abuse, but did not perceive his actions as a restriction at the time. Facility records and staff interviews confirmed that the resident's care plan did not include the use of restraints, and the facility's policy promoted restraint-free care. The resident's primary mode of mobility was his wheelchair, and the restraint directly impeded his ability to move freely. The event was not immediately reported to the state, and there was a lack of timely notification to the facility administrator. The deficiency was identified based on staff interviews, resident records, and review of facility policies, which all indicated that the use of physical restraints in this manner was not permitted and violated the resident's right to dignity and freedom from unnecessary restraint.
Failure to Ensure Accurate Medication Administration and Dosage Verification
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and consumption of medications for a resident with multiple diagnoses, including metabolic encephalopathy, anxiety disorder, and acute kidney failure. Observations revealed that the resident had multiple medication cups and loose pills, including hydrocodone-acetaminophen and tamsulosin, left in his room and not consumed as intended. Nursing staff admitted to leaving medications at the bedside and not verifying that the resident had actually swallowed the medications, despite being trained to do so. The resident was cognitively intact and had a history of rejecting care, but staff did not consistently follow procedures to ensure medication administration was completed as required. Additionally, the facility failed to ensure the resident received the correct dosage of hydrocodone-acetaminophen as prescribed by the physician. The physician's order was for 10/325 mg, but the resident was administered 5/325 mg tablets on multiple occasions. This discrepancy occurred after a new prescription was filled by the pharmacy, and nursing staff did not verify the medication received against the physician's order. Multiple nurses administered the incorrect dosage, assuming the medication on hand was correct, and did not clarify the discrepancy with the physician or pharmacy. The error was only discovered after review and interviews with staff and pharmacy personnel. Interviews with nursing staff and administration confirmed that the facility's policy required verification of the right dose and observation of medication consumption, but these procedures were not followed. Staff acknowledged being aware of the resident's behaviors and the need for careful administration but failed to adhere to established protocols. The facility's Director of Nursing and Assistant Director of Nursing both stated that medications should not be left at the bedside and that the correct dosage must be verified before administration, but these expectations were not met in practice.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, documentation of the administration of hydrocodone-acetaminophen (Norco) was missing from the electronic medical record (MAR) for several dates, despite the medication being signed out on the controlled drug record. Multiple nurses, including LVNs, administered the medication but did not consistently document the administration in the electronic medical record as required by facility policy. Interviews with nursing staff confirmed that the medication was given but not always recorded in the MAR, with one LVN admitting to forgetting to document after administration. The resident involved was a cognitively intact male with diagnoses including metabolic encephalopathy, anxiety disorder, and acute kidney failure, and had a care plan for pain management that included active participation in care decisions. The resident reported that his pain was well controlled and that the medication was essential for him. The facility's policy required documentation of medication administration in the MAR after the resident took the medication, but this was not consistently followed, resulting in incomplete medical records for the resident.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility's Dietary Services failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. During an initial tour, it was noted that the kitchen freezer contained packages of frozen pork sausage patties and chicken nuggets that were opened and not sealed, which the Nutritional Services Director (NSD) acknowledged could lead to freezer burn and contamination. Additionally, gnats were observed flying in the dry storage area, and the NSD admitted that this might be due to unclean drains. The ice machine in the kitchen had a black substance in the area where ice was dispensed, and hard water stains were present on the outside. Similar issues were found in the nutrition room of the [NAME] Neighborhood, where the ice machine also had a black substance on the hood, and food in the freezer was unlabeled. Interviews with the NSD and the Registered Dietician highlighted concerns about improper cleaning and maintenance practices that could lead to foodborne illnesses. The NSD admitted that the dietary staff was responsible for cleaning the fridges and ice machines, but these tasks had not been completed as required. The Registered Dietician emphasized the importance of keeping the kitchen clean to prevent foodborne illnesses and noted that improper food storage could lead to cross-contamination. A review of the facility's policies revealed that there was a comprehensive cleaning schedule in place, but it was not being followed, contributing to the observed deficiencies.
Failure to Notify Resident Representative of Condition Changes
Penalty
Summary
The facility failed to immediately notify the resident representative of significant changes in the resident's condition, specifically the development of multiple facility-acquired pressure ulcers. The resident, a male with a history of multiple serious health conditions including stage 4 pressure ulcers and diabetes, was admitted to the facility from an acute care hospital. Despite the resident's care plan indicating the need for notification of changes in condition, the facility did not inform the resident's representative of new pressure ulcers that developed over a 12-day period. The resident's medical records showed that he had several pre-existing conditions upon admission, including a stage 4 sacral ulcer and unstageable deep tissue injuries. However, during his stay, additional pressure ulcers developed on various parts of his body, which were not communicated to his family or representative. The resident's family only became aware of the worsening condition and new wounds after a visit from a family friend, which led to the resident being sent to the hospital for further evaluation. Interviews with facility staff revealed confusion and lack of clarity regarding who was responsible for notifying the family about changes in the resident's condition. The wound care nurse and other staff members admitted to not notifying the family, despite documentation suggesting otherwise. This lack of communication resulted in the family being unaware of the resident's declining condition, leading to distress and a decision to transfer the resident to a hospital for further care.
Inaccurate MDS Assessment for Resident's Diet
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one resident reviewed for MDS assessments. Specifically, the quarterly MDS assessment for a resident inaccurately indicated that the resident was on a therapeutic diet, while the resident was actually ordered a regular diet. This discrepancy was identified through interviews and record reviews, which revealed that the resident's comprehensive care plan also inaccurately reflected a therapeutic diet. The resident's electronic medical record and diet orders confirmed that a regular diet had been ordered, and the resident was observed consuming a regular meal. Interviews with facility staff, including an RN and the DON, confirmed that the MDS and care plan were not updated to reflect the resident's current diet order. The RN acknowledged that the NSOT order was outdated and that the regular diet was the accurate order. The DON emphasized the importance of accurate MDS and care plans to prevent missed care. The CMS Long-Term Care Facility Resident Assessment Instrument manual underscores the regulatory requirement for assessments to accurately reflect the resident's status.
Failure to Update Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which could lead to missed or inaccurate care. Resident #35, who was admitted with diagnoses including dysphagia, vascular dementia, and neuropathic bladder, had a supra-pubic indwelling urinary catheter that was not reflected in her current care plan. Despite the catheter being active since February 2024, the care plan was not updated to include this critical aspect of her care. This oversight was confirmed through interviews with RN A and the DON, who acknowledged the necessity of updating the care plan to accurately reflect the resident's needs. Similarly, Resident #71, who was admitted with conditions such as heart disease, disorders of the peritoneum, atrial fibrillation, and an intellectual disability, did not have his PASRR services or intellectual disability documented in his care plan. The admission MDS assessment indicated a positive PASRR level II screening, yet this was not incorporated into the care plan. Interviews with RN A and the DON highlighted the importance of including these details to ensure the resident's care needs are met and not overlooked. The facility's policy on comprehensive care planning emphasizes the need for care plans to include measurable objectives and time frames based on comprehensive assessments, which was not adhered to in these cases.
Failure to Update Care Plans After Assessments
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team after their respective assessments. Resident #15's care plan was not updated following a quarterly MDS assessment to reflect a change from a therapeutic diet to a regular diet, despite the diet order being changed months prior. Observations and interviews confirmed that the resident was receiving a regular diet, and both the RN and DON acknowledged the care plan's inaccuracy, which could lead to missed care. Similarly, Resident #70's care plan was not revised after an annual MDS assessment to accurately reflect the resident's therapeutic and mechanically altered diet. The resident's diet order had been updated to LCS pureed, but the care plan still contained outdated information. Interviews with the RN and DON confirmed the need for revision to prevent potential care discrepancies. The CMS MDS 3.0 Manual mandates that care plans be reviewed and revised after each assessment, highlighting the facility's failure to comply with these requirements.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper security and labeling of drugs and biologicals within one of the four medication carts observed. During an observation, a medication cup containing an unlabeled small yellow pill was found in the top drawer of a locked medication cart in hallway 100. RN B admitted to pre-pouring the medication, identified as Eliquis 25 mg for a resident, and storing it in the cart when the resident was found sleeping. RN B acknowledged that pre-pouring medications was against facility policy and could lead to residents not receiving their medications as prescribed or the wrong resident receiving the medication. A review of the resident's Medication Administration Record (MAR) showed that the medication was not documented as given. The facility's policy on medication storage requires drugs to be stored in their original packaging or dispensing systems.
Improper Garbage Disposal Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, compromising the cleanliness and safety of the environment for residents. Observations on 7/23/2024 revealed garbage, including used incontinent briefs and plates, scattered on the ground around the dumpsters located at the back of the building near the kitchen doors. During an interview, the Nursing Services Director (NSD) acknowledged the overflow of garbage and stated that when the garbage truck emptied the dumpsters, some garbage fell onto the ground. The NSD admitted to noticing the garbage before a morning meeting but chose not to clean it to avoid being late. She recognized that leaving garbage on the ground could attract pests and rodents. The Registered Dietitian (RD) confirmed that the dumpster area should be free from debris to prevent pests and rodents from entering the building. A review of the facility's Dumpster Protocol policy, dated 12/2023, indicated that the dumpster area should remain free of debris, with the Director of Maintenance or a designee responsible for daily checks. Additionally, any facility staff observing debris should report it to the Executive Director or Director of Maintenance.
Failure to Accurately Document Family Notifications for Resident Wound Care
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #96, which is a violation of accepted professional standards and practices. The deficiency was identified through observation, interview, and record review. Specifically, the facility documented that the family of Resident #96 was notified about wound assessments when, in fact, they were not. This discrepancy was confirmed by RN C, who admitted to documenting family notifications that did not occur due to time constraints. Resident #96 was a male admitted to the facility with multiple serious health conditions, including a stage 4 pressure ulcer, type 2 diabetes, and a gastrostomy malfunction. The resident was cognitively intact but had limited mobility and was dependent on assistance for various activities. During the resident's stay, several new deep tissue injuries developed, and the family expressed concerns about the resident's worsening condition and lack of communication regarding these changes. Interviews with staff, including RN C and the Director of Nursing (DON), revealed that the failure to notify the family as documented could lead to miscommunication among staff. The facility's policy on charting and documentation required that family notifications be accurately recorded, which was not adhered to in this case. This failure in documentation could result in confusion and decreased continuity of care for the resident.
Deficient Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in the dry storage area of the kitchen. During an observation, approximately five gnats were seen flying around food items on the top shelf, near packages of pasta and dry foods. This issue was identified during a survey on July 23, 2024, at 9:30 AM. The Nutrition Services Director (NSD) acknowledged the presence of the gnats and admitted that she had not requested pest control services for this issue, indicating a lapse in the facility's pest control procedures. Interviews with the NSD and the Registered Dietician revealed that the gnats might have been attracted due to improper cleaning, possibly from the kitchen drains. Both staff members expressed concerns that the presence of gnats could lead to foodborne illnesses among residents. A review of the facility's pest control policy, dated November 3, 2004, outlined a procedure for reporting pest sightings, which was not followed in this instance. The Maintenance Supervisor confirmed that the pest control service was scheduled to visit monthly and as needed, but he was not informed of the gnat issue until the day of the interview, preventing timely intervention.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order, which is a critical aspect of respecting residents' rights to formulate advance directives. The resident in question was a female with severe cognitive impairment, admitted with conditions including hemiplegia, cerebrovascular disease, and seizures. Despite being a DNR in the hospital, the facility's records did not reflect this status. The resident's face sheet, admission MDS assessment, baseline care plan, comprehensive care plan, and order summary report all lacked documentation of an advanced directive or code status order. The admission packet was signed by the resident, who was not in a position to make informed decisions, and the pages containing DNR information were unsigned. Interviews with the resident's responsible party (RP) and facility staff revealed systemic failures in the process of documenting and honoring advance directives. The RP was not consulted about the resident's code status upon admission, and attempts to communicate with the social worker (SW) were unsuccessful. The SW admitted to not running the necessary reports to identify residents needing code status orders and was unaware of the resident's DNR status. The Director of Nursing (DON) confirmed that without an advanced directive, CPR would be performed, which contradicts the resident's wishes. The facility's policy required acknowledgment of advance directives upon admission and regular review, but these procedures were not followed, leading to the deficiency.
Failure to Implement Admission Policy for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement its admission policy for a resident, resulting in a deficiency. The resident, a female with severe cognitive impairment due to hemiplegia following a nontraumatic subarachnoid hemorrhage, cerebrovascular disease, and seizures, was admitted without the proper admission documents being provided to her responsible party (RP). The admission packet was signed by the resident herself, despite her severe cognitive impairment, and was completed five days after her admission. The resident's face sheet indicated that she was her own RP, but her advanced directive was left blank. Interviews revealed discrepancies in the understanding of the resident's ability to make decisions. The resident's RP stated that they did not complete any paperwork upon admission and expressed confusion about the resident's care plan. The RP also mentioned a lack of communication from the facility. A Licensed Vocational Nurse (LVN) noted that the resident's responses were inappropriate and that she should not be her own RP. The facility's Clinical Resource Coordinator (CRC) claimed that the resident understood the admission packet and signed it herself, while the RP denied refusing to sign any paperwork. The facility's policy requires that all residents have a signed and dated admission agreement on file, which was not adhered to in this case.
Failure to Incorporate PASRR Recommendations and Submit Required Paperwork
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report into the assessment, care planning, and transitions of care for a resident with Down Syndrome and other medical conditions. The resident, who was severely impaired for cognitive skills, was identified as PASRR positive. Despite discussions by the IDT team to obtain an air mattress through PASRR, the vendor did not come, and the facility provided an overlay air mattress instead. Additionally, paperwork for a custom wheelchair was submitted, but the facility did not have an expected delivery date. The MDS Nurse admitted to receiving several emails and phone calls from the PASRR office but failed to submit the required paperwork by the due date, which was within 20 days of the IDT care plan meeting. The facility needed to submit NFSS forms for PASRR Specialized Services for a mattress and a customized manual wheelchair by specific deadlines, which were missed. This failure could place residents at risk for not receiving specialized services in a timely manner.
Failure to Implement Baseline Care Plan and Confirm Code Status
Penalty
Summary
The facility failed to implement a baseline care plan for a newly admitted resident, which included the necessary instructions to provide effective and person-centered care. The resident, a cognitively impaired elderly female with a history of hemiplegia, cerebrovascular disease, and seizures, was admitted without a clear code status documented. The face sheet and comprehensive care plan lacked advanced directive information, and the baseline care plan incorrectly listed the resident as a full code without proper authorization or signature from the resident or their representative. Interviews revealed that the resident's representative was not consulted about the code status upon admission, and the social worker had not completed the necessary paperwork for advance directives. The representative expressed confusion and frustration over the lack of communication and stated that the resident was a DNR in the hospital. The social worker admitted to not being aware of the resident's DNR status and had not spoken to the representative, citing a busy workload as a reason for the oversight. The facility's policy required a nursing assessment and a baseline care plan to be completed within 48 hours of admission, including details such as code status. However, the social worker and other staff failed to adhere to these protocols, resulting in a lack of clarity and potential risk for the resident's care. The Director of Nursing confirmed that without an advanced directive, staff would perform CPR, which could contradict the resident's wishes if they were a DNR.
Failure to Update Emergency Contact Information
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the update of emergency contact information. The resident, a female with severe cognitive impairment due to conditions such as hemiplegia following a nontraumatic subarachnoid hemorrhage, cerebrovascular disease, and seizures, had outdated emergency contacts listed on her face sheet. The listed contacts included a deceased family member, which was not updated despite the resident's cognitive limitations and the information being available to the facility staff. During an interview, the CRC admitted to using hospital paperwork to fill out the emergency contact information and acknowledged that the resident had mentioned the passing of the family member during the admission process. However, the CRC stated that in an emergency, they would contact the other family member listed before the deceased one. The facility was unable to provide a policy for the accuracy of medical records when requested, indicating a lack of adherence to professional standards in maintaining resident records.
Failure to Notify Resident and Ombudsman of Discharge
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident, her representative, and the State Long-Term Care Ombudsman regarding the resident's discharge. The resident, a female with a history of spondylosis, vascular dementia, and borderline personality disorder, was admitted to the hospital after an alleged suicide attempt involving bleach ingestion. Despite being cognitively intact and having no documented history of psychiatric issues or suicidal ideation, the facility decided not to readmit her after her hospital stay, citing safety concerns. The facility did not provide written notification of the discharge to the resident's representative or the Ombudsman, as required by policy. The resident's representative was informed verbally by the Director of Nursing (DON) that the facility would not readmit the resident due to her disclosed history of suicidal ideation. This decision was made without providing the required 30-day notice or documenting the discharge in writing, which is a violation of the facility's policy and regulatory requirements. Interviews with the resident's representative and facility staff revealed that the resident was unhappy with the care she received and had expressed frustration, leading to the alleged suicide attempt. The facility's failure to notify the Ombudsman and provide written discharge notices could disrupt the resident's care continuity and violate her rights to appeal the discharge decision. The facility's policy requires that such notices be given in a timely manner and in a language and form that the resident and their representative can understand, which was not adhered to in this case.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to establish and follow a written policy on permitting residents to return after hospitalization, specifically in the case of a resident who was not readmitted following a hospital stay. The resident, a female with a history of spondylosis, vascular dementia, and borderline personality disorder, was sent to the hospital after an alleged suicide attempt involving bleach. Despite being medically cleared for discharge and expressing a desire to return to the facility, the resident was not readmitted. The facility's decision not to readmit the resident was based on newly disclosed information about her history of suicidal ideation, which was not documented prior to her hospitalization. The facility's Director of Nursing (DON) informed the resident's representative that the facility would not take her back, citing the resident's past suicidal ideation as the reason. This decision was made without providing the required written notification to the resident's representative or the LTC Ombudsman, as stipulated by the facility's policy. Interviews with facility staff revealed that the decision not to readmit the resident was influenced by the contentious relationship between the resident and her representative, as well as the facility's lack of awareness of her psychiatric history. The facility's policy required that residents sent to acute care settings be allowed to return unless their health or safety, or that of others, would be endangered. However, the facility did not provide the necessary documentation or follow the proper procedures for discharge, resulting in a deficiency in their handling of the resident's case.
Failure to Prevent Access to Hazardous Items
Penalty
Summary
The facility failed to maintain a safe environment for two residents by allowing them unsupervised access to disposable razors, which posed a risk of injury. Resident #2, who has vascular dementia with behavioral disturbance and moderate cognitive impairment, was found with 15 disposable razors and a pair of scissors in his restroom drawer. Despite having no history of suicidal ideation or aggression, the presence of these items was confirmed by the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN), who acknowledged that Resident #2 should not have unsupervised access to such sharp objects. Similarly, Resident #3, diagnosed with paranoid schizophrenia, dementia, and severe cognitive impairment, was found with 5 disposable razors in his restroom drawer. Although Resident #3 also denied any thoughts of self-harm or harm to others, the ADON and LVN confirmed that these razors should not have been accessible to him. The Director of Nursing (DON) agreed that the razors should not have been present given the residents' diagnoses, acknowledging the potential risk of injury. The facility's policy on safety and supervision, revised in 2017, emphasizes the importance of resident supervision based on individual needs and environmental hazards. However, the presence of razors in the residents' restrooms indicates a lapse in adhering to this policy, as the facility did not adequately assess and mitigate the potential hazards posed by these items in the residents' environment.
Failure to Include Required Information in Discharge Notices
Penalty
Summary
The facility failed to ensure that 30-day discharge notices included a statement of the resident's right to appeal, which should have included the name, address (mailing and email), and telephone number of the entity that receives such requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. This deficiency was identified for three residents who were reviewed for discharge. The notices also lacked the name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman. Resident #1, who had diagnoses including type 2 diabetes mellitus with complications and end-stage renal disease, received a discharge notice that did not include the required information. The resident expressed a desire to remain in the facility due to her medical needs and had previously attempted to appeal a discharge notice with the Ombudsman, but no action was taken. The resident's comprehensive care plan did not include a plan or goals for discharge. Resident #2, who was admitted with diagnoses such as obstructive and reflux uropathy and chronic kidney disease, also received a deficient discharge notice. The resident was cognitively intact and had not achieved her goal of walking, remaining bed-bound. She had previously sought help from the Ombudsman but did not appeal the current discharge notice due to a lack of information and assistance from the facility. Similarly, Resident #3, who had heart failure and type 2 diabetes mellitus, received a discharge notice without the required information. The resident was transferred to another facility without understanding his right to appeal. Interviews with the facility staff revealed a lack of knowledge and communication regarding the discharge process and residents' rights to appeal.
Failure to Implement Effective Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective person-centered discharge plan for three residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental and psychosocial needs. Resident #1, who had moderate cognitive impairment and required assistance due to renal dialysis, was given a 30-day discharge notice for an unpaid balance without a discharge plan or goals documented in her care plan. Despite her desire to remain in the facility and her communication with the Ombudsman, no effective discharge planning was conducted, and she was not provided with appropriate assistance to address her unpaid balance or alternative arrangements that met her needs. Resident #2, who was cognitively intact but bed-bound due to a severe infection, also received a 30-day discharge notice for nonpayment. She had not achieved her goal of walking and was not provided with a discharge plan or goals in her care plan. Despite her refusal to apply for Medicaid to avoid losing her house, the facility did not engage in effective discharge planning or provide her with viable options that met her needs and preferences. She expressed uncertainty about her discharge options and felt unsupported by the facility. Resident #3, who had moderate cognitive impairment and was wheelchair-bound after completing therapy services, was transferred to another nursing facility without a documented discharge plan or goals in his care plan. He was given a 30-day discharge notice for an unpaid balance and was unaware of the plans until the transfer occurred. The facility's social worker and MDS Coordinator acknowledged the lack of discharge planning documentation and the importance of including discharge planning in comprehensive care plans, but no effective measures were taken to address the residents' needs and preferences for discharge.
Failure to Ensure Nursing License Renewal
Penalty
Summary
The facility failed to ensure that LVN A renewed his nursing license before the expiration date, resulting in him practicing nursing with an expired license. This was discovered through record review, observation, and interviews. LVN A's personnel file revealed that his Texas LVN nursing license had expired, and verification on the Texas Board of Nursing website confirmed the delinquent status. Despite this, LVN A continued to work for five days, providing care to residents without a valid license. During interviews, LVN A stated he was unaware of the expiration and believed his license was valid until 2025. The HR Coordinator, responsible for verifying licenses, also failed to notice the expired license and did not communicate this information to the Director of Nursing (DON) or other management members. The HR Coordinator admitted to not sending a license report to the DON or any other member of management and relied on the nurses to renew their licenses. The Administrator, who was new to the facility, and the DON both stated that they were not informed about the expired license until after surveyor intervention. The facility's policy required the HR Coordinator to monitor license expirations monthly, but this was not effectively implemented. As a result, LVN A worked a total of 47.15 hours with a delinquent license, which was only addressed after the surveyor's intervention.
Improper Transfer and Discharge of Resident
Penalty
Summary
The facility failed to ensure that residents were not transferred or discharged without adequate reason and proper documentation. Specifically, Resident #3 was transferred to another facility while his Medicaid application was still pending, and without waiting for the appeal process to be completed. The discharge notice given to Resident #3 did not include necessary information such as the contact details of the State Long-Term Care Ombudsman, the Texas Health and Human Services office, or instructions on how to file an appeal. This led to Resident #3 being transferred against his wishes and without proper communication regarding his rights to appeal the discharge decision. Resident #3 had a history of heart failure, type 2 diabetes mellitus, and generalized osteoarthritis. He was admitted to the facility after a fall at home, a hospital stay, and a wound that required therapy services. Despite completing therapy and having his wound healed, Resident #3 remained wheelchair-bound and unable to care for himself. He expressed frustration over the lack of communication regarding his Medicaid application and ultimately agreed to the transfer after months of not receiving any information. Interviews with facility staff revealed a lack of understanding and communication regarding the Medicaid application process and medical necessity determinations. The Financial Manager admitted to not reviewing the facility's discharge policy and not fully understanding medical necessity requirements. The MDS Coordinator determined that Resident #3 did not meet medical necessity based on his diagnoses and cognitive impairment score, but this decision was not communicated effectively to the resident or other staff members. The Social Worker also failed to discuss the discharge notice or appeal rights with Resident #3. The new facility that received Resident #3 was able to obtain Medicaid approval for him, highlighting inconsistencies in the original facility's handling of the situation.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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