South Dallas Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 3808 S Central Expwy, Dallas, Texas 75215
- CMS Provider Number
- 675440
- Inspections on file
- 43
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at South Dallas Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that one of two oxygen cylinders stored next to a crash cart behind a nurse’s station was not secured in a rack, contrary to NFPA 99 requirements that freestanding cylinders be properly chained or supported. An LVN acknowledged the tank was unsecured, stated she had just started her shift and had not noticed it, and confirmed it should always be secured because it was a hazard and could cause a fire. The DON reported she was unaware the tank was unsecured, indicated that night shift staff were responsible for checking crash carts and may have changed out the tank and failed to return it to the storage room, and stated her expectation that oxygen tanks be secured at all times, while also noting the facility lacked a policy on oxygen storage.
Four dietary staff members, including cooks and aides, were found to be working without valid Texas Food Handler's Licenses despite being employed for over 30 days. Interviews revealed staff were unaware of the certification requirement, and the dietary manager and administrator could not provide documentation of completed training as required by state regulations.
Surveyors found that the facility failed to maintain proper kitchen sanitation and maintenance, including non-functioning handwashing sinks, poor drainage in the dishwashing area, and evidence of pest activity. Staff confirmed that these issues had persisted for over a month, and observations showed that food storage and preparation areas were not kept clean as required by facility policy.
The facility did not maintain the kitchen range hood in working order for an extended period, resulting in a nonfunctional hood and smoky conditions during meal preparation. Staff interviews confirmed the hood had been out of service for at least one to four months, affecting all residents who received food from the kitchen.
The facility did not maintain an effective pest control program, resulting in the presence of gnats and rodent droppings in the kitchen. Staff reported repeated sightings of rats and mice, evidence of rodents eating food, and ongoing issues with gnats. Pest control services were provided twice monthly, but pest activity and droppings persisted, and cleaning responsibilities were unclear among staff.
A resident with severe cognitive impairment and multiple diagnoses was not included, nor was their representative invited, in care plan meetings. Facility staff confirmed that the responsible party was not contacted for participation, and documentation of their involvement was lacking, despite facility policy requiring such inclusion.
A resident with multiple chronic conditions fell while attempting an unassisted transfer, resulting in injury. Although nursing staff documented that the physician, hospice, and family were notified, the resident's family reported not being informed of the incident until the resident was sent to the hospital. Documentation did not confirm timely or successful family notification, contrary to facility policy.
A resident with multiple medical and cognitive conditions made an allegation of rough care and inappropriate conduct by a hospice aide. The facility's investigation was incomplete, lacking identification of the alleged perpetrator, notification to hospice, and required documentation, with the DON not informed until much later. Facility policy for incident investigation and reporting was not followed.
A resident with severe cognitive impairment and multiple comorbidities was not promptly referred for dental services after losing dentures. Facility staff failed to communicate and document the issue, resulting in the resident not being included on the dental provider's appointment list until the deficiency was identified. The resident continued on a regular diet without assessment for chewing or swallowing difficulties, contrary to facility policy.
Three residents with cognitive impairment and orders for wander guards did not have these interventions documented in their care plans. Despite physician orders and progress notes indicating the use of wander guards for exit-seeking or wandering behaviors, the care plans failed to reflect this service. Facility staff confirmed that care plans were not updated to include the required interventions.
Two residents with severe cognitive impairment and a history of exit-seeking were not provided with functioning wander guard devices as required by their care plans and physician orders. Despite staff documentation indicating regular checks, direct observation showed that the devices were not active and did not trigger the alarm system when tested. This failure to ensure proper operation of safety devices resulted in inadequate supervision and increased risk of incidents.
A resident with hemiplegia and cognitive impairment experienced a slip during a transfer from a shower chair, which staff failed to report as a fall or document. No pain or skin assessments were performed, resulting in an undiagnosed fracture for 11 days. After hospitalization, the facility did not arrange the required orthopedic follow-up, and there was no documentation of communication with hospice regarding the appointment, leading to a prolonged delay in specialist care.
A resident with left-sided paralysis and cognitive impairment was transferred from a shower chair to a wheelchair by a CNA and an LVN without the use of a gait belt and while still wet, contrary to facility protocol. The resident slipped during the transfer and later was found to have sustained a comminuted fracture to the left shoulder. The incident was not immediately reported or documented, and staff interviews confirmed that required safety measures were not followed.
A resident receiving hospice care, who had significant physical and cognitive impairments, did not have a designated staff member responsible for coordinating care and communication with the hospice agency. Instead, multiple staff members were involved inconsistently, and the hospice social worker was not notified of important care events. Facility policy required a specific team member to be assigned for this role, but this was not done, resulting in lapses in communication and care planning.
Multiple residents reported and were observed to have issues with roaches and mice in their rooms and hallways, with evidence of pest activity such as droppings and food damage. Staff interviews confirmed ongoing pest problems, and record review showed lapses in pest control service and documentation, despite facility policy requiring regular treatment and monitoring.
A resident with hemiplegia and dementia experienced a slip in the shower chair during transfer, resulting in a shoulder fracture. The incident was not documented or reported by staff at the time, and there was no evidence of timely pain or skin assessment. Hospice staff later identified the injury and notified facility staff, but the required report to the State Agency was not made within the mandated 2-hour window, in violation of facility policy and regulatory requirements.
The facility failed to provide adequate pharmaceutical services, resulting in deficiencies in medication administration and documentation for two residents. One resident did not receive pain medications as ordered upon admission, while another did not receive intravenous antibiotics timely. The facility's policies on medication administration and documentation were not followed, leading to incomplete MARs and missing pharmacy delivery receipts.
A resident's request to receive medications at a later time was not honored, despite his care plan allowing for decision-making in his treatment regime. The resident, with multiple health conditions, refused medications offered earlier than his preferred time, and staff did not return to administer them later. The LVN cited no risk for missing one dose, while the DON emphasized medication administration without addressing self-determination.
A resident with moderate cognitive impairment was found using a portable heater in their room due to a malfunctioning in-wall unit. The heater, provided by the facility, was used for two days without direct supervision, posing a fire risk. Staff were unaware of the heater's presence, and no fire watches were conducted. The facility failed to provide a policy on portable heaters, highlighting inadequate supervision and potential hazards.
A resident with diabetes did not receive daily fasting blood sugar checks as ordered by the physician on multiple occasions. The resident was aware of the missed checks but did not report them, assuming facility management was aware. Interviews with staff indicated the checks were the responsibility of the overnight nurse, but there was no documentation of refusal by the resident. The DON and Administrator were unaware of the issue until it was reported.
A facility failed to provide a safe and homelike environment, as seen in a resident's bathroom and a communal shower room. The resident's bathroom had visible plumbing and smeared tiles, while the shower room was unsanitary with foul odors, missing tiles, and a black substance around the shower. Despite complaints, the Maintenance Supervisor was unaware of these issues, and no maintenance requests were logged. The shower room, the only functional one, was used for storing dirty linen and trash, worsening the conditions.
The facility failed to ensure a sharps container in the Hall 300 shower room was monitored and emptied before becoming overfilled, leaving used razors unsecured. The shower room door was found open and unattended, posing a risk to residents. Staff interviews confirmed the door should have been locked and the container emptied when full, as per facility policy. The DON and ADM acknowledged the potential hazard, emphasizing the responsibility of nursing staff to manage sharps disposal.
The facility failed to provide adequate pharmaceutical services, as expired medications and supplies were found in the medication room. This included IV administration sets, IV insertion cannulas, and acetaminophen suppositories. The deficiency potentially affected a resident receiving IV medications and another prescribed the expired suppositories. Interviews revealed a lack of awareness and accountability regarding the expired supplies, and the facility's policy on medication storage was not followed.
The facility failed to maintain essential kitchen equipment, resulting in a non-functional handwashing sink and drainage issues with the dishwashing sink and dishwasher. These problems persisted for over a year, posing risks of unsanitary conditions and staff injury. Despite efforts by the new Administrator and Dietary Manager to address the issues, they remained unresolved due to delays in receiving necessary invoices for funding.
The facility's pest control program was ineffective, as evidenced by live flies and roaches in the only active shower room. Observations and interviews with residents and staff confirmed the presence of pests, with reports of roaches and flies in both the shower room and residents' rooms. The pest control log showed sporadic entries, and staff acknowledged the issue but lacked consistent documentation and response.
Two residents in the facility were observed without privacy covers on their catheter bags, compromising their dignity and privacy. Despite care plans and facility policies emphasizing the importance of maintaining resident dignity, staff interviews revealed a lack of awareness and communication regarding the absence of these covers. The residents, one with severe cognitive impairment and the other with chronic health conditions, were left exposed, with their catheter bags visible from doorways.
A resident with a seizure disorder had an abnormal Keppra level that was not promptly reported to the physician, as required by facility policy. The lab results were not flagged in the electronic medical record system, leading to the oversight. The DON and ADON acknowledged the lapse, and the physician expected all lab results to be reported, despite routine monitoring not being deemed necessary unless symptoms were present.
Two residents with cognitive impairments eloped from a facility due to inadequate supervision and access to door codes. One resident was arrested after leaving the facility, while the other suffered a stroke and was hospitalized. The facility's failure to monitor and restrict access contributed to these incidents.
Two residents with dementia eloped from a facility due to inadequate supervision and failure to follow protocols. One resident, with moderate cognitive impairment, left unnoticed and was arrested for obstructing a train. The second resident, wearing a wander guard, eloped and suffered a stroke. Staff failed to perform required checks and ensure wander guard functionality, leading to these incidents.
Two residents with cognitive impairments eloped from a facility due to inadequate supervision and assistance devices. One resident, with dementia, left the facility after obtaining a door code from another resident and was later arrested for impeding a train. Another resident, at high risk for wandering, left the facility multiple times despite wearing a wander guard, and was found at a transfer station after suffering a stroke. The facility failed to effectively monitor and manage these residents' exit-seeking behaviors.
Two residents in an LTC facility did not receive scheduled showers or bed baths, as required for their ADL care. One resident, cognitively intact, reported not receiving bed baths due to staff shortages, while another with moderate cognitive impairment had inadequate documentation of care. Staff interviews revealed a lack of awareness and scheduling issues in the electronic care system, leading to the deficiency.
A facility failed to protect a resident's medical information when an LVN left a computer displaying wound care details unlocked and unattended. The resident, who was cognitively intact and had multiple medical conditions, had their privacy compromised as two residents and a visitor passed by the nurse's station during this time. The LVN admitted to the oversight, which violated the facility's policy on resident privacy.
A resident in an LTC facility was found with a 0.9% sodium chloride syringe left on his bedside table, contrary to State and Federal laws requiring drugs and biologicals to be stored in locked compartments. The resident, who was cognitively intact, reported that nurses often left items in his room. LVN D, the assigned nurse, acknowledged it was her responsibility to remove such items but did not recall leaving the syringe. The facility's policy mandates secure storage of medications, highlighting a lapse in adherence to these guidelines.
A facility failed to maintain an effective pest control program, leading to a gnat infestation in a resident's room. The resident, who was nonverbal, confirmed the issue but could not specify to whom it was reported. The LVN and DOM were unaware of the problem, despite the facility's pest control company visiting monthly and no pest reports documented in the maintenance logs.
The facility failed to update the daily nurse staffing information on one of the reviewed days. Observations showed that the posting near the dining room was outdated, displaying the previous day's date. The DON was unaware of the lapse, attributing it to the ADON not providing the necessary staffing sheets for the current pay period. The ADMIN confirmed the oversight and noted that the ADON and receptionist were responsible for the updates.
Unsecured Oxygen Cylinder at Nurse’s Station
Penalty
Summary
The facility failed to provide a safe environment by not securely storing one of two oxygen cylinders observed at a nurse’s station. During observation, two oxygen cylinders were seen next to the crash cart behind the nurse’s station, with one cylinder properly secured in a rack and the other left unsecured. Later observation and interview with an LVN confirmed the oxygen tank was not secured; the LVN stated she had just started her shift, had not noticed the unsecured tank, and acknowledged it should always be secured in a rack because it was a hazard and could cause a fire. In a subsequent interview, the DON stated she was not aware the tank was unsecured, explained that night shift staff had been tasked with checking crash carts and had probably changed out the tank and forgotten to return it to the storage room, and stated her expectation that tanks be secured at all times because they could be knocked over. The DON also reported that the facility did not have a policy on oxygen storage, despite NFPA 99, 2012 Edition, Section 11.6.2.3 requiring freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart. No specific residents were identified as directly involved at the time of the observation, and no resident medical histories or conditions were described in relation to this deficiency.
Failure to Ensure Dietary Staff Hold Required Food Handler Certification
Penalty
Summary
The facility failed to employ sufficient dietary staff with the appropriate competencies and skill sets, as evidenced by four out of five reviewed dietary staff members lacking a valid Texas Food Handler's License. Record reviews confirmed that Cook A, three other dietary staff, and a dietary aide had all been employed for more than 30 days without obtaining the required certification. Multiple interviews with these staff members revealed they were unaware of the requirement or the timeframe for obtaining the food handler's license. The new dietary manager, hired nine days prior to the survey, also confirmed she could not locate any current food handler certificates for these staff members and acknowledged her responsibility for ensuring staff training and certification. Further interviews with the Administrator and dietary manager indicated a lack of oversight and understanding regarding the process and timeline for obtaining food handler certification. Despite requests, the facility was unable to provide documentation of food handler licenses for the kitchen staff prior to the survey exit. Review of Texas Department of State Health Services regulations confirmed that all food employees, except for the certified food protection manager, must complete accredited food handler training within 30 days of employment, and the facility must maintain certificates on the premises.
Deficient Kitchen Sanitation and Maintenance
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food service safety and sanitation. Both handwashing sinks were not in proper working order: one leaked from a pipe beneath the sink, requiring a basin to catch water, while the other was non-functioning with no running water from the faucet. The dishwashing room also had drainage issues, with water not draining properly and staff using a wet vacuum to remove water from the floor. Pest droppings were found in all three sections of a nonfunctioning dishwashing sink and on the floor beneath another nonfunctioning sink, and several gnats were observed in the nonfunctioning handwashing sink. Interviews with staff confirmed that the plumbing and drainage issues had persisted for at least a month and a half. Staff described using a wet vacuum to manage water overflow due to the drainage problem. The dietary manager and administrator were aware of the plumbing and pest issues, with the dietary manager stating that plumbing was a top priority and the administrator confirming knowledge of the problems prior to the survey. The facility's Nutrition Services Policy & Procedures required food storage areas to be kept clean at all times, but observations indicated this standard was not met.
Failure to Maintain Kitchen Range Hood in Safe Working Order
Penalty
Summary
The facility failed to maintain the kitchen range hood in good repair, resulting in the equipment being nonfunctional for an extended period. Multiple staff interviews confirmed that the range hood had not worked for at least one to four months, during which time the kitchen would become smoky when cooking on high. Staff reported that all residents received food prepared in this kitchen. The Dietary Manager (DM) and other staff were aware of the issue, and there were occasions when the kitchen was full of smoke due to the inability to use the range hood. The Administrator acknowledged awareness of the nonfunctional range hood prior to the survey and stated that a work order and quotes for repair had been obtained. The maintenance service policy required that equipment be maintained in a safe and operable manner at all times, but the range hood remained out of service until after the deficiency was identified. The facility census at the time was 68 residents, all of whom relied on the kitchen for meals.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and rodent droppings in the kitchen over multiple days. Observations included pest droppings in all three sections of a nonfunctioning dishwashing sink, another nonfunctioning sink, and on the floor beneath that sink. Five gnats were observed in a nonfunctioning hand washing sink near the dishwasher. Multiple staff interviews confirmed repeated sightings of rats and mice in the kitchen and pantry, with one staff member reporting that bread had to be stored in the freezer due to rodents eating through packaging. Staff also reported that rodents had been caught in traps and that gnats were present throughout the kitchen. The Maintenance Director stated that the rodent issue began after concrete was broken up on the back patio and had been addressed with sticky bait, but he was unaware of ongoing sightings in the kitchen. Pest control services were documented as occurring twice per month, with logs indicating recent captures of mice and fruit flies. The Administrator acknowledged the presence of pest droppings and stated that kitchen cleaning was the responsibility of the dietary manager, but was unsure when the droppings were last cleaned. The facility's pest control policy emphasized frequent treatment and monitoring, but the observed conditions and staff reports indicated that the kitchen was not being maintained free of pests.
Failure to Include Resident Representative in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was invited to participate in the development and implementation of the resident's person-centered care plan. Record reviews and interviews revealed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 3 and diagnoses including Alzheimer's disease, heart failure, hypertension, and a psychotic disorder, was not able to respond to questions and relied on a responsible party for decision-making. Despite this, there was no evidence that the responsible party was invited to or included in care plan meetings. Interviews with facility staff, including the social worker (SW), MDS coordinator, and administrator, confirmed that the SW was responsible for coordinating care plan meetings and inviting responsible parties or family members. However, the SW admitted to not having coordinated a care plan meeting for the resident in question during her tenure. The responsible party also reported never being invited to a care plan meeting, despite being contacted for medical consents and expressing a desire to be included. The MDS coordinator could not recall if the responsible party was invited to the most recent care plan meeting and was unable to provide sign-in sheets or documentation showing their participation. Review of the resident's care conference assessments showed attendance by facility staff but no indication that the responsible party or family attended. Additionally, the facility's policies required resident and/or representative participation in care planning and outlined procedures for notifying them in advance, but these were not followed in this case. Documentation for some care plan meetings was missing, further indicating a lack of compliance with established procedures.
Failure to Notify Family of Resident Injury After Fall
Penalty
Summary
The facility failed to notify a resident's representative following an incident that resulted in injury. A male resident with multiple diagnoses, including type 2 diabetes with foot ulcer, atherosclerotic heart disease, congestive heart failure, and stage 3 chronic kidney disease, experienced a fall while attempting to transfer from his bed to a wheelchair without assistance, despite requiring a two-person assist and a Hoyer lift for transfers. The resident was later observed with swelling to his face and right arm, and was subsequently sent to the hospital after physician notification. Interviews with nursing staff revealed inconsistencies in the notification process. One nurse stated she notified the physician, hospice, and family members after the fall, while another nurse relied on previous charting that indicated family notification had occurred. However, the resident's family member reported not being informed of the fall until the resident was being sent to the hospital, and documentation did not clearly indicate whether a message was left or if follow-up attempts were made after an initial unsuccessful call. Record reviews showed that progress notes and incident reports documented that the physician, hospice, and family were notified, but there was no conclusive evidence that the family was actually reached or informed in a timely manner. The facility's policies required immediate notification of family and documentation of such notifications following incidents or changes in condition, but these procedures were not consistently followed in this case.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. Specifically, a resident with multiple diagnoses, including dementia, schizoaffective disorder, and cognitive communication deficit, made an allegation that a hospice aide was rough during perineal care and did not stop when requested. Additionally, the resident alleged inappropriate sexual contact and racial slurs by a hospice aide. The investigation report completed by the previous administrator did not identify the alleged perpetrator, lacked documentation that hospice was notified, did not include safe surveys, and failed to provide evidence of abuse and neglect in-services being conducted. Interviews revealed that the hospice Director of Nursing was not notified of the allegation until months later, and the current administrator, who was not involved in the original investigation, could not locate further information or documentation regarding the incident. Facility policy required thorough documentation of incidents, including witness accounts, physician notification, and corrective actions, but these elements were missing from the investigation. The resident later stated they did not recall the alleged abuse, but the lack of a comprehensive investigation and documentation was evident.
Failure to Timely Refer Resident for Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to assist a resident in obtaining routine and emergency dental care in a timely manner. The resident, an elderly male with Alzheimer's disease, chronic obstructive pulmonary disease, and a history of subdural hemorrhage, was admitted to the facility with his own teeth intact according to initial assessments and care plans. However, subsequent observations and interviews revealed that the resident had no upper or lower teeth and could not recall what happened to his dentures or missing teeth. Despite this, there was no documentation or prompt referral for dental services when the dentures were reported missing. Interviews with facility staff indicated a lack of communication and unclear responsibility regarding the referral process for dental care. The Assistant Director of Nursing (ADON) stated she was not informed about the missing dentures and believed it was the responsibility of the Social Worker (SW) to submit referrals. The SW reported receiving a verbal complaint from the resident's family about the missing dentures but could not provide documentation or a specific date for when a referral was made. The resident was not initially included on the list for upcoming dental appointments, and only after further inquiry was a referral form completed and the resident added to the list. Further interviews with the Director of Rehabilitation, Dietitian, and Administrator confirmed that there was no prior notification or assessment regarding the resident's missing dentures or need for a diet change. The resident continued on a regular diet without documented chewing or swallowing difficulties, and staff were unaware of the dental issue until it was brought to their attention during the survey. Facility policy required prompt referral and documentation for such issues, which was not followed in this case.
Care Plans Lacked Documentation of Wander Guard Interventions
Penalty
Summary
The facility failed to ensure that the care plans for three out of four residents included documentation of services provided, specifically the use of wander guards. For one resident with severe cognitive impairment and a history of exit-seeking behavior, the care plan did not document the presence of a wander guard, despite physician orders and progress notes indicating its use. This resident had diagnoses including unspecified dementia, psychotic and mood disturbances, anxiety, hypertension, hypothyroidism, edema, and psychotic disorders with hallucinations and delusions due to physiological conditions. The resident's progress notes reflected active exit-seeking behavior, and orders were in place for a wander guard to be checked every 10 hours, but this intervention was not reflected in the care plan. Another resident, also with severe cognitive impairment and daily wandering behavior, had similar omissions. This resident's diagnoses included unspecified dementia, psychotic and mood disturbances, anxiety, sequelae of cerebral infarction, neuroleptic-induced Parkinsonism, chronic kidney disease stage 4, hypertension, anemia, cognitive communication deficit, difficulty in walking, and schizoaffective disorder. Despite daily wandering and an order for a wander guard, the care plan did not document this intervention. Progress notes indicated active exit-seeking behavior, but the care plan failed to reflect the use of the wander guard as an intervention. A third resident, with moderate cognitive impairment and no documented wandering behavior, also had an order for a wander guard, but the care plan did not include this intervention. Diagnoses for this resident included unspecified dementia, psychotic and mood disturbances, anxiety, hypothyroidism, difficulty in walking, generalized muscle weakness, and unspecified pain. The care plan lacked documentation of the wander guard, even though orders were in place for its use. Interviews with facility staff confirmed that the care plans were not updated to reflect the use of wander guards for these residents.
Failure to Ensure Functioning Wander Guard Devices for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that two residents with severe cognitive impairment received adequate supervision and functioning assistance devices to prevent incidents related to wandering and potential elopement. Both residents had diagnoses including unspecified dementia, psychotic disturbances, mood disturbances, and anxiety, with one also experiencing neuroleptic-induced Parkinsonism and chronic kidney disease. Documentation showed that both residents had orders for wander guard devices to be present and functioning on their lower extremities, with checks required every shift and specific instructions to test the devices at the front door to ensure alarms would sound. Despite these orders, observations revealed that neither resident's wander guard device was functioning properly at the time of survey. When tested at the front door, the devices did not activate the alarm, although the door alarm itself was operational. Staff interviews confirmed that checks for placement and functioning of the wander guards were documented as completed every shift, but the devices were not active during the survey. The ADON and maintenance staff stated that the system was checked regularly, and maintenance logs indicated that the system had passed recent checks. However, the handheld device used to activate or deactivate the wander guards was found to be inactive during the survey. Further review of records and interviews indicated that the facility had experienced previous issues with the wander guard system, including a recent repair to the front door alarm system. Despite staff and administrative claims that the system was functioning and that no residents had eloped, the direct observation of non-functioning wander guards for two residents with a history of exit-seeking behavior constituted a failure to provide adequate supervision and accident hazard prevention as required.
Failure to Report Fall, Assess Pain, and Arrange Follow-Up Care After Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to provide timely pain assessments and follow-up care for a resident with significant medical needs, including hemiplegia, vascular dementia, and aphasia. The resident experienced a slip during a transfer from a shower chair to a wheelchair, which was not reported as a fall by the staff involved. There was no documentation of the incident, pain, or skin assessments in the resident's records for the relevant period. The incident was only brought to the facility's attention after the resident and family reported ongoing pain, leading to a delayed diagnosis of a comminuted fracture in the left humeral bone, which went undetected for 11 days. The staff involved in the transfer did not use a gait belt and did not report the slip or any potential injury, as they believed the resident had not fallen and showed no immediate signs of pain or injury. The lack of reporting meant that the incident was not entered into the facility's accident log, and no immediate medical evaluation or x-ray was performed. The resident continued to experience pain, which was eventually communicated to hospice staff, who then notified the facility nurse and ordered pain medication. However, the underlying injury remained undiagnosed until the family intervened and requested further assessment. Additionally, after the resident was hospitalized and discharged with an order for an orthopedic follow-up, the facility failed to arrange the required appointment. There was no documentation that the hospice agency had been contacted regarding the follow-up, and the appointment was not made for several months. Interviews with facility staff revealed confusion over responsibilities for arranging such appointments, particularly in the absence of the social worker, resulting in a prolonged lack of necessary specialist care for the resident.
Failure to Use Gait Belt and Dry Resident During Transfer Results in Serious Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistive devices during a transfer. Specifically, a male resident with left-sided hemiplegia, vascular dementia, and aphasia required substantial assistance for transfers and was dependent on staff for mobility and toileting. During a transfer from a shower chair to a wheelchair, staff did not use a gait belt as required by facility protocol, and the resident was not dried off prior to the transfer, resulting in the resident slipping and sustaining a comminuted fracture to the left humeral neck and glenoid bone. The incident was not immediately reported or documented in the facility's records. The resident did not report the incident until several days later, and there was no evidence in the facility's incident log or electronic health record of a fall, near fall, or injury during the relevant period. Staff involved in the transfer stated that the resident began to slip but was caught before falling, and no pain or injury was reported at the time. However, subsequent medical evaluation revealed significant fractures, and the resident required additional pain management and orthopedic consultation. Interviews with staff and review of facility policy confirmed that the use of a gait belt and ensuring the resident was dry before transfer were required safety measures that were not followed. The facility's policy also required ongoing assessment of residents' transfer needs and proper documentation, which was not evident in this case. The failure to adhere to established protocols and to document and report the incident led to the identification of an Immediate Jeopardy situation.
Failure to Designate Staff for Hospice Communication and Coordination
Penalty
Summary
The facility failed to designate a specific interdisciplinary team member responsible for collaborating with hospice representatives and coordinating the participation of LTC facility staff in the hospice care planning process for residents receiving hospice services. Instead, communication with hospice agencies was handled inconsistently, with various staff members such as nurses, the DON, the Administrator, and the Social Worker all potentially communicating with hospice, but without a clear assignment of responsibility. This lack of a designated point of contact was confirmed in interviews with the Administrator and DON, who both stated that no single person was assigned to communicate with hospice agencies. A resident with a history of hemiplegia, vascular dementia, and aphasia was admitted to the facility and later placed on hospice care. The resident required significant assistance with activities of daily living and had moderate cognitive impairment. Record reviews showed that the resident was admitted to hospice services, but there was no evidence that a specific staff member was coordinating care or communication with the hospice agency as required by facility policy. Further, the hospice social worker reported not being notified by the facility about the resident's follow-up appointments or receiving discharge paperwork after a hospital visit. The facility's policy required a designated team member to coordinate care and communication with hospice, but the policy form was left blank regarding the responsible individual's name and title. This failure to assign and document a responsible staff member led to gaps in communication and coordination of care for the resident receiving hospice services.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and rodents in multiple resident rooms and a main hallway. Observations and interviews revealed that several residents saw roaches in their rooms and hallways, with some reporting the issue had been ongoing for months. One resident reported seeing mice in his room, with small black pellets observed under his air conditioning unit. Another resident reported mice chewing through his food, with similar pellets found behind his refrigerator and in his closet. Residents stated they had informed staff about these pest issues. The Maintenance Supervisor confirmed there had been a significant roach problem previously due to non-payment to the pest control company, resulting in missed treatments. He also acknowledged an ongoing mouse problem and recent placement of traps. Review of pest management records showed sporadic documentation of pest sightings and a lack of receipts or evidence of pest control service visits for several months. The facility's pest control policy required frequent and periodic treatments, monitoring, and prompt reporting, but these measures were not effectively implemented as evidenced by the continued presence of pests.
Failure to Timely Report Alleged Neglect and Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, as required by regulation. Specifically, an incident involving a resident with left-sided hemiplegia, vascular dementia, and aphasia was not reported to the State Agency within the mandated timeframe. The resident, who required substantial assistance for activities of daily living, experienced a slip in the shower chair while being transferred, which was not documented or reported at the time of occurrence. The incident was initially not recognized or documented by facility staff, and there was no evidence of a fall, skin, or pain assessment in the resident's records for the relevant dates. The resident later reported pain and a fall to hospice staff, who then notified the facility nurse and ordered pain medication. Despite this, the facility's incident and accident log did not reflect any record of the event, and the required reporting procedures were not followed. Interviews with staff revealed confusion and assumptions regarding who was responsible for reporting the incident, leading to a delay in notification to the Director of Nursing and the Administrator. The facility's policy required prompt investigation and reporting of all accidents or incidents, with documentation to be submitted to the Director of Nursing within 24 hours. However, in this case, the policy was not followed, and the incident was not reported to the appropriate authorities within the required 2-hour window. This lapse in procedure was confirmed through interviews and record reviews, which showed a lack of timely communication and documentation regarding the resident's fall and subsequent injury.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, resulting in deficiencies in medication administration and documentation. For one resident, the facility did not administer pain medications as ordered upon admission, despite the resident's request for pain relief. The resident, who had diagnoses including sepsis, polyneuropathy, and paraplegia, did not receive oxycodone until more than 24 hours after admission. The facility also failed to administer and document scheduled doses of gabapentin and trazodone for this resident, leading to a delay in pain management and insomnia treatment. Another resident, admitted with conditions such as a multidrug-resistant organism and septicemia, did not receive intravenous antibiotics as ordered. The facility failed to acquire and administer the antibiotics timely, and there were gaps in the medication administration record (MAR) for several medications. The resident's family reported that the facility did not provide medications for a day and a half after admission, and the resident eventually chose to go to the hospital to receive the necessary antibiotics. The facility's documentation and communication with the pharmacy were inadequate, contributing to the delay in medication delivery. The facility's policies on medication administration and documentation were not followed, resulting in incomplete MARs and missing pharmacy delivery receipts. The Director of Nursing (DON) acknowledged the delays in medication delivery and the lack of documentation for some medications. The facility's failure to ensure timely and accurate medication administration placed residents at risk of inadequate disease management and uncontrolled pain.
Failure to Honor Resident's Medication Timing Preference
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating his request to receive medications at a later time. The resident, who had diagnoses including sepsis, polyneuropathy, muscle spasm, and paraplegia, expressed his preference to receive his medications later in the evening, as he was accustomed to from his previous hospital stay. On the evening in question, the resident refused his medications when they were offered earlier than his preferred time, leading to a situation where his choice was not respected. The resident's care plan indicated that he was resistive to care and should be allowed to make decisions about his treatment regime. Despite this, the staff did not return to administer the medication at the time requested by the resident. The LVN involved acknowledged the resident's refusal and did not attempt to administer the medication later, citing no risk to the resident for missing one dose. The DON confirmed that medications should be administered as ordered but did not address the importance of respecting the resident's self-determination in care decisions.
Inadequate Supervision and Hazardous Equipment Use in Resident's Room
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accident hazards for a resident who was using a portable heater in their room. The resident, who had moderate cognitive impairment and required assistance for transfers and personal hygiene, was found with a portable heater operating within close proximity to their bed and privacy curtain. The heater was provided by the facility due to a malfunctioning in-wall heating unit, and the resident had been using it for two days without direct supervision. Interviews with staff revealed a lack of awareness and monitoring regarding the use of portable heaters in the facility. The Maintenance Supervisor acknowledged the potential fire risk posed by the heater and stated that it had been removed after replacing the in-wall unit. However, no fire watches were conducted during the heater's use, and the facility did not provide a policy on portable heaters when requested. This oversight placed residents at risk for accidents or injuries due to inadequate supervision and potential fire hazards.
Failure to Follow Physician Orders for Blood Sugar Checks
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not follow physician orders for daily fasting blood sugar checks for a resident on multiple occasions. The resident, who was cognitively intact and had a history of diabetes mellitus with neuropathy, was aware that his blood sugar should be checked every morning but reported that the facility nurses did not perform these checks consistently. The resident did not report the missed checks to facility management, assuming they were already aware of the issue. Interviews with facility staff revealed that the responsibility for the blood sugar checks was assigned to the overnight nurse, but there was no documentation indicating that the resident refused the checks. The Director of Nursing (DON) and the Administrator were not aware of the missed checks until the issue was brought to their attention. The facility's medication administration record confirmed the missed checks, and there was no related policy provided by the DON or Administrator before the exit.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the conditions in Resident #8's bathroom and the shower room used by multiple residents. Resident #8, who has a history of major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and mild cognitive impairment, reported that her bathroom wall had been in disrepair since her admission, with visible plumbing and smeared tiles. Despite her complaint to the Maintenance Supervisor, no action was taken, and the issue was not logged in the maintenance records for several months. Additionally, the shower room on the 300 hall was found to be unsanitary and in poor condition, with a strong foul odor, missing tiles, and a black substance around the shower edges. Residents reported the room as "nasty" and infested with roaches, with dirty briefs and overflowing trash contributing to the unsanitary conditions. The Maintenance Supervisor was unaware of these issues, as no maintenance requests had been submitted, and the room's condition was not documented in the maintenance logs. Interviews with staff revealed that the shower room was the only functional one available, and it was used to store dirty linen and trash, exacerbating the odor and cleanliness issues. The Assistant Director of Nursing (ADON) acknowledged the problem but had not yet found an alternative storage solution. The facility's policy on maintaining a homelike environment was not adhered to, as evidenced by the lack of cleanliness and order in the resident's bathroom and the communal shower room.
Failure to Secure Sharps Container and Shower Room
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that a sharps container in the shower room on Hall 300 was properly monitored and emptied before becoming overfilled. Observations revealed that the sharps container was overflowing past the fill line, with five used disposable razors left unsecured on top. The shower room door was found open and unattended, posing a risk of injury to residents who might access the room unsupervised. Interviews with staff, including a medication aide and a licensed vocational nurse, confirmed that the door should have been locked and the sharps container emptied when full. Both staff members acknowledged the potential hazard posed by the unsecured razors. The Director of Nursing (DON) and the Administrator (ADM) confirmed that the facility's policy required used razors to be disposed of in sharps containers and that these containers should be emptied when reaching the fill line. The DON stated that all nursing staff were responsible for ensuring the containers were emptied, and keys to the containers were accessible to staff. Despite these protocols, the failure to secure the shower room and properly manage the sharps container created a potential risk for residents, particularly those with dementia, who could have accessed the razors and harmed themselves.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the presence of expired medications and supplies in the medication room. During an observation, it was noted that the medication room contained an almost full box of IV administration sets with an expiration date of June 5, 2024, ten IV insertion cannulas with an expiration date of February 28, 2024, and six acetaminophen 650mg suppositories with a use-by date of December 11, 2023. These expired items were not removed or disposed of according to the facility's policy, which states that discontinued, outdated, or deteriorated drugs should be returned to the dispensing pharmacy or destroyed. The deficiency potentially affected two residents: one receiving IV medications and another prescribed the expired acetaminophen suppositories. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed a lack of awareness and accountability regarding the expired supplies. The ADON mentioned that the medication room was checked monthly for expired items, but the expired supplies were still present. The DON acknowledged the risk posed by the expired IV supplies but did not specify who was responsible for monitoring expiration dates. The facility's policy on medication storage was not adhered to, leading to the presence of expired medications and supplies in the medication room.
Deficiencies in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff, as evidenced by issues with essential kitchen equipment. Specifically, the handwashing sink in the kitchen was non-functional, with no running water available from the faucet. Additionally, the dishwashing sink and dishwasher were unable to drain properly, leading to water accumulation. These deficiencies were observed during a survey of the kitchen, where a wet vacuum was noted to be used to manage the water overflow, indicating a persistent drainage problem. Interviews with the Dietary Manager and the Administrator revealed that these issues had been ongoing for at least a year. The Dietary Manager acknowledged the risk of injury to staff and the potential for an unsanitary kitchen environment due to the drainage problems. The Administrator, who took over the facility in June 2024, confirmed that the issues were known during the turnover with the previous administrator. Despite attempts to resolve the problems, including hiring a new dietary manager and contacting plumbers, the issues remained unresolved due to delays in receiving necessary invoices for funding approval.
Ineffective Pest Control Program in Shower Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live small flies and roaches in the only active shower room. Observations revealed a small fly on the door frame and multiple live roaches and flies in the shower room. Interviews with staff and residents confirmed the presence of pests, with reports of roaches and flies in both the shower room and residents' personal rooms. The pest control log indicated sightings of roaches on several occasions, but entries were sparse and did not reflect the ongoing issue. The contracted pest control company had visited the facility and treated for various pests, but the problem persisted. Staff interviews revealed a lack of consistent documentation of pest sightings in the pest control log, which was supposed to guide pest control efforts. The Maintenance Supervisor and other staff acknowledged the issue and the potential impact on residents' quality of life, but there was no evidence of a comprehensive or effective response to the pest problem.
Failure to Maintain Resident Dignity Due to Lack of Privacy Covers
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents by not providing privacy covers for their catheter bags. Observations revealed that the catheter bags of these residents were left uncovered and visible from the doorways, which could lead to embarrassment and low self-esteem for the residents. This issue was identified during multiple observations over two days, where the catheter bags were consistently found without privacy covers. Resident #49, a male with a history of cerebral infarction, hemiplegia, and severe cognitive impairment, required extensive assistance with daily activities and had an indwelling catheter. Similarly, Resident #57, a male with chronic health conditions and cognitive intactness, was completely dependent on assistance and used an external catheter. Both residents' care plans included interventions to maintain their dignity and prevent catheter-related issues, yet the lack of privacy covers was not addressed. Interviews with staff, including CNAs and the DON, highlighted a lack of awareness and communication regarding the absence of privacy covers. Staff acknowledged the importance of privacy covers for maintaining resident dignity but were unaware of any shortages or missing covers. The facility's policy emphasized the importance of promoting resident dignity and privacy, yet this was not upheld in practice, as evidenced by the observations and staff interviews.
Failure to Notify Physician of Abnormal Keppra Levels
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal laboratory results for a resident taking Keppra, an antiseizure medication. The resident, who had a seizure disorder and moderate cognitive impairment, had a Keppra level that was out of the normal range on a specific date. Despite the facility's policy requiring prompt notification of high or toxic medication levels, the abnormal result was not communicated to the physician. Interviews revealed that the lab results were not flagged in the electronic medical record system, leading to the oversight. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lapse, noting that the results were available in the electronic medical records and should have been communicated during shift reports. The facility's policy stated that nurses should notify physicians of high or toxic levels promptly, but this was not done. The physician indicated that routine monitoring of Keppra levels was not necessary unless the resident showed symptoms, but expected all lab results to be reported. The failure to notify the physician could result in the physician not being fully aware of the resident's clinical condition.
Facility Fails to Prevent Resident Elopement Leading to Arrest and Hospitalization
Penalty
Summary
The facility failed to prevent the elopement of two residents, leading to significant incidents. The first resident, diagnosed with dementia and other conditions, was able to leave the facility without supervision due to inadequate monitoring and access to the door code. Despite being assessed as a low risk for wandering, the resident left the facility and was later arrested for obstructing a train. The facility's failure to properly supervise and restrict access to the door code contributed to this incident. The second resident, also with cognitive impairments, repeatedly attempted to leave the facility and was eventually successful. Despite wearing a wander guard, the resident managed to exit the facility and was found at a transfer station, having suffered a stroke. The facility's inability to effectively monitor and prevent the resident's elopement, despite clear signs of exit-seeking behavior, resulted in the resident's hospitalization. Both incidents highlight the facility's failure to ensure adequate supervision and security measures for residents at risk of elopement. The lack of proper monitoring, failure to restrict access to door codes, and insufficient response to residents' exit-seeking behaviors were significant factors leading to these deficiencies.
Failure to Prevent Resident Elopement and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures to prevent neglect, resulting in two residents eloping from the facility. The first resident, diagnosed with dementia and moderate cognitive impairment, was able to leave the facility without supervision. Despite being assessed as a low risk for wandering, the resident had access to the door code, which was shared by another resident. The resident left the facility unnoticed and was later arrested for obstructing a train. The facility's failure to conduct proper monitoring and ensure the resident's safety led to this incident. The second resident, also diagnosed with dementia and wearing a wander guard, repeatedly attempted to leave the facility. Despite being on 15-minute checks, the resident managed to elope and was found at a transfer station, having suffered a stroke. The facility's staff did not perform the required checks, and the wander guard system failed to prevent the resident from leaving. The resident's elopement and subsequent medical emergency highlight the facility's inability to adequately supervise and protect residents at risk of wandering. Interviews with staff and record reviews revealed that the facility did not adhere to its protocols for monitoring residents at risk of elopement. Staff failed to conduct regular checks and did not ensure that wander guard devices were functioning correctly. The facility's lack of effective supervision and failure to follow established procedures contributed to the residents' elopements and the resulting adverse outcomes.
Inadequate Supervision Leads to Resident Elopements
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents, leading to incidents of elopement. The first resident, who had moderate cognitive impairment due to dementia, was able to leave the facility without being noticed. This resident had access to the door code, which was given by another resident, and left the facility to smoke off property. The resident was later found 3.5 miles away and was arrested for impeding a train. Despite having a low risk for wandering, the resident's elopement risk assessments did not account for the possibility of obtaining the door code from another resident. The second resident, who was at high risk for wandering due to dementia, was wearing a wander guard device. However, the resident managed to leave the facility multiple times, including an incident where the resident was found lying on the ground at a transfer station after suffering a stroke. The resident's care plan included interventions to distract from wandering, but these measures were insufficient to prevent the resident from leaving the facility. The resident's behavior of packing belongings and expressing a desire to leave was noted, but the facility's interventions failed to effectively manage these behaviors. Both incidents highlight a lack of effective monitoring and supervision, as well as inadequate use of assistance devices like wander guards. The facility's failure to ensure that wander guards were functioning properly and to prevent residents from obtaining door codes contributed to these elopements. The facility's staff did not adequately monitor the residents' movements, and there was a lack of timely response to the residents' exit-seeking behaviors.
Failure to Provide Scheduled ADL Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs) independently, specifically in maintaining good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in two residents who did not receive their scheduled showers or bed baths as required. Resident #2, a cognitively intact male with a history of stroke and other medical conditions, reported not receiving bed baths according to his schedule due to staff shortages. He expressed dissatisfaction with the situation, having last received a bed bath on a specific date, despite his requests for assistance. Resident #1, who had moderate cognitive impairment and required substantial assistance with ADLs, also did not receive regular showers or bed baths. The facility's records showed a lack of documentation for showering tasks over the past 30 days, with only one bed bath recorded for Resident #1 during this period. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed a lack of awareness regarding the issue and confirmed that showers were not scheduled in the electronic care system, leading to a failure in documentation and task completion. The DON and other staff members acknowledged the oversight in scheduling and documenting showers, which resulted in residents not receiving the care they needed. The facility's policy on supporting ADLs emphasized the importance of providing appropriate care and services to maintain residents' hygiene and well-being. However, the failure to adhere to this policy and ensure proper documentation and scheduling of showers contributed to the deficiency observed by the surveyors.
Failure to Secure Resident's Medical Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. During an observation, a computer displaying wound care information for a resident was left unlocked and unattended at the nurse's station. This occurred while the Licensed Vocational Nurse (LVN) responsible for the computer walked away to check on the resident's wound status. During the time the computer was unattended, two residents and a visitor passed by the nurse's station, potentially exposing the resident's sensitive medical information. The resident involved was a cognitively intact male with a history of cerebral infarction, hemiplegia, Type II diabetes, atrial fibrillation, cellulitis, and a congenital pancreatic cyst. The LVN admitted to forgetting to lock the computer, acknowledging that this action violated the resident's privacy. The Director of Nursing (DON) and the Administrator were not initially aware of the incident but confirmed that it was against the facility's policy and expectations for staff to leave resident information unsecured.
Improper Storage of Medication in Resident's Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. This deficiency was observed in the case of a resident who had a packaged syringe labeled 0.9% sodium chloride and several alcohol swabs left on his bedside table. The resident, who was cognitively intact, reported that the facility nurses used the saline solution in his port and often left items in his room. This oversight was confirmed during an interview and observation with LVN A, who was unaware of the syringe being left in the resident's room. Further investigation revealed that LVN D, the resident's assigned nurse for the shift, had used the saline flush for the resident's central line before and after medication administration. However, LVN D did not recall leaving the flush in the room and acknowledged it was her responsibility to remove all medications and biologicals from the resident's room. The DON was informed of the incident and stated that it was against the facility's expectations for medication supplies to be left in a resident's room, as they could be contaminated or misused. The facility's policy on the storage of medications, revised in April 2007, mandates that drugs and biologicals be stored in a safe, secure, and orderly manner. The policy specifies that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary manner. Despite this policy, the incident with the saline flush syringe indicates a lapse in adherence to these guidelines, potentially placing residents at risk of medication misuse.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in one of the resident rooms. During an observation and interview, a resident was found lying in bed with gnats flying off of him, indicating a pest issue in the room. The resident, who was nonverbal but able to answer yes and no questions, confirmed the presence of gnats and mentioned having reported the issue to staff, although he could not specify to whom. Despite the resident's report, the Licensed Vocational Nurse (LVN) and the Director of Maintenance (DOM) were unaware of the pest problem in the room. The facility's pest control program involved a pest control company visiting the facility monthly, with no reports of pests documented in the maintenance logs for the months reviewed. The DOM was responsible for pest control and expected staff to document pest concerns in the pest control binder or report them directly to him. However, the lack of awareness and documentation of the gnat issue in the resident's room suggests a breakdown in communication and reporting within the facility's pest control program.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted on a daily basis, as required, for one of the twenty-one days reviewed. On 05/17/24, observations at multiple times throughout the day revealed that the daily nursing staff posting near the dining room displayed the date of 05/16/24, indicating that it had not been updated. This oversight was confirmed during an interview with the Director of Nursing (DON), who was unaware that the posting had not been updated for the current day. The DON explained that the Assistant Director of Nursing (ADON) was responsible for updating the postings daily and typically provided staffing sheets in two-week increments at each pay period. However, the ADON had not provided the necessary sheets for the current pay period. The Administrator (ADMIN) also confirmed that the nurse staffing posting had not been updated for 05/17/24 and acknowledged that it should have been updated at the start of the day. The ADMIN stated that both the ADON and the receptionist were responsible for updating the daily nurse staffing posting. Despite the oversight, the ADMIN believed that residents were not affected as they did not pay attention to the posting, but acknowledged that they would be misinformed if the post was not updated daily. A related policy was requested from the ADMIN but was not provided before the exit.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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