St. Teresa Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 10350 Montana Avenue, El Paso, Texas 79925
- CMS Provider Number
- 676342
- Inspections on file
- 59
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at St. Teresa Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to maintain complete and accurate medical records and to submit detailed Provider Investigation Reports (PIRs) to HHSC for incidents involving two residents with significant cognitive and medical conditions. For one bedbound resident with dementia and a history of falls, documentation noted ankle swelling and later a fracture, but the trauma-informed assessment showed no negative findings and the chart lacked clear documentation of investigative steps and interventions such as pain management, therapy evaluation, and compression. For another resident with DM2, cerebrovascular disease, anoxic brain damage, and sarcopenia, PIRs similarly lacked detail on interviews, records reviewed, and interventions. The DON and Administrator stated that interviews and interventions occurred, but acknowledged that PIRs were vague and that the Administrator kept investigative notes in a personal notebook instead of in the medical record or PIR, contrary to policy and HHSC requirements for thorough, documented investigations.
Surveyors found that the facility failed to update a comprehensive, person-centered care plan after a resident with dementia and severe cognitive impairment experienced a fall. The resident’s care plan identified general fall risk and listed standard fall-prevention interventions, but did not address the specific in-facility fall as a change of condition. The MDS nurse, DON, and Administrator all acknowledged that such a fall should have been added to and updated in the care plan, consistent with facility policy requiring comprehensive care plans with measurable objectives and timeframes that are revised with significant changes in condition.
A resident with multiple Stage 4 pressure ulcers and significant comorbidities received wound care from a Wound Care RN who applied Arginaid powder directly to buttock wounds, allowing the powder to spill onto the resident’s brief and then securing the soiled brief without changing it. The resident had physician orders for daily and PRN wound care and a care plan including wound care and Arginaid, and prior documentation indicated the wounds were healing without signs of infection. The DON later stated that wound care must follow facility policy and acknowledged that leaving a brief with spilled medication in place was not acceptable and could cause infection, while the facility’s wound treatment policy required treatments per orders and dressing changes when dressings are soiled or wet.
Two residents with indwelling Foley catheters did not receive proper catheter securement or perineal care, as Catheter Holders were found loose or detached and perineal cleaning was performed from back to front instead of front to back, contrary to facility policy and staff training. Both residents had significant medical histories requiring careful catheter management, but care plans and observed practices did not consistently address or follow required procedures.
A resident with multiple complex medical conditions, including ventilator dependence and a persistent vegetative state, was issued a 30-day discharge notice for non-payment, but the facility failed to initiate or develop a discharge plan at that time. The care plan lacked discharge planning, and staff interviews confirmed that no steps were taken to assess or coordinate the resident's post-discharge needs, especially during a period when the facility was without a social worker.
A facility failed to employ a qualified full-time social worker, resulting in lapses in grievance handling and discharge planning for a resident with complex medical needs, including ventilator dependence and multiple chronic conditions. During the vacancy, administrative and nursing staff attempted to cover social work duties, but discharge planning and grievance documentation were not consistently completed according to policy.
A resident with a wound and indwelling medical devices did not receive Enhanced Barrier Precautions (EBP) during high-contact care activities, despite staff training, available PPE, and posted signage. Staff failed to don gowns and gloves or perform hand hygiene before direct care, and the care plan and physician orders did not document EBP requirements. Staff interviews revealed confusion about EBP necessity and lapses due to being rushed, contrary to facility policy.
Two residents with cognitive impairments were involved in a physical altercation when one resident entered another's room and was struck in the face and had items thrown at her, resulting in visible bruising. Staff intervened after hearing yelling and found the scene with scattered belongings and spilled water. Both residents had no prior history of aggression, but the incident revealed a failure to prevent abuse and ensure resident safety.
A resident with a history of nutritional deficiency and protein-calorie malnutrition was not provided with the correct enteral feeding rate as ordered. The resident was supposed to receive Isosource 1.5 at 50 ml/hr, but the feeding pump was set to 65 ml/hr. The DON admitted to not following up on the order change, and the dietician had concerns about caloric intake. The resident's weight increased slightly, but the PCP noted no health risk.
A facility failed to maintain accurate inventory records for a resident with dementia, leading to a grievance about a missing blanket. The DON confirmed the grievance, and staff interviews revealed inconsistencies in inventory procedures. The facility's policy required documentation of sentimental items, which was not followed.
A resident with respiratory issues and a BiPAP order did not have the use of the BiPAP machine included in their care plan. Despite physician orders and consistent monitoring of oxygen saturation levels, the care plan only addressed oxygen therapy. Interviews with facility staff revealed that the omission was an oversight, with responsibilities for updating care plans acknowledged by the DON, MDS Coordinator, and Administrator.
Two residents in the facility, both requiring assistance with ADLs, were found with long and dirty fingernails, indicating a failure in providing necessary personal hygiene care. One resident, with dementia and hemiplegia, was dependent on staff for nail care, which was overlooked despite regular bathing schedules. Another resident, with tracheostomy and gastrostomy status, also had long, jagged nails, posing a risk of self-injury. Staff interviews revealed a lack of awareness and communication regarding nail care responsibilities, contrary to the facility's policy.
A facility failed to properly label a resident's enteral feeding bag, risking inadequate nutrition. The resident, with a history of gastro-esophageal reflux disease and malnutrition, was on continuous g-tube feeding. The DON confirmed the labeling requirement, and the LVN admitted to not labeling the bag due to an interruption, acknowledging the risk of incorrect feeding and monitoring issues.
The facility failed to properly handle advance directives for residents, specifically DNR orders. A resident's DNR request was pending a physician's signature, and there was no scanned document in the records. Another resident's OOH DNR was not signed by a physician, and the process was incomplete. The facility began the enactment process, but the document was scanned before being signed, resulting in an incomplete DNR status.
The facility failed to ensure that residents were not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. A resident received Risperidone for Delusional disorder without indicators of psychosis, another was prescribed Aripiprazole for depression despite no symptoms, and a third received Quetiapine for dementia without psychosis. The DON acknowledged the inappropriate use of these medications.
A long-term care facility failed to maintain an effective infection prevention and control program. A resident with Shingles was placed under incorrect precautions, lacking necessary airborne measures. Additionally, urinary catheters for three residents were improperly maintained, with bags found on the floor, increasing infection risk. Staff interviews revealed a lack of adherence to facility policies, contributing to these deficiencies.
A deficiency was identified involving the improper maintenance of oxygen machines, specifically the checking of oxygen filters. The DON was informed that the RT is responsible for ensuring the machines function properly. This oversight risks the resident not receiving adequate oxygen, increasing the risk of infection.
A facility failed to ensure a resident was free from physical restraints not required for medical symptoms. A concave mattress was used without assessment, physician's order, or consent, despite the resident's difficulty in getting out of bed. The DON concluded the mattress was not a restraint, but facility policy required a physician's order and consent for restraints.
A facility failed to implement a comprehensive care plan for a resident, omitting interventions for several medical and psychosocial needs, including urinary tract infection, shortness of breath, and depression. The care plan also lacked specific goals for self-care deficits. Staff interviews revealed a lack of personalization and a system to identify incomplete care plans, potentially risking unmet care needs.
Two residents in an LTC facility were found with long fingernails, indicating a failure to provide necessary grooming and hygiene services. Both residents had significant medical histories and required assistance with ADLs. Staff interviews revealed that nail care was supposed to be performed during showers, but this was not consistently done, leading to a deficiency in maintaining proper hygiene.
A resident with limited range of motion did not receive adequate treatment and services to maintain or improve her condition. Despite having moderate cognitive impairment and requiring assistance for daily activities, her care plan lacked specific interventions for range of motion. The facility's restorative program was suspended, and there was no clear process for monitoring changes in residents' functioning, leading to a deficiency in care.
A resident with paralysis and high fall risk experienced a fall due to inadequate supervision and improper use of a mechanical lift by staff. The staff demonstrated incorrect transfer techniques, including jerking the lift over fall mats, which posed a risk of injury. The facility's training and supervision were insufficient to ensure safe transfers.
A deficiency was identified when a resident's urinary catheter bag was found resting on a fall mat, contrary to infection control protocols. A staff member confirmed the improper placement, and the DON admitted to not knowing the policy on privacy bag sufficiency, acknowledging a potential infection risk. All clinical staff are responsible for catheter care.
Two residents receiving oxygen therapy were found with dusty oxygen concentrator filters, despite orders for regular maintenance. Staff interviews revealed confusion over responsibility for filter upkeep, risking inadequate oxygen delivery and respiratory issues.
A resident did not receive the prescribed multivitamin with minerals due to an LVN administering the wrong supplement. Additionally, expired insulin pens were found in two medication carts, indicating a failure in medication storage management. The DON and Administrator acknowledged these deficiencies, which were contrary to the facility's pharmacy policy.
A deficiency was identified in a LTC facility regarding medication administration and storage. An LVN administered a multivitamin without minerals to a resident, contrary to the physician's order, and failed to report the unavailability of the correct medication. Additionally, expired insulin pens were found in medication carts, indicating lapses in monitoring and disposal practices. The DON and Administrator acknowledged these failures, which could affect the efficacy of resident treatments.
The facility failed to maintain accurate DNR documentation for three residents. A resident's DNR status was recorded without a completed Texas OOH DNR form, another resident was listed as DNR without the necessary form, and a third resident's DNR form lacked a physician's signature. The facility's policy was to treat residents as DNR based on a signed request form, even if the official documentation was incomplete.
A resident's family reported a privacy violation during perineal care, as CNAs left the curtain open, exposing the resident to her roommate. Despite being informed, the Weekend Supervisor and ADON did not initiate a formal grievance, failing to document or investigate the issue as per the facility's policy.
Two residents requiring assistance with ADLs were found with long, jagged fingernails, indicating a failure in personal hygiene care. One resident, with Parkinson's and other medical conditions, was dependent on staff for hygiene, yet his nails were neglected. Another resident, cognitively intact but requiring max assistance, expressed dissatisfaction with his nail care. Interviews with staff revealed inconsistencies in nail care responsibilities, despite a facility policy emphasizing regular nail management.
A resident with Parkinson's disease and other medical conditions was found with their call light out of reach, tangled under a monitor, preventing them from contacting staff for assistance. Despite the care plan's requirement to keep the call light accessible, staff interviews confirmed the oversight, highlighting a deficiency in ensuring resident needs are met.
A resident's privacy was compromised when two CNAs provided perineal care without closing the curtain, allowing the roommate to potentially view the care. The resident, who was severely cognitively impaired and dependent on toileting, had a history of vascular dementia, cerebral infarction, and tracheostomy status. Despite training on privacy, the CNAs involved were not identified, and the incident was reported by the resident's responsible party.
A resident with multiple diagnoses, including dementia and seizures, required two-person assistance for bathing as per their care plan. However, a CNA bathed the resident alone due to pressure to complete showers, risking injury. Facility policies and interviews with staff confirmed the need to follow care plans for safety, but the care plan was not adhered to, placing the resident at risk.
A facility failed to replace a resident's tracheostomy ventilation circuit tubing that contained red/brownish particles for two days. The resident, who had vascular dementia and tracheostomy status, was observed with the contaminated tubing without showing distress. Interviews revealed that the RT did not notice the particles, and the DON confirmed that the equipment should be checked and replaced as needed, placing the resident at risk of infection.
A resident with severe cognitive impairment and muscle weakness fell and sustained a laceration after a CNA provided perineal care without the required two-person assistance. Despite knowing the resident's care plan, the CNA chose to perform the task alone, leading to the fall and injury.
The facility failed to ensure proper catheter care for two residents, leading to potential risks of infection. One resident's urinary catheter was mishandled, causing urine spillage, while another resident did not receive required catheter care every shift as indicated in their care plan.
The facility failed to document a COVID-19 positive resident in the Infection Control Log and a CNA did not change gloves after cleaning a resident's BM, continuing ADL assistance with dirty gloves. These actions violated infection control protocols and placed residents at risk for infection.
The facility failed to document physician orders for a resident who was Covid-19 positive and placed in isolation. Despite detailed care instructions in the resident's care plan, the necessary physician orders were missing, as confirmed by both an LVN and the DON.
Incomplete Medical Records and Vague Provider Investigation Reports for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and to provide accurate, detailed self-reports to HHSC for incidents involving two residents. For one resident, an elderly female with hypertension and dementia and a BIMS score indicating severe cognitive impairment, documentation showed an event note on 12/25/25 indicating ankle swelling with no pain reported and notification of the physician and responsible party. However, the trauma-informed PRN assessment documented no negative findings, despite the prior observation of swelling and the later discovery of an ankle fracture. The Administrator later stated the resident was bed bound, had a history of falls, and that CNAs observed swelling while showering the resident, but these investigative details and related interventions were not reflected in the resident’s chart or in the formal investigation documents. For the second resident, an elderly female with type 2 diabetes mellitus, cerebrovascular disease, anoxic brain damage, and sarcopenia, records showed significant cognitive and physical impairments, including inability to participate in the BIMS. The Provider Investigation Reports for incidents involving both residents lacked detailed information such as which staff and residents were interviewed, what documentation was reviewed, and what specific interventions were implemented to address or prevent further incidents. The DON reported that staff, including CNAs, nurses, the residents, and therapy staff, were interviewed as part of the investigations and that interventions such as pain medication management, therapy evaluation, and compression were implemented for the first resident after her fall, but these actions were not clearly documented in the investigation reports. Interviews with the DON and Administrator confirmed that the Provider Investigation Reports submitted to HHSC were vague and did not include the interventions or investigative steps they described verbally. The Administrator acknowledged that she documented her investigative findings in a personal notebook rather than in the residents’ medical records or in the Provider Investigation Reports, and that this information was not incorporated into the official documentation sent to HHSC. Facility policy and HHSC guidance require that comprehensive investigations be conducted and documented in the Provider Investigation Report, including the nature and extent of injuries, subsequent negative outcomes, and other pertinent information, but the reports reviewed did not meet these standards.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes addressing a resident’s fall that occurred in the facility. The resident was an elderly female with hypertension and dementia, with a BIMS score of 7 indicating severe cognitive impairment, initially admitted in mid-November and readmitted in late December. Record review showed that although the resident’s care plan, revised at the end of January, identified her as being at risk for falls related to impaired mobility and listed general fall-prevention interventions (such as anticipating needs, keeping the call light within reach, and educating resident/family/caregivers about safety and what to do if a fall occurs), it did not include the specific fall event that occurred on 12/25/25. Observation on 02/03/26 found the resident in bed in the lowest position with the call light within reach, and she did not respond to the surveyor’s questions about the facility’s care or services. Interviews with facility staff confirmed that the fall should have been incorporated into the resident’s care plan as a change of condition. The MDS nurse stated that a fall is considered a change of condition that must be added to and updated in the care plan, that care plans are individualized to inform staff how to provide care, and that ADONs are responsible for making acute changes while MDS nurses review care plans quarterly or as needed for significant changes. The DON similarly stated that the fall was a change of condition that should have been included in the care plan and that nursing staff are responsible for monitoring and updating care plans for acute changes, with MDS nursing reviewing care plans quarterly and monitoring daily. The Administrator stated that the care plan is intended to paint a picture of residents’ needs and provide information to all staff, and that care plans are reviewed quarterly by MDS nursing and updated immediately by nursing staff when there is a change of condition. The facility’s undated Comprehensive Care Planning policy stated that the facility will develop and implement a comprehensive care plan for each resident, consistent with resident rights, including measurable objectives and timeframes to meet identified needs, and that care plans will be reviewed and revised after admission, quarterly, annually, and/or with significant change MDS assessments and in response to current interventions.
Improper Wound Care and Infection Control During Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and maintain infection prevention and control practices for a resident on transmission-based precautions with multiple Stage 4 pressure ulcers. The resident was an elderly female with a history of Type 2 diabetes mellitus, cerebrovascular disease, anoxic brain damage, and sarcopenia, who was unable to participate in the BIMS and unable to answer questions due to her medical condition. Her physician orders required daily and PRN wound care for Stage 4 pressure wounds on the left buttock, right buttock, and sacrum, and her care plan included wound care and administration of Arginaid as ordered. A wound care progress note documented that all wound sites were healing with no signs of infection. During an observation of wound care, the Wound Care RN applied Arginaid, a powder-form nutritional supplement, directly onto the resident’s right and left buttock wounds. The powder was observed spilling from the wounds onto the resident’s brief. The Wound Care RN then secured the brief on the resident without changing it, leaving the spilled medication on the brief. In a subsequent interview, the DON stated that wound care nurses were responsible for providing wound care per facility policy and that it was not acceptable for the Wound Care RN to leave a brief on the resident with contaminated spilled medication, acknowledging that this could lead to possible infection or illness and could infect the resident’s other wounds. The facility’s wound treatment management policy stated that wound treatments would be provided in accordance with physician orders and that dressing changes may be provided outside the usual frequency when the dressing is soiled or otherwise wet.
Failure to Provide Proper Catheter Securement and Perineal Care
Penalty
Summary
The facility failed to provide appropriate care for residents who were incontinent of bowel and bladder, specifically in the areas of catheter care and perineal hygiene, as observed in two residents. Both residents had indwelling Foley catheters and were dependent on staff for all activities of daily living, including toileting and hygiene. Observations revealed that the catheter drainage tubes for both residents were not properly secured with a Catheter Holder prior to turning and repositioning in bed. The Catheter Holders were found to be loose or detached, and staff interviews confirmed that this was a recurring issue, particularly after showers or when lotion was applied. Staff were aware of the need to report and replace detached Catheter Holders, but this was not consistently done in practice. In addition to issues with catheter securement, perineal care was not performed according to facility policy for one resident. During an observed episode of incontinence care, a CNA cleaned the perineal area from back to front, rather than from front to back as required by policy and training. This method of cleaning increases the risk of cross-contamination from fecal matter to the urethral and vaginal areas. The CNA used multiple wipes but did not adhere to the correct technique, despite having been trained on the proper procedure. Interviews with other staff confirmed that the expectation was to always clean from front to back to prevent contamination and infection. Record reviews for both residents indicated a history of significant medical conditions, including chronic kidney disease, neuromuscular dysfunction of the bladder, and a history of antibiotic-resistant urinary tract infection. Care plans and physician orders specified the need for catheter care every shift and the use of Catheter Holders to prevent trauma and infection. However, the care plans did not always address the presence of a Foley catheter, and the observed practices did not align with facility policy or physician orders. The facility was unable to provide a current catheter care policy upon request by the surveyor.
Failure to Develop and Initiate Discharge Plan for Medically Complex Resident
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and that the discharge planning process resulted in the development of a discharge plan when a 30-day discharge notice was issued due to non-payment. The resident in question had a complex medical history, including coronary artery disease, diabetes mellitus, heart failure, COPD, peripheral vascular disease, hypertension, prior stroke, chronic kidney disease, anoxic encephalopathy, and was ventilator dependent with a tracheostomy and PEG tube. The resident was bedbound, in a persistent vegetative state, and required extensive care for multiple stage IV pressure ulcers. Despite these significant care needs, the facility did not initiate a discharge plan at the time the discharge notice was issued. Record review showed that the resident's care plan did not include a discharge plan, and the quarterly MDS assessment left the resident's overall goal blank, with no active discharge planning or referral to the Local Contact Agency. The responsible party for the resident had not paid the required applied income, leading to the issuance of the discharge notice. Facility staff, including the DON, ADONs, and Business Office Manager, reported that the social worker responsible for discharge planning had left the facility, and a replacement was not in place during the critical period. Attempts to contact the responsible party were limited to phone calls and emails, with no other methods used to facilitate discharge planning or ensure the resident's needs and preferences were addressed. Interviews with facility staff confirmed that no discharge plan was developed or initiated when the discharge notice was issued. The scheduled orientation for discharge planning was not conducted, and there was no documentation of efforts to coordinate a safe and appropriate discharge for the resident, who remained in a highly dependent state. The facility's own policy required assessment of continuing care needs and coordination of post-discharge services, but these steps were not taken in this case.
Failure to Employ Full-Time Social Worker and Complete Discharge Planning
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for facilities with more than 120 beds. According to interviews and record reviews, the facility had not had a full-time social worker since December 11, 2025. The Director of Nursing (DON) and Administrator confirmed that the responsibilities of the social worker, including addressing grievances and initiating discharge plans, were being handled by themselves and Assistant Directors of Nursing (ADONs) in the absence of a social worker. The Administrator stated that although a new social worker was hired on November 24, 2025, this individual was terminated on December 11, 2025, and the position remained vacant at the time of the survey. A specific case involved a resident with complex medical needs, including a persistent vegetative state, ventilator dependence, multiple chronic conditions (such as CAD, DM, heart failure, COPD, PVD, HTN, prior CVA, CKD 3, and anoxic encephalopathy), and multiple stage IV pressure ulcers. The resident was bedbound, non-responsive, and required extensive care, including wound management, nutritional support, and mechanical ventilation. The resident's family desired all life-sustaining measures, and the care plan required ongoing monitoring and adjustment. Despite the issuance of a discharge notice due to non-payment, there was no active discharge planning or documentation of a discharge plan in the resident's care plan, and scheduled discharge planning orientation was not conducted as planned. Staff interviews revealed that grievances and discharge planning were not consistently managed according to facility policy during the period without a social worker. The DON and Administrator acknowledged lapses in grievance documentation and communication with families. The MDS nurses confirmed that the social worker would typically initiate interdisciplinary discharge planning, but this was not done for the resident in question. The facility was unable to provide a copy of the social worker job description when requested by the surveyor, and evidence of ongoing recruitment for the position was provided.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBP) during high-contact care activities for a resident with a wound and indwelling medical devices. The resident in question had a history of frequent urinary tract infections, an indwelling Foley catheter, a feeding tube (G-tube), and a stage 2 pressure ulcer. The care plan and physician orders did not document the need for EBP, despite the resident's risk factors. Staff interviews confirmed that EBP training had been provided, and signage and personal protective equipment (PPE) were available near the resident's room. During direct observation, a nurse and a CNA entered the resident's room, failed to wash their hands, and did not don gowns or gloves before providing direct care, which included turning the resident and checking for skin breakdown. Both staff members acknowledged after the fact that they had been trained on EBP but failed to follow the protocol due to nervousness and being rushed. The CNA incorrectly believed EBP was no longer necessary because the resident's catheter had been discontinued, although the resident still had a G-tube and a pressure ulcer, which required continued EBP according to facility policy. Interviews with additional staff, including the DON and RN, confirmed that EBP should be followed for residents with indwelling medical devices or wounds during high-contact care activities. The facility's policy, effective as of April 2024, clearly outlined the requirements for EBP, including the use of gowns and gloves during specific care activities. Despite this, the observed failure to implement EBP placed the resident at risk for cross-contamination and the potential spread of infections.
Failure to Protect Residents from Abuse During Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure the right to be free from abuse for two residents, resulting in an incident where one resident physically assaulted another. On the date of the incident, a female resident with dementia, anxiety disorder, and impulse disorder, who had a history of wandering and required redirection, entered the room of a male resident with vascular dementia and severe cognitive impairment. The male resident, who had no prior history of physical aggression, was found by a staff member yelling for the other resident to leave his room. The staff member discovered the female resident in the male resident's room, with personal belongings scattered and water spilled on the floor. According to staff and documentation, the male resident hit the female resident in the face and threw items at her, resulting in immediate bruising to her face, knuckles, and shin. The female resident reported being hit, and a head-to-toe assessment confirmed the injuries. The incident was witnessed by a staff member, who intervened and removed the female resident from the room. Both residents were assessed for safety following the event. Prior to this incident, there were no documented altercations or aggressive behaviors between these two residents, and neither had exhibited physical or verbal aggression toward others according to their care plans and assessments. The facility's abuse and neglect policy required protection of residents from abuse by anyone, including other residents, and mandated prompt reporting and investigation of such incidents. However, the failure to prevent the altercation and protect the residents from abuse constituted a deficiency in upholding resident rights and safety.
Failure to Administer Correct Enteral Feeding Rate
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via a gastrostomy tube was provided with the correct feeding as ordered. The resident, who had a history of nutritional deficiency and protein-calorie malnutrition, was supposed to receive Isosource 1.5 at a rate of 50 ml/hr. However, the feeding pump was set to administer the formula at a continuous rate of 65 ml/hr, which was not in accordance with the updated order. This discrepancy was identified during an observation and interview, where the resident confirmed receiving all nutrition through the tube feeding without any issues. The Director of Nursing (DON) acknowledged the importance of following orders for patient care and admitted that a breakdown occurred when he did not follow up to ensure the feeding order change was implemented. The dietician had changed the order due to concerns about the resident's caloric intake and potential weight gain, but the change was not communicated effectively to the nursing staff. The resident's weight increased slightly from 146.2 lbs to 148.0 lbs during the period when the incorrect feeding rate was administered. Interviews with the primary care physician and the administrator highlighted the importance of adhering to feeding orders to ensure proper nutrition, although the physician noted that the feeding order discrepancy did not pose a health risk to the resident.
Failure to Maintain Accurate Resident Inventory Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the inventory of personal items. The resident, an elderly female with dementia and severely impaired cognition, had an inventory sheet that did not accurately document her belongings. The inventory sheet was marked as having no items of significant value, despite a grievance from a family member about a missing Christmas blanket. The Director of Nursing (DON) confirmed receiving a grievance about the blanket, which was later replaced by the facility. Interviews with facility staff revealed inconsistencies in the process of inventorying residents' personal items. The Medical Records/Central Supply staff indicated that items brought in by family or visitors should be declared and inventoried, but acknowledged that there would be no negative outcome if items were not inventoried. The Admission Coordinator noted that only three inventory sheets were available, with one being incomplete and unsigned. The facility's policy required items of sentimental value to be documented, but this was not adhered to, leading to the deficiency.
Failure to Include BiPAP in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident's use of a BiPAP machine. The resident, a cognitively intact female with a history of acute and chronic respiratory failure, chronic obstructive pulmonary disease, and dependence on supplemental oxygen, was admitted and readmitted to the facility. Despite having physician orders for nighttime use of a BiPAP machine to maintain oxygen saturation levels above 90%, the resident's care plan did not include this critical intervention. The care plan only addressed oxygen therapy without mentioning the BiPAP, even though the resident's oxygen saturation levels were consistently monitored and maintained as per the physician's orders. Interviews with the Director of Nursing (DON), MDS Coordinator, and the Administrator revealed that the omission of the BiPAP from the care plan was an oversight. The DON acknowledged that it was the responsibility of the nursing and MDS nurses to ensure care plans are updated and accurate, and admitted that the BiPAP should have been included. The MDS Coordinator explained that the resident was treated as a new admission upon readmission, and the BiPAP was not included in the care plan during the quarterly review. The Administrator confirmed that while the resident received the necessary services, the care plan did not reflect the use of the BiPAP, posing a risk of treatment not being provided if the care plan is not accurate.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, resulting in long and dirty fingernails. Resident #16, a male with dementia, hemiplegia, and major depressive disorder, was observed with long and dirty fingernails. He was dependent on staff for personal hygiene due to his medical conditions, including left-sided weakness from a cerebral infarction. Despite being scheduled for regular bathing, staff did not notice or address his nail care needs, leading to potential risks of skin tears and infection. Resident #17, a male with tracheostomy and gastrostomy status, also required substantial assistance with ADLs. He was cognitively intact but dependent on staff for personal hygiene. His fingernails were observed to be long and jagged, and he expressed concern about the risk of self-injury. The staff, including the Assistant Director of Nursing (ADON), acknowledged the oversight in nail care, which should have been performed as needed during bathing. Interviews with staff, including CNAs and the Regional Compliance Nurse, revealed a lack of awareness and communication regarding the residents' nail care needs. The facility's policy on nail care emphasized regular maintenance to prevent infection and injury, but this was not adhered to, resulting in the observed deficiencies. The Administrator confirmed the responsibility of CNAs, Med Aides, and nurses in ensuring proper nail care for residents dependent on staff assistance.
Failure to Label Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not properly label the enteral feeding formula for a resident, which put the resident at risk of not receiving adequate nutrition. The resident, a male with a history of gastro-esophageal reflux disease, protein-calorie malnutrition, and gastronomy status, was observed to be on continuous g-tube feeding. During an observation, it was noted that the feeding bag was not labeled with the resident's name, date, and time it was hung, as required by the facility's policy. The Director of Nursing (DON) acknowledged that the feeding bag should have been labeled to ensure the proper feeding was administered and to monitor the feeding as ordered. The Licensed Vocational Nurse (LVN) responsible for the resident admitted to hanging the feeding bag without labeling it, stating he was interrupted by another resident. The LVN recognized the risk of administering the wrong feeding and the lack of monitoring due to the absence of labeling. The facility's gastronomy tube care policy requires that formula and feedings be labeled with at least the date and time the administration began.
Deficiency in Handling Advance Directives
Penalty
Summary
The deficiency involves the mishandling of advance directives, specifically Do Not Resuscitate (DNR) orders, for multiple residents. Resident #97 had a DNR request initiated by a social worker, but the document was pending a physician's signature, and there was no scanned DNR document in the electronic records. The compliance nursing team noted the need for a valid Texas Out-of-Hospital (OOH) DNR for in-house requests, but this was not completed. Similarly, for Resident #259, the OOH DNR was not signed by a physician, and the process was not completed. The facility began the enactment process for the DNR, but the document was scanned before the physician signed it, leading to an incomplete DNR status. The family had signed a request for DNR, but the necessary medical documentation was not finalized.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for three residents who were reviewed for unnecessary medications. Resident #27 was administered Risperidone, an antipsychotic, to treat Delusional disorder, despite having no indicators of psychosis. The Director of Nursing (DON) expressed uncertainty about the appropriateness of the diagnosis for the use of an antipsychotic. Resident #93 was prescribed Aripiprazole, an antipsychotic, to treat depression, although his assessment showed no symptoms of delirium, depression, or psychosis. The DON acknowledged that prescribing an antipsychotic for depression was incorrect and highlighted the risks associated with such medications, including sleepiness and extrapyramidal effects. Resident #255 received Quetiapine, an antipsychotic, for dementia, despite having no symptoms of psychosis or behavioral symptoms. The DON confirmed that dementia was not an appropriate diagnosis for the use of Quetiapine and noted that it was the responsibility of the Assistant Director of Nursing (ADON) or the DON to contact the physician when a medication was prescribed with an incorrect indication.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Resident #155, who had Shingles, was placed under contact precautions instead of the required airborne and contact precautions. This oversight was confirmed by the Director of Nursing (DON), who acknowledged that the current precautions were incorrect and that the Shingles virus could potentially spread due to this error. The facility did not provide masks in the personal protective equipment (PPE) cart, and staff were observed entering the resident's room without masks, further compromising infection control measures. Additionally, the facility failed to ensure that urinary catheters for Residents #4, #33, and #73 were properly maintained off the floor, as required by their care plans. Observations revealed that the catheters were either dragging on the floor or improperly secured, increasing the risk of urinary tract infections (UTIs). Interviews with staff, including Licensed Vocational Nurses (LVNs) and the DON, highlighted a lack of adherence to the facility's policy on catheter care, which mandates that catheters be kept off the floor and in privacy bags. The DON admitted that approximately 20% of residents with catheters had UTIs, indicating a significant concern for infection control. The report also noted that the facility's staff, including CNAs, LVNs, and RNs, were responsible for monitoring catheter care but failed to consistently do so. The DON and other staff members acknowledged the potential risks associated with catheters being on the floor, such as contamination and injury to residents. Despite the facility's policy and the staff's awareness of the correct procedures, the lack of consistent implementation and monitoring led to the observed deficiencies in infection control practices.
Oxygen Machine Maintenance Deficiency
Penalty
Summary
The deficiency involves a failure to ensure that oxygen machines are functioning properly, specifically regarding the maintenance and checking of oxygen filters. The Director of Nursing (DON) was informed about the issue at 3:40 PM on July 25, 2024, highlighting that the responsibility lies with the respiratory therapist (RT) to ensure the oxygen machines are operating correctly. This oversight poses a risk to the resident, as it may result in the resident not receiving the desired effect of the oxygen, potentially leading to an increased risk of infection.
Failure to Assess and Document Use of Concave Mattress as Restraint
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints that were not required to treat medical symptoms, specifically concerning a concave mattress used for Resident 259. The resident, who was cognitively intact with a BIMS score of 14, had functional limitations in one arm and one leg and required assistance for mobility. Despite these needs, there was no documented assessment, physician's order, or consent for the use of a concave mattress, which was placed on her bed in early June. The resident expressed difficulty in getting out of bed due to the mattress's high sides, which she was told were intended to prevent falls. The Director of Nursing (DON) stated that an assessment was conducted to determine if the concave mattress was a restraint, concluding it was not because the resident could get out of bed without additional difficulty. However, the facility's policy required a physician's order and informed consent for any restraint, which was not obtained in this case. The facility's policy defined a physical restraint as any equipment that restricted freedom of movement and could not be easily removed by the resident, necessitating a physician's order and consent from the resident or responsible party.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not include interventions for the resident's urinary tract infection, shortness of breath, hypotension, impaired cognitive function, cellulitis, potential nutritional problem, mood problem, and depression. Additionally, the care plan for the resident's self-care deficit did not specify which areas of function, such as bed mobility, transfers, or toilet use, were to be maintained or improved. Interviews with facility staff revealed that the care plan was not personalized after the resident's admission, and there was no system in place for identifying incomplete care plans. The MDS Nurse indicated that the 5-day assessment should have triggered a review for inclusion in the comprehensive care plan, but this did not occur. The DON acknowledged that the care plan was not updated and that there was no routine for reviewing care plans to ensure completeness. This lack of a comprehensive care plan could result in the resident's care needs not being met.
Failure to Maintain Resident Nail Care
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and hygiene for two residents who were unable to perform activities of daily living independently. Specifically, the facility did not trim the fingernails of these residents, which was observed during a survey. Resident #26, who had a history of hypertension, cerebral infarction, and respiratory failure, required total assistance with ADLs and was unable to communicate effectively. During an observation, it was noted that Resident #26 had long fingernails, and interviews with staff revealed that nail care was supposed to be performed during showers, but this was not adequately done. Similarly, Resident #29, who also had a history of hypertension, cerebral infarction, and respiratory failure, was observed with long fingernails. This resident had severe cognitive impairment and difficulties in communication, making it challenging for him to express his needs or preferences regarding nail care. Staff interviews indicated that CNAs were responsible for the residents' hygiene, including nail care, but the necessary actions to maintain proper grooming were not consistently executed. The facility's policy on nail care, which includes regular cleansing, trimming, and smoothing of nails to prevent infection and injury, was not adhered to in these cases. The failure to maintain proper nail care for these residents placed them at risk of poor hygiene and potential health issues, as noted by the staff during interviews. The observations and interviews highlighted a deficiency in the facility's provision of personal hygiene services for residents who are unable to perform these tasks themselves.
Failure to Provide Adequate Range of Motion Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, identified as Resident #97, to maintain or improve her condition. Resident #97, who has moderate cognitive impairment and several medical diagnoses, was dependent on staff for various activities and had impairments in her range of motion in both arms and legs. Despite receiving some occupational and physical therapy, there was no recorded time for restorative therapy, and her care plan lacked specific interventions to address her range of motion issues. Interviews revealed that Resident #97 was discharged from physical and occupational therapy due to a change in her payer source, even though she had not met all her therapy goals. The Director of Rehabilitation acknowledged that the facility's restorative program had been discontinued months prior, and there was uncertainty about whether nurses were effectively monitoring residents for changes in functioning. The MDS Nurse and DON confirmed that changes in a resident's level of functioning would typically be identified through therapy assessments or reports from nursing staff, but there was no clear process in place following the suspension of the restorative program. The facility lacked policies and procedures regarding range of motion exercises and the restorative program, as confirmed by the DON. The Administrator mentioned that the restorative program was suspended, not discontinued, but the last time restorative staff worked was several months ago. This lack of structured support and monitoring for residents like Resident #97, who require ongoing therapy to prevent further decline, contributed to the deficiency identified in the report.
Deficiency in Resident Transfer Safety
Penalty
Summary
The facility failed to ensure adequate supervision and proper use of assistance devices for a resident, leading to a deficiency in accident prevention. The resident, who was at high risk for falls and had a history of paralysis following a stroke, was completely dependent on staff for transfers. Despite being identified as high risk, the resident experienced a fall when attempting to get out of bed, resulting in redness to the left arm. The incident highlighted the need for proper supervision and the use of appropriate safety measures, such as bed rails and low beds, to prevent accidents. During an observation, two aides were seen performing a mechanical lift transfer for the resident. The aides, one of whom was new to the facility, demonstrated improper techniques, including manually sliding the resident and jerking the lift over fall mats. The lift was lifted manually over the mats while the resident was unsecured, which posed a risk of injury. The Director of Nursing (DON) stated that the expectation was for transfers to be completed with two people, with the lift locked during the process, and that the staff had been trained on proper lift use. Interviews with staff revealed inconsistencies in training and understanding of proper mechanical lift procedures. The Physical Therapy Assistant (PTA) described the correct process, emphasizing the importance of locking the lift's brakes and using two staff members for transfers. However, the facility's in-service training and nurse aide checklist did not address specific issues such as jerking the lift over uneven surfaces. This lack of adherence to proper procedures and inadequate supervision contributed to the deficiency in ensuring resident safety during transfers.
Improper Handling of Urinary Catheter Bag
Penalty
Summary
A deficiency was identified involving the improper handling of a urinary catheter bag for a resident. On July 23, 2024, it was observed that the catheter bag was placed in a privacy bag but was resting on a fall mat, which is not in compliance with infection control protocols. An interview with a staff member confirmed that the catheter bag was touching the floor due to the fall mat, and it was acknowledged that the bag should not be on the floor for infection control reasons. On July 25, 2024, the Director of Nursing (DON) was questioned about the catheter bag being on the floor and admitted to not knowing the policy regarding whether the privacy bag provided sufficient protection. The DON recognized that if the privacy bag was not adequate, there was a risk of infection. It was noted that all clinical staff, including CNAs, are responsible for ensuring proper catheter care.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during a survey. Resident #256, who had a history of stroke and was receiving oxygen therapy, was found with an oxygen concentrator filter that had accumulated dust. The resident's care plan lacked specific interventions for maintaining the oxygen equipment, and the staff responsible for the care of the oxygen filters did not ensure they were clean. This oversight increased the risk of the resident inhaling dust and germs, potentially compromising their oxygen absorption. Similarly, Resident #38, who had acute respiratory failure and was also on oxygen therapy, was observed with a dusty oxygen concentrator filter. Despite having a physician's order to clean or change the filter weekly, the filter was found with a dense accumulation of dust. Interviews with staff revealed a lack of clarity regarding the responsibility for maintaining the filters, which posed a risk of inadequate oxygen delivery and increased the potential for respiratory complications.
Deficiencies in Medication Administration and Storage
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications, as evidenced by the case of a resident who did not receive the prescribed multivitamin with minerals. The resident, who was admitted with diagnoses of nutritional deficiency and pressure ulcer, was given a multivitamin without minerals by LVN A, contrary to the physician's orders. LVN A admitted to not being sure if the correct multivitamin with minerals was available and later found it in the medication room, indicating a lapse in following the physician's order and ensuring the correct medication was administered. Additionally, the facility failed to manage medication storage properly, as observed with expired insulin pens found in two medication carts. Insulin pens in the carts for halls 400 and 500 were past their expiration dates, as indicated by the manufacturer's instructions. LVN A and LVN B, who were responsible for these carts, acknowledged that it was their responsibility to monitor and remove expired medications but failed to do so. This oversight could lead to residents receiving expired insulin, which may not provide the desired therapeutic effect. The Director of Nursing (DON) and the Administrator were informed of these deficiencies. Both acknowledged that the nursing staff should have followed the physician's orders and removed expired medications from the carts. The facility's pharmacy policy and procedure manual, which outlines the correct procedures for medication administration and storage, was not adhered to, contributing to these deficiencies.
Medication Administration and Storage Deficiencies
Penalty
Summary
The report identifies a deficiency related to medication administration and storage within the facility. During an interview and observation, an LVN admitted to administering a multivitamin without minerals to a resident, contrary to the physician's order for a multivitamin with minerals. The LVN was unsure if the correct vitamin was available and later found the appropriate vitamin in the medication room. The Director of Nursing (DON) and the Administrator acknowledged that the nurse should have followed the physician's order and reported the unavailability of the correct medication to ensure the resident received the intended treatment. Additionally, the report highlights issues with medication storage, specifically concerning expired insulin pens. During inspections of medication carts, it was found that some insulin pens were past their expiration date. The LVN acknowledged that it was the responsibility of each nurse to monitor and remove expired medications from the cart. The DON confirmed that insulin pens should be dated upon opening and are good for 28 days, and noted that expired insulins were not disposed of as expected. The Administrator also recognized the failure to remove expired insulins, which could result in residents not receiving the desired effect of the medication. The report includes multiple observations of medication carts and storage areas, noting that while controlled medications were properly accounted for, there were lapses in the management of regular medications, particularly with expired insulin pens. The facility's failure to ensure proper medication administration and storage practices led to the identified deficiencies, as staff did not adhere to established protocols for medication handling and reporting shortages.
Deficiency in DNR Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for three residents regarding their Do Not Resuscitate (DNR) status. For Resident #97, the facility documented a DNR status in the resident's chart without having a completed Texas Out of Hospital DNR form. The social worker indicated that the family had requested a DNR, and the facility considered the family member's signature on the DNR request as valid, even though the official document was pending a physician's signature. Resident #155 was listed as DNR in the facility's records, but there was no Out-of-Hospital DNR form present. The resident had verbally requested a DNR, which was documented and signed by two witnesses, but the necessary OOH-DNR form was not completed. The LVN noted that the electronic files showed the resident as DNR, but acknowledged the need for the actual form to validate the DNR status. For Resident #259, the facility documented a DNR status without a physician's signature on the Texas OOH DNR form. The social worker admitted to not noticing the missing signature and stated that the document was scanned into the system before the physician could sign it. The facility's policy was to treat residents as DNR once a request form was signed, even if the official OOH-DNR form was incomplete.
Failure to Address Grievance on Privacy Violation
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances, specifically for a resident whose family member raised concerns about privacy violations during perineal care. The resident, an elderly female with severe cognitive impairment and dependent on toileting, was observed on video footage receiving care from two CNAs with the privacy curtain open, exposing her to her roommate. The resident's representative reported this incident to the Weekend Supervisor and the Assistant Director of Nursing (ADON), but no formal grievance was initiated or documented. Interviews revealed that the Weekend Supervisor and ADON were aware of the privacy concern but did not follow the facility's grievance policy, which requires documentation and investigation of grievances. The Weekend Supervisor educated the CNAs on privacy but did not remember their identities, and the ADON verbally addressed the issue without initiating a grievance. The facility's Administrator acknowledged the lack of a grievance process, which resulted in no documentation or monitoring of the response to the family's concerns.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, resulting in inadequate personal hygiene care. Resident #19, a male with Parkinson's disease, tracheostomy, gastrostomy, and dependence on mechanical ventilation, was observed with long, jagged fingernails with dark discoloration. Despite being dependent on staff for personal hygiene, there was no record of when his nails were last trimmed, and the Licensed Vocational Nurse (LVN) was unaware of the last time the resident was bathed. Similarly, Resident #20, a male with tracheostomy, gastrostomy, and anxiety disorder, required maximum assistance with personal hygiene. He was found with long, jagged fingernails and expressed dissatisfaction with their length, indicating that staff should have been responsible for trimming them. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, revealed inconsistencies in the execution of nail care responsibilities. The ADON and DON acknowledged that nail care should be performed during bathing, but there was no clear timeframe for when this should occur. The facility's policy on nail care, dated 2003, emphasized regular and safe nail management to prevent infection and injury, yet this was not adhered to, as evidenced by the condition of the residents' nails. The lack of proper nail care could lead to poor care, lack of dignity, and potential skin tears for residents dependent on staff assistance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which could prevent the resident from having their needs met. The resident, a male with Parkinson's disease, tracheostomy status, gastrostomy status, and dependence on mechanical ventilation, was observed lying in bed with the call light tangled under the wheels of a monitor and out of reach. The resident was unable to communicate effectively due to a communication problem related to no speech and was rarely or never understood. The comprehensive care plan for the resident included ensuring the call light was within reach, but this was not adhered to during the observation. Interviews with facility staff, including a CNA, ADON, DON, and the Administrator, confirmed that it was the responsibility of all staff to ensure call lights were within reach of residents. The CNA acknowledged the call light was out of reach, and the ADON and DON emphasized the importance of call lights for residents to contact staff for assistance. The Administrator reiterated the expectation that call lights should be within reach and mentioned ongoing re-education efforts. Despite these acknowledgments, the deficiency was noted due to the failure to maintain the call light within the resident's reach, as required by the care plan.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to ensure personal privacy during personal care for a resident, identified as Resident #22, by not closing the curtain while providing perineal care. This incident was observed in video footage where two CNAs were seen providing care with the curtain open, allowing the roommate to potentially view the care being given. The resident's responsible party (RP) had placed a video camera in the room and reported witnessing the incident to the Weekend Supervisor and ADON D. The resident, who was severely cognitively impaired and dependent on toileting, had a history of vascular dementia, cerebral infarction, and tracheostomy status. Interviews with the Weekend Supervisor, ADON D, and the Administrator revealed that the CNAs had been trained on providing privacy during care upon hire and as needed. However, the specific CNAs involved in the incident were not identified. The Weekend Supervisor and ADON D acknowledged the failure to close the curtain as a violation of the resident's privacy and dignity. The facility's Resident Rights policy emphasized the resident's right to personal privacy, which was not upheld in this instance.
Failure to Follow Care Plan for Resident Bathing Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident with multiple diagnoses, including dementia, seizures, schizophrenia, anxiety disorder, and moderate intellectual disability. The resident was dependent on staff for showering and required two-person assistance as per their comprehensive care plan. However, during an observation, a CNA was seen showering the resident alone, contrary to the care plan's requirements. The CNA admitted to bathing the resident alone due to pressure to complete showers, despite knowing the care plan required two-person assistance. The CNA acknowledged the risk of injury to the resident when not following the care plan. Interviews with the ADON, DON, and Administrator confirmed that the care plan should be followed for safety reasons and that staff are trained to refer to the Kardek for assistance requirements. The facility's policies on bathing and comprehensive care planning emphasize the need for staff to be familiar with the type and pattern of assistance required for each resident. The failure to adhere to the care plan placed the resident at risk of not receiving necessary care and services, potentially leading to accidents or harm.
Failure to Replace Contaminated Tracheostomy Tubing
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, specifically by not replacing the tracheostomy ventilation circuit tubing that contained red/brownish particles for two days. The resident, an elderly female with vascular dementia, cerebral infarction, and tracheostomy status, was observed on two separate occasions with the contaminated tubing. Despite the presence of these particles, the resident showed no signs of distress and was non-verbal. Interviews with the respiratory therapist (RT) and the Director of Nursing (DON) revealed a lack of adherence to the facility's protocol for maintaining clean tracheostomy equipment. The RT, who was responsible for the resident's care, admitted to not noticing the particles and stated that the equipment was replaced weekly. The DON confirmed that the nursing department was responsible for ensuring the cleanliness of the equipment and that RTs should check and replace equipment as needed. The failure to replace the contaminated tubing placed the resident at risk of infection.
Failure to Provide Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure that Resident #10 received adequate supervision and assistance devices to prevent accidents. On 3/7/24, CNA G provided perineal care to Resident #10, who required two-person assistance, without asking for help. During the care, Resident #10 started coughing and rolled off the bed, resulting in a fall and a laceration above her right eyebrow. This incident was documented by LVN F and ADON D, who both confirmed that Resident #10 required two-person assistance for perineal care, which CNA G failed to obtain. Resident #10, a [AGE] year-old female with severe cognitive impairment, muscle weakness, and tracheostomy status, was dependent on staff for toileting and required two-person assistance for incontinent care as per her care plan and Kardex. On the day of the incident, CNA G, despite being aware of the requirement for two-person assistance, chose to perform the task alone, leading to the resident's fall and subsequent injury. The resident was assessed on the floor, and emergency services were called to transport her to the hospital, where she received treatment for her laceration. Interviews with the involved staff revealed that CNA G was aware of the need for two-person assistance but failed to ask for help, believing it would be easier to perform the care alone. This lapse in following the care plan directly resulted in the resident's fall and injury. The facility had already implemented corrective actions before the surveyor's investigation began, but the incident highlighted a significant lapse in adherence to care protocols, which could place residents at risk of accidents and potential harm.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for two residents reviewed for urinary catheter care. Specifically, Resident #9's urinary catheter was observed placed on top of the bed without a privacy bag, and during the process of emptying the catheter, urine spilled on the floor, which was cleaned with adult wipes that do not have disinfectant agents. CNA A admitted to not following proper procedures due to nervousness from being observed, which was confirmed by ADON D who stated that CNAs are trained to empty urine below the bladder to prevent backflow and spillage, and that failure to do so could lead to cross-contamination and infection. Resident #9 had diagnoses including quadriplegia, tracheostomy, muscle wasting, and anxiety, and required 2-person assistance with bed mobility and toileting, with an intact cognition as per his MDS assessment dated 4/1/24. The facility's failure to follow proper catheter care procedures placed Resident #9 at risk of infection. Additionally, the facility failed to provide catheter care for Resident #4 every shift as required. Resident #4, a male diagnosed with sepsis, urinary tract infection, and mechanical complication of urinary catheter, had a care plan that included providing catheter care every shift. However, records showed multiple instances where catheter care was not provided on various dates across several months. The DON confirmed that catheter care should be provided every shift as indicated and acknowledged that failure to do so could result in a risk for infection. The facility's catheter care policy emphasized keeping the drainage bag below the level of the bladder, but this was not consistently followed for Resident #4, leading to potential risks of infection.
Infection Control and Perineal Care Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which led to deficiencies in the care of two residents. One resident, who was COVID-19 positive, was not recorded in the Infection Control Log, which is essential for surveillance and monitoring of outbreaks. The Director of Nursing (DON), who is also the Infection Preventionist, acknowledged that the resident's COVID-19 status should have been documented to prevent the spread of infection and to comply with the facility's infection control plan. The failure to document this case in the Infection Control Log was a significant oversight in the facility's infection control practices. Another deficiency was observed during the provision of perineal care to a resident. A Certified Nursing Assistant (CNA) failed to change gloves after cleaning the resident's bowel movement (BM) and continued to provide activities of daily living (ADL) assistance with the same dirty gloves. This included applying lotion, fixing bed sheets, and adjusting the resident's tracheostomy tube. The CNA admitted that she should have changed gloves to prevent cross-contamination and reduce the risk of infection. The Assistant Director of Nursing (ADON) confirmed that CNAs are trained to change gloves after handling soiled briefs to prevent cross-contamination. The facility's policies on infection control and bowel incontinence care were not followed, leading to these deficiencies. The Infection Control Plan requires maintaining records of infections and performing surveillance to prevent the spread of disease. The Bowel Incontinence Care policy mandates the disposal of soiled briefs using universal precautions, but it did not specify the need to change gloves after handling soiled briefs. These lapses in following established protocols placed residents at risk for infection and highlighted gaps in the facility's infection control practices.
Failure to Document Physician Orders for Covid-19 Isolation
Penalty
Summary
The facility failed to ensure that medical records for Resident #7 were complete and accurately documented. Specifically, there were no physician orders for Resident #7, who was Covid-19 positive on 01/31/24 and placed in isolation. The resident's care plan required isolation precautions due to an active Covid-19 infection, but the necessary physician orders were not documented. This oversight was confirmed during interviews with LVN C and the Director of Nursing (DON), who both acknowledged the absence of physician orders for the isolation. Resident #7, a [AGE] year-old female with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was re-admitted to the facility on 01/11/24. The resident's care plan included specific instructions for managing her Covid-19 infection, such as isolation, fluid intake, and oxygen availability. Despite these detailed care instructions, the facility did not have the required physician orders for the isolation, as confirmed by the DON. Additionally, a request for the facility's Physician Orders policy was not fulfilled by the Administrator, further highlighting the deficiency in documentation and procedural adherence.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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