Sunny Springs Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Sulphur Springs, Texas.
- Location
- 1200 Jackson St N, Sulphur Springs, Texas 75482
- CMS Provider Number
- 675664
- Inspections on file
- 26
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Sunny Springs Nursing & Rehab during CMS and state inspections, most recent first.
Surveyors found that staff failed to secure a medication cart and an insulin pen, allowed a resident to keep wound cleanser in his room, and left medications unattended on a resident's tray. Facility leadership confirmed that these actions did not meet expectations for medication security and administration.
A resident with multiple health conditions, who was cognitively intact but dependent on staff for daily activities, reported that meals were consistently cold and unappetizing. Similar complaints were echoed by a group of residents. During a meal observation, surveyors found some food items to be lukewarm and bland. Dietary and administrative staff were unaware of these issues, despite facility policies requiring meals to be palatable and served at appropriate temperatures.
The facility did not inform a resident or their representative about the option to enter into a binding arbitration agreement or their right to refuse, resulting in a lack of awareness of their legal rights regarding arbitration.
The facility did not ensure hospice documentation was consistently updated and maintained for three residents receiving hospice care, resulting in missing or outdated plans of care, medication lists, and IDG meeting notes. Staff interviews revealed confusion about responsibility for updating hospice binders, and recent staffing changes in medical records contributed to lapses in documentation and care coordination.
Staff failed to consistently follow infection control protocols, including proper use of PPE, glove changes, and hand hygiene, during care of residents on Enhanced Barrier Precautions and during routine care. These lapses included not changing gloves between dirty and clean tasks, not performing hand hygiene, and wearing contaminated PPE outside resident rooms, placing residents at risk for cross-contamination.
A resident with dementia and impaired decision-making was administered Remeron, an antidepressant, without a signed psychotropic consent form. Facility staff, including the charge nurse and nursing management, acknowledged that consent was not obtained prior to administration, contrary to facility policy and care plan requirements.
A resident with acute and chronic respiratory failure and moderately impaired cognition was readmitted without a physician's order for DNR status entered into the electronic medical record, despite having a care plan and Out-of-Hospital DNR form indicating DNR. Staff interviews confirmed that the required process for entering and monitoring DNR orders was not followed, resulting in the omission.
A resident with multiple medical conditions, including a recent abdominal surgery, was receiving IV antibiotics via a central line, but the care plan did not address this therapy. Although the medication was administered as ordered, the omission in the care plan meant staff may not have been aware of the need to monitor for side effects. Facility staff interviews revealed confusion over responsibility for updating care plans, and the facility's policy required comprehensive documentation of all services provided.
A resident who was fully dependent on staff for ADLs and incontinent did not receive scheduled showers or bed baths over an extended period. Despite being cognitively intact and expressing the need for hygiene care, the resident was not offered alternative bathing when the shower was unavailable, and staff failed to communicate or document missed care as required by facility policy.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care in these areas.
A resident with legal blindness and multiple health conditions was found to have three unsecured razors in his drawer, including one without a blade cover, despite requiring total assistance with personal hygiene. Facility staff and leadership acknowledged that the razors should not have been accessible, as this posed a risk of injury to the resident and others, especially with other residents known to wander. The facility's policy required daily monitoring of resident rooms to ensure safety, but the razors were not removed after care.
A resident with a feeding tube did not receive enteral nutrition as ordered by the physician, as nursing staff failed to restart the feeding pump after it was turned off for care activities, resulting in the resident missing required nutrition for a period longer than allowed. Documentation did not indicate when the feeding was to be restarted, and staff did not communicate the lapse during shift change.
A resident with COPD and shortness of breath was observed receiving oxygen therapy without a current physician's order, despite the care plan indicating a need for oxygen. Staff interviews and record review confirmed the absence of an order, and facility policy required a physician's order for oxygen administration.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, nor did it ensure appealing meal options were available. This was identified through observations and review of food service practices, showing that some residents did not receive meals tailored to their individual dietary requirements.
A resident with severe cognitive impairment was found with a bruise and skin tear on her arm, but staff did not follow required protocols for investigation, documentation, or reporting. The incident was not properly assessed, reported to management, or updated in the care plan, and no internal investigation or state notification occurred, despite facility policy requiring these actions.
A resident with severe cognitive impairment was found to have a bruise and skin tear of unknown origin, which was documented by an LPN after being reported by a family member. The required notifications to the DON, Administrator, and state agency were not completed, and no incident report or care plan updates were made. Interviews revealed that staff did not consistently follow the facility's policy for reporting and investigating such incidents, resulting in the event being overlooked and not reported as required.
The facility did not update or implement comprehensive care plans for two residents requiring contact isolation due to ESBL and MRSA infections. One resident's care plan failed to address contact isolation for ESBL, while another's care plan did not include interventions for MRSA isolation or her refusal to comply with isolation protocols, despite physician orders and staff awareness of these needs.
Staff failed to follow contact isolation protocols for two residents with ESBL and MRSA, including not wearing required PPE during care and not ensuring a resident remained in isolation. One resident with severe cognitive impairment received care from staff who did not use gowns or gloves, while another resident with MRSA was allowed to participate in group activities without proper education or care plan updates. Facility policies and physician orders for contact precautions were not consistently implemented.
The facility failed to protect residents from abuse, as evidenced by three incidents of resident-to-resident altercations. A resident with dementia was struck by another resident, another resident was grabbed under the arm, and a third resident was pushed on the head. Staff intervened in each case, but the incidents highlight a failure to ensure a safe environment.
A resident with dementia in an LTC facility did not receive medications as scheduled, including calcium, pantoprazole, and sitagliptin-metformin, leading to potential inconsistencies in treatment. Additionally, Estrace vaginal cream was not administered as ordered, and the resident received an incorrect dosage of Vitamin B-12. Staff interviews revealed lapses in following medication administration protocols.
A facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies. One resident's MDS did not reflect antibiotic use or a MRSA diagnosis, while another's discharge destination was incorrectly documented. Staff interviews confirmed the errors and emphasized the importance of accurate coding for care and billing.
The facility failed to conduct scheduled activities on two consecutive days, impacting residents' physical, mental, and psychosocial well-being. The Activity Director was absent during these times, leading to the cancellation of activities like bean bag toss and Skip Bo. The DON and Administrator acknowledged the importance of adhering to the activity schedule to prevent resident boredom and depression.
The facility failed to coordinate hospice care effectively for three residents, resulting in missing or outdated hospice documentation in their medical records. This included plans of care, medication lists, and other essential documents, which were not properly uploaded or maintained, potentially impacting the quality of end-of-life care provided.
A resident was administered Bupropion HCL ER (Wellbutrin) for depression without obtaining informed consent, as required by the facility's policy. The resident, who was cognitively intact, did not have documented consent for this psychotropic medication. Interviews with staff, including an LVN, the ADON, the DON, and the Administrator, confirmed that the consent process was not followed, and the oversight was only discovered during a state surveyor's inquiry.
A resident with multiple health conditions, including end-stage renal disease, refused ordered lab draws for four weeks, and the facility failed to notify the physician of these refusals. The LVN did not document the refusals or notify the physician, contrary to facility policy. The DON and Administrator confirmed the expectation for physician notification and documentation, which was not met.
A resident's Medication Administration Record was left visible and unattended by the ADON, compromising privacy. The resident, with a history of stroke and diabetes, required extensive assistance. The DON and Administrator emphasized the importance of confidentiality, but the facility's policy lacked specific guidance on protecting health information.
A facility failed to report an alleged neglect incident involving a resident with dementia and other conditions, who was left soiled and shaking. A CNA admitted to not attending to the resident due to the resident's behavior. Despite the facility's policy requiring immediate reporting of such incidents, the DON and Administrator did not report it, considering it merely a grievance.
A resident with dementia and other health issues was found in a neglected state by a family member, who reported the incident to the facility. The CNA involved allegedly refused care due to the resident's behavior. Despite the facility's policy requiring immediate reporting of such incidents, the Administrator and DON did not report it to the State Agency, viewing it as a grievance rather than neglect.
A facility failed to include a resident's MRSA diagnosis in their care plan, despite the resident's complex medical history. The omission was due to a lack of awareness and communication among staff, posing a risk of miscommunication and inadequate care.
An unsecured oxygen cylinder was found at the nurse's station, which was acknowledged by an LVN and the Activity Director, who admitted to forgetting to secure it. The ADON, DON, and Administrator emphasized the importance of securing oxygen cylinders to prevent accidents, as per facility policy.
A resident with end-stage renal disease did not have a physician's order for dialysis treatment, and the facility failed to monitor the resident's dialysis catheter as required. The facility's policy allowed dialysis instructions to be placed under special instructions, leading to the absence of a formal order. Staff interviews revealed a misunderstanding of the need for formal orders, placing the resident at risk for complications.
A facility failed to monitor the behavior and side effects of psychotropic medications for a resident with depression and anxiety. Despite being on Bupropion, Sertraline, and Clonazepam, there was no documentation of monitoring in the resident's records. Interviews with staff revealed a lack of awareness and adherence to the facility's policy on psychotropic medication monitoring.
The facility failed to secure a medication cart on hall 100, leaving it unlocked and unattended, which allowed unauthorized access by staff, residents, and visitors. The ADON admitted to forgetting to lock the cart, and interviews with staff, including an LVN, DON, and the Administrator, confirmed that the cart should always be locked when unattended. The facility's policy requires medication carts to be locked when not attended by authorized personnel.
A resident with a MRSA infection in his hip wound was not placed on transmission-based precautions, despite having an antibiotic order. The facility failed to update the resident's care plan and medical records to reflect the MRSA diagnosis. Staff interviews revealed a lack of communication and understanding regarding necessary precautions, with the DON believing enhanced-barrier precautions were sufficient. The facility's policy on transmission-based precautions was not followed, posing a risk of MRSA transmission.
A facility failed to follow its smoking policy by not completing quarterly smoking assessments for a resident, as required. The resident, who was cognitively intact and required supervision for smoking, had not been assessed for over a year. Interviews with the ADON, DON, and Administrator revealed that the nursing staff was responsible for these assessments, but a system failure led to the oversight, posing a risk of burns to residents.
A resident with severe cognitive impairment did not receive proper pharmaceutical services when a card of 30 Hydrocodone-Acetaminophen tablets went missing. The medication was not secured properly by LVN C, leading to a discrepancy discovered by CMA H and RN F. The facility's procedures for handling controlled substances were not followed, posing a risk of unauthorized access to medications.
A facility failed to coordinate hospice care for a resident with dementia and Parkinson's, leading to improper transfers without a mechanical lift. Despite the care plan requiring a mechanical lift for transfers, a hospice aide was not informed of this requirement, resulting in a transfer without the lift. Facility staff did not communicate the change in transfer needs to hospice, placing the resident at risk for falls and injuries.
A CNA failed to perform hand hygiene between glove changes while providing perineal care to a resident, risking cross-contamination and infection. The resident required assistance with personal hygiene due to conditions like dementia and diabetes. Despite facility policies and expectations for hand hygiene, the CNA did not wash hands or use sanitizer between glove changes, as confirmed by interviews with facility staff.
Two residents in a facility did not have their restorative care programs included in their care plans, despite having mobility and strength issues. The care plans lacked measurable objectives and timeframes, and there were no orders for the restorative programs. Interviews revealed a lack of communication and understanding of responsibilities among staff, leading to these omissions.
The facility failed to provide appropriate restorative care to two residents with limited range of motion, as required by their Nursing Restorative Care Program plans. One resident, with severe cognitive impairment, had no documentation of a restorative program in her care plan, and there were significant gaps in the documentation of care provided. Another resident, with moderate cognitive impairment and functional limitations, also lacked documentation of a restorative program, with multiple days showing no record of care being offered. Interviews revealed a lack of oversight and understanding of responsibilities among staff, leading to the deficiency.
Failure to Secure and Properly Administer Medications
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and administration of drugs and biologicals. One nurse left a medication cart unlocked and unattended in a hallway, with an insulin pen left unsecured on top of the cart. The nurse acknowledged that she was responsible for ensuring the cart and medications were secured but failed to do so when responding to a resident's call light. Both the DON and Administrator confirmed that their expectation was for medication carts and medications to be locked and secured when not in direct view of authorized staff. Another deficiency was observed when a resident, who was legally blind and had multiple diagnoses including prostate cancer and depression, was found to have a bottle of wound cleanser in his bedside drawer. The resident reported that items were sometimes removed and returned to his room by staff. Facility leadership, including the ADON, DON, and Administrator, all stated that wound care items such as wound cleanser should not be stored in resident rooms and should be removed by nursing staff after treatments. A further incident involved a medication aide leaving a cup of medications on a resident's breakfast tray without ensuring the medications were taken. The resident, who had diagnoses including diabetes, schizoaffective disorder, and depression, was found with the full cup of medication after breakfast. The medication aide admitted to leaving the medications due to being in a hurry, and facility leadership confirmed that medications should not be left at the bedside and that staff are expected to ensure medications are administered and swallowed before leaving the room.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for at least one resident and during one observed meal. A male resident with legal blindness, high blood pressure, prostate cancer, and depression, who was cognitively intact but required assistance with most activities of daily living, reported that his food was consistently cold and unappetizing when served in his room. He had not requested reheating due to concerns about staff being short-handed. Additionally, a confidential group interview with four residents revealed similar complaints about food being cold and bland. During a lunch meal observation, surveyors and the Dietary Manager sampled a tray and found that while the fajita chicken was warm and tasted good, the refried beans and Spanish rice were lukewarm and bland. The Dietary Manager and Dietitian were unaware of any food complaints, and both, along with the DON and Administrator, stated expectations that food should be palatable and at the correct temperature. However, none were aware of the ongoing concerns. Facility policies required meals to meet nutritional standards and be served at proper temperatures, but these were not consistently followed as evidenced by resident complaints and surveyor observations.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to inform residents or their representatives of their choice to enter into a binding arbitration agreement and their right to refuse such an agreement. This omission resulted in residents or their representatives not being made aware of their legal rights regarding arbitration agreements at the time of admission or during their stay.
Failure to Maintain and Update Hospice Documentation and Coordination
Penalty
Summary
The facility failed to properly collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. For three residents reviewed, the facility did not maintain or update hospice binders with essential documentation such as the most recent plan of care, hospice election forms, medication lists, and physician recertifications. In one case, a resident with diagnoses including malnutrition, anxiety, and COPD had a hospice binder missing updated care plans, medication lists, and IDG meeting notes, with the last recertification and documentation being outdated. Interviews with hospice staff confirmed that documentation should be updated at least weekly after IDG meetings, but this was not consistently done. Another resident, who was legally blind and had diagnoses including prostate cancer and depression, had a hospice binder lacking an IDG comprehensive assessment and an up-to-date medication review. The most recent plan of care was outdated, and the facility's electronic medical record had not been updated with hospice documents for several months. The hospice RN acknowledged responsibility for updating the binder but noted frequent changes and admitted the binder was not current, which could result in the facility not having accurate information. A third resident with end-stage heart failure and renal disease also had a hospice binder missing updated plans of care, medication lists, and notes from nurses, aides, and social workers since the last IDG meeting. Facility staff, including the DON, Social Services, and Medical Records, were unclear about who was responsible for maintaining the hospice binders and how often updates should occur. The facility had recently experienced a gap in medical records staffing, leading to a lack of a system to ensure hospice documentation was consistently updated and available for continuity of care.
Failure to Maintain Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff caring for residents on Enhanced Barrier Precautions (EBP) and during routine care. In several instances, staff members did not adhere to required protocols for the use of personal protective equipment (PPE), glove changes, and hand hygiene. For example, a CNA was observed leaving a resident's room while still wearing the same gown and gloves used during direct care, then returning and continuing care without changing gloves. The same CNA also picked up linens from the floor, placed them in a bag, and resumed care without changing gloves. Another CNA picked up a plastic bag from the floor and placed it on a resident's bed during care. Additional observations included staff not wearing gloves or gowns throughout the entirety of care for a resident on EBP, and failing to change gloves between dirty and clean surfaces during incontinent care. Residents involved in these deficiencies had significant medical histories and care needs. One resident was dependent on staff for most activities of daily living, had moderate cognitive impairment, was always incontinent, and was on EBP due to a multidrug-resistant organism (MDRO) infection. This resident also had chronic kidney disease, diabetes, and a history of urinary tract infection with ESBL resistance. Another resident required total assistance with toileting, transfers, bathing, and bed mobility, and was observed receiving care where gloves were not changed between dirty and clean tasks, and hand hygiene was not performed between glove changes. A third resident, with chronic obstructive pulmonary disease and diabetes, was observed during a blood glucose check where the nurse failed to remove gloves or perform hand hygiene before handling the insulin pen and nurse’s cart, despite having just obtained a blood sample. Interviews with staff, including CNAs, LVNs, the DON, and the Administrator, confirmed knowledge of proper infection control procedures, such as changing gloves between dirty and clean tasks, performing hand hygiene, and not wearing PPE outside of resident rooms. However, the observed failures demonstrated a lack of consistent adherence to these protocols. Facility policies reviewed also outlined the correct procedures for perineal care, hand hygiene, and blood glucose monitoring, emphasizing the importance of glove changes and hand hygiene to prevent cross-contamination and infection.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident received informed consent prior to the administration of a psychotropic medication, specifically Remeron (Mirtazapine), which is an antidepressant. The resident, who had diagnoses including dementia, stroke, and high blood pressure, was his own responsible party but was rarely able to understand or be understood by others, and had severe daily decision-making impairment. Despite this, the resident was administered Remeron on two occasions without a signed psychotropic consent form present in his chart. The care plan indicated that staff were to educate the resident or family about the risks, benefits, and side effects of the medication, but this was not documented as having occurred. Interviews with facility staff, including the charge nurse, ADON, DON, and Administrator, confirmed that the required consent was not obtained prior to medication administration. The charge nurse admitted to forgetting to complete the consent form, and both the ADON and DON acknowledged that obtaining consent was their responsibility and should have occurred before the medication was given. The facility's policy also required that no psychotropic medication be administered without informed consent unless in an emergency, which was not the case in this situation.
Failure to Ensure DNR Order Entered in Medical Record
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for Do Not Resuscitate (DNR) status was present in the medical record for one resident upon readmission. The resident, a male with acute and chronic respiratory failure and moderately impaired cognition, had a care plan and an Out-of-Hospital DNR form indicating DNR status. However, the physician's order for DNR was not entered into the electronic medical record at the time of readmission. Interviews with the ADON, DON, and Administrator confirmed that the process for entering and monitoring such orders was not followed, resulting in the omission. The facility's policy required that all documents regarding decision-makers and DNR orders be included in the resident's medical record. The ADON acknowledged that the order was missed during the admission process, and both the DON and Administrator stated that it was the responsibility of the charge nurse to input the code status and for the ADON to monitor the orders. The absence of the DNR order in the resident's chart was identified through record review and staff interviews.
Failure to Include IV Antibiotic Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the inclusion of IV antibiotic therapy administered via a central line. The resident, an adult female with diagnoses including partial intestinal obstruction, type 2 diabetes, and atrial fibrillation, was admitted following abdominal surgery and was receiving meropenem IV antibiotics through a central catheter. Although her care plan noted a skin impairment related to the central catheter, it did not address the ongoing IV antibiotic therapy, despite physician orders and documented administration of the medication. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans. The Regional MDS Coordinator, DON, and ADON each provided differing accounts of who was responsible for ensuring the care plan reflected the resident's IV antibiotic therapy. The ADON acknowledged that the omission could result in staff being unaware of the need to monitor for side effects, and the Administrator confirmed that the care plan should have included the IV medication as part of the resident's care. Review of facility policy indicated that comprehensive care plans should describe all services to be furnished to meet the resident's needs.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for activities of daily living, including bathing, did not receive scheduled showers or bed baths over a ten-day period. The resident, who was cognitively intact and required total assistance for showering, dressing, and transferring, was always incontinent of bowel and bladder. Documentation and interviews confirmed that the resident was not bathed on multiple scheduled days, and staff failed to provide either a shower or a bed bath, even when the shower room was out of order. The resident reported not being offered showers or bed baths as scheduled and expressed feeling unclean. Staff interviews revealed a lack of communication and follow-through regarding the resident's bathing schedule. The assigned CNA did not provide alternative bathing methods when the shower was unavailable, and the shower aide did not inquire about the resident's absence from scheduled showers. Nursing staff and administration were unaware that the resident had missed multiple baths, and there was no documentation of refusals or reasons for missed care. The facility's policy required residents to be offered showers at least once weekly and as requested, but this was not followed for the resident in question.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to vision and hearing services. The facility failed to ensure that the resident received necessary support to obtain these services, resulting in the resident not having access to appropriate vision and hearing care as required.
Failure to Secure Razors Creates Accident Hazard for Visually Impaired Resident
Penalty
Summary
A deficiency was identified when a resident's environment was not kept free from accident hazards, specifically involving the improper storage of razors. During observation and interviews, it was found that a male resident with legal blindness, prostate cancer, high blood pressure, and depression had three razors in his drawer—one without a cover and two in an open package. The resident required total assistance with several activities of daily living, including personal hygiene, and staff were responsible for shaving him. Despite this, the razors were accessible in his room, contrary to facility policy and staff expectations. Interviews with the ADON, DON, and Administrator confirmed that the resident should not have had razors in his room due to the risk of injury to himself and others, especially considering his visual impairment and the presence of other residents who wander throughout the facility. The facility's policy required staff to ensure a safe environment and to monitor resident rooms daily, but the razors were not removed after care, resulting in a failure to prevent an accident hazard.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with a feeding tube by not administering enteral feeding as ordered by the physician. The resident, a male with dysphagia and gastrostomy status, had a physician order for enteral feeding to be administered for at least 20 hours daily. Record review showed that the enteral feeding was removed at 11:00 AM each day, but there was no documentation of when it was restarted. On the day in question, observations confirmed that the resident's feeding pump was off from 11:10 AM through 4:20 PM, exceeding the allowed 4-hour downtime specified for care activities. Nursing staff interviews revealed that the feeding was not restarted as required, and the lapse was not communicated during shift change. The responsible nurses acknowledged that the resident was at risk for not receiving adequate nutrition due to the failure to follow the physician's orders. The facility's policy required that tube feedings be administered according to physician orders to meet nutritional requirements. The Director of Nursing and the Administrator both confirmed that the nurses were responsible for ensuring the feeding was not off for a prolonged period and that failure to do so could result in the resident not receiving necessary nutrition. The deficiency was identified through interviews, record reviews, and direct observation, all indicating that the resident's enteral feeding was not managed in accordance with the prescribed orders.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to a resident who required oxygen therapy, as there was no physician's order in place for the administration of oxygen. The resident, an older adult with diagnoses including shortness of breath, obesity, depression, diabetes, and COPD, was observed wearing oxygen at 2 liters per minute via nasal cannula on multiple occasions. The resident's care plan indicated a need for oxygen for shortness of breath and COPD, with instructions for staff to administer oxygen as ordered by a physician. However, a review of the resident's physician orders revealed that there was no order for oxygen therapy at the time of the observations. Staff interviews confirmed that the resident had been receiving oxygen without a current physician's order, and nursing staff acknowledged the importance of having such an order to ensure proper care. The facility's policy required a physician's order specifying the oxygen flow rate, method of administration, usage, and indication for use. Despite this, the order was missing until after surveyor intervention, and staff could not explain why the order had not been entered into the electronic records. The deficiency was identified through observation, interview, and record review.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not provide appealing options as required. This deficiency was identified through observations and review of food service practices, which revealed that residents were not consistently offered meals that met their individual dietary needs and preferences.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and did not establish or follow policies and procedures to report and investigate such allegations for one resident. A resident with severe cognitive impairment, dementia, diabetes, and depression was found with bruising and a skin tear on her left arm. The incident was first reported by a family member to a nurse, who documented the injuries and provided first aid, but did not initiate a full investigation or complete all required notifications and documentation as outlined in facility policy. Subsequent record reviews showed that there were no physician orders for monitoring or treating the injuries, and no skin assessment was completed after the injuries were noted. The resident's care plan was not updated to reflect the new injuries, and there was no incident report or evidence of an internal investigation. Interviews with nursing staff revealed inconsistent understanding and application of the facility's abuse and injury reporting protocols, with some staff unaware of the incident and others unsure of the required steps for reporting and investigation. The Director of Nursing and Administrator were either unaware of the incident or did not recall it, and the required internal investigation and reporting to the state agency did not occur. The facility's own Abuse Prohibition Policy required prompt investigation and reporting of injuries of unknown origin, but this was not followed in this case, resulting in a failure to protect the resident and ensure proper oversight and response to potential abuse or neglect.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than two hours after the allegation was made. Specifically, a resident with severe cognitive impairment, as indicated by a BIMS score of 00 and diagnoses including dementia, diabetes, and depression, was found to have a bruise and a skin tear of unknown origin on her left arm. The injuries were first reported by a family member to the charge nurse, who documented the findings in the resident's progress notes. Despite the documentation of the injuries, there was no evidence that the incident was reported to the state agency as required. The facility's records did not show any incident report, physician orders for monitoring or treating the injuries, or updated care plans reflecting the new injuries. Interviews with nursing staff and facility leadership revealed that the required notifications and investigations were not completed. The charge nurse, who was new at the time, reported the injuries to the Administrator and DON but did not complete an incident report or follow all notification protocols. The Administrator and DON did not recall being notified or investigating the incident, and the event was not identified during routine reviews of the 24-hour report. The facility's policy required immediate reporting and investigation of all allegations of abuse, neglect, or injuries of unknown origin, but this process was not followed in this case. Staff interviews indicated a lack of clarity and consistency in following the reporting procedures, and the incident was ultimately overlooked by facility management. As a result, the required reporting to the state agency did not occur, and the incident was not properly investigated or documented according to facility policy.
Failure to Update Care Plans for Residents on Contact Isolation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who required contact isolation due to infections with ESBL and MRSA. For one resident with a history of urinary tract infection, diabetes, stroke, and severe cognitive impairment, a urinalysis revealed ESBL, and physician orders were in place for both antibiotics and contact isolation. However, the resident's care plan only addressed the UTI and did not include any interventions or objectives related to contact isolation for ESBL, despite visible isolation signage and orders in the medical record. For another resident with dementia, UTI, anxiety, and cognitive intactness, a urinalysis detected MRSA, and physician orders included antibiotics and contact isolation. The care plan did not address the need for contact isolation or the resident's refusal to comply with isolation protocols, as the resident was observed participating in group activities outside her room while on contact precautions. The care plan was only updated after surveyor intervention to include isolation measures. Interviews with facility staff, including the ADON, DON, Regional MDS nurse, and Administrator, revealed that care plan updates were the responsibility of the MDS nurses and management team, and that changes such as new orders should be reflected in the care plan within 24-48 hours. However, staff acknowledged that the care plans for these residents had not been updated to reflect the new isolation requirements or behavioral issues related to isolation refusal, despite being aware of the orders and discussing resident changes in daily meetings.
Failure to Adhere to Contact Isolation Protocols for Residents with ESBL and MRSA
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to contact isolation protocols for two residents with communicable infections. One resident, a severely cognitively impaired female with a history of urinary tract infection (UTI) and extended-spectrum beta-lactamase (ESBL) in her urine, was placed on contact isolation per physician order. Despite a sign posted on her door, both an LVN and a CNA entered her room and provided care, including blood sugar checks, insulin administration, and personal care, without donning the required gown and gloves. The CNA also failed to properly dispose of contaminated linen, and both staff members acknowledged their lapses, citing reasons such as forgetting the precautions or not seeing the necessary PPE supplies nearby. Another resident, who was cognitively intact and diagnosed with MRSA in her urine, was also placed on contact isolation. However, she was observed participating in group activities and socializing with other residents outside her room. Interviews revealed that she had not been adequately educated about the need to remain in her room or the nature of her infection, and her care plan did not initially address contact isolation or refusal to comply with isolation protocols. Facility leadership, including the ADON and DON, provided inconsistent information regarding the expectations for residents on contact isolation, with some staff unsure of policy details and others stating that residents should be encouraged to stay in their rooms and that refusals should be documented and care plans updated accordingly. Record reviews confirmed that both residents had physician orders for contact isolation and that facility policies required the use of gowns and gloves for staff entering rooms of residents on contact precautions. Observations and interviews demonstrated that these policies were not consistently followed, and that signage, PPE availability, and staff education were insufficient to ensure compliance. These failures were directly observed by surveyors and confirmed through staff interviews and record reviews.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, as evidenced by incidents involving resident-to-resident altercations. In the first incident, a resident with severe cognitive impairment was struck on the shoulder by another resident, also with dementia, during an altercation in the dining room. The incident was witnessed by a staff member who intervened immediately. Both residents involved had impaired cognitive functions, and the altercation arose over a misunderstanding about personal items. In the second incident, a resident with intact cognition was grabbed under the arm by another resident with severe cognitive impairment and a history of physical behavior towards others. This occurred as they passed each other in the hallway. Initially, the resident did not report any harm, but later informed the nurse that he had been grabbed. The staff was present during the incident and intervened promptly. The third incident involved a resident with dementia being pushed on the head by another resident with intact cognition and a history of potential physical behaviors. This occurred in a common area when the resident with dementia approached a family member. The staff witnessed the incident and separated the residents immediately. These incidents highlight the facility's failure to ensure a safe environment free from abuse for all residents involved.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident. The resident, a female with dementia, was not administered her medications at the scheduled times. Specifically, her calcium, pantoprazole sodium, and sitagliptin-metformin HCI were given outside the prescribed time frames, which could potentially affect the consistency of the medication's presence in her bloodstream. The Medication Administration Audit Report indicated discrepancies in the timing of medication administration, and interviews with staff revealed a lack of adherence to the scheduled times. Additionally, the resident was not administered Estrace vaginal cream as ordered. A telephone order indicated the cream was to be applied every Monday, Wednesday, and Friday, but it was not given on one of the scheduled days. The Assistant Director of Nursing (ADON) admitted to marking the task as completed without actually administering the medication, which was only discovered after a family member raised the issue. This oversight highlights a lapse in the facility's medication administration process. Furthermore, the resident was not given the correct dosage of Vitamin B-12. The order summary report specified a dosage of 2000 mcg, but only 1000 mcg was administered. The Medication Aide (MA) acknowledged the error during an interview, noting that this could lead to a vitamin deficiency. The Director of Nursing (DON) and the Administrator both emphasized the importance of following physician orders to prevent medication errors, yet the facility's policy on medication administration was not adhered to, resulting in these deficiencies.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. For one resident, the MDS did not reflect that the resident had received antibiotics during the 7-day look-back period, nor did it indicate a diagnosis of MRSA infection in the right hip. This resident, who had severe cognitive impairment and required significant assistance with daily activities, was taking antibiotics for MRSA, as confirmed by the MDS Nurse and the Director of Nursing (DON). The omission in the MDS was attributed to the MDS Nurse's lack of awareness at the time of completion. Another resident's MDS inaccurately documented the discharge destination. The MDS indicated a discharge to the hospital, whereas the resident was actually discharged to their residence. This error was acknowledged by the MDS Nurse, who admitted to relying on hearsay rather than the resident's chart for information. The Assistant Director of Nursing (ADON) and the DON both confirmed the mistake and emphasized the importance of accurate MDS coding for proper care and billing. Interviews with facility staff, including the Administrator, highlighted the expectation for accurate MDS assessments. The facility's policy on the MDS process was referenced, underscoring the need for adherence to proper coding procedures. The deficiencies in the MDS assessments were recognized as potentially impacting the care and services provided to the residents.
Failure to Conduct Scheduled Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities based on the comprehensive assessment to meet the interests and support the physical, mental, and psychosocial well-being of each resident. On two consecutive days, four out of eight scheduled activities were not conducted as per the August 2024 activity schedule. Specifically, the bean bag toss and Help Your Neighbor activities were not held on the first day, and the ball toss and Skip Bo activities were not conducted on the second day. Observations confirmed the absence of these activities in the dining room, where they were supposed to take place. Interviews revealed that the Activity Director, who had been in the role since 2017, was not present during the scheduled activities as she left the facility to pick up her grandchildren from school. The Activity Director admitted to not conducting the scheduled activities and acknowledged that residents who were bedridden received one-on-one activities. The Director of Nursing (DON) and the Administrator both stated that activities should be conducted as per the schedule to prevent residents from becoming bored or depressed. The facility's policy on the activities program did not address the need to conduct scheduled activities.
Deficiency in Hospice Care Coordination
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for three residents who were reviewed for hospice services. The facility did not obtain necessary hospice documentation, including the most recent plans of care, hospice election forms, physician certifications, and hospice medication lists for these residents. This lack of documentation and coordination could place residents at risk of receiving inadequate end-of-life care. Resident #38, a male with a diagnosis of neurocognitive disorder with Lewy bodies, cerebral infarction, seizures, and hypertension, was admitted to hospice care on 07/09/24. However, his electronic medical record did not include a hospice plan of care, hospice election form, physician certification, or hospice medication list. Despite the hospice Director of Nursing updating the hospice binder, it could not be located, and the facility had requested all documents be uploaded to the electronic medical record, which was not done. Resident #31, a male with prostate cancer and other conditions, had been on hospice services since 02/27/24. His electronic medical record lacked the most recent hospice plan of care and medication list, which should have been updated as of 08/15/24. The hospice team manager confirmed that these documents were brought to the facility but were not uploaded. Similarly, Resident #8, a male with atherosclerotic heart disease and other diagnoses, had discrepancies between his hospice orders and the medications he was receiving. The hospice nurse confirmed that updated records were delivered, but some pages were missing, and the facility's Director of Nursing acknowledged that the documents were not properly uploaded.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were informed and participated in their treatment, specifically regarding the administration of psychotropic medication. Resident #179, a cognitively intact male with diagnoses including spinal stenosis, schizophrenia, depression, and PTSD, was administered Bupropion HCL ER (Wellbutrin) for depression without obtaining informed consent. The resident's records lacked documentation of consent for this medication, which is required to inform residents or their responsible parties about the risks and benefits of the treatment. Interviews with facility staff, including an LVN, the ADON, the DON, and the Administrator, revealed that the consent process was not followed as per the facility's policy. The staff acknowledged that consent should be obtained before administering psychotropic medications, as these can alter a resident's demeanor and have potential side effects. The ADON admitted to being the admitting nurse for Resident #179 and not realizing the consent was missing until questioned by the state surveyor. The facility's policy on psychotherapeutic drug management mandates that informed consent must be obtained and documented before administering such medications, except in emergencies.
Failure to Notify Physician of Lab Draw Refusals
Penalty
Summary
The facility failed to consult with a resident's physician immediately when there was a need to alter treatment significantly. This deficiency was identified for one resident who refused ordered lab draws for four weeks. The resident, who had diagnoses including end-stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, and chronic obstructive pulmonary disease, was supposed to have weekly CBC lab draws due to low hemoglobin levels and a refusal of a blood transfusion at the hospital. Despite the resident's repeated refusals of the lab draws, the facility did not notify the physician of these refusals. The Licensed Vocational Nurse (LVN) responsible for the resident's care acknowledged that she did not document the refusals or notify the physician, stating that if it was not charted, it did not happen. The Director of Nursing (DON) and the Administrator both confirmed that the expectation was for the physician to be notified and for the refusals to be documented in the resident's medical record. The facility's policy required that changes in a resident's condition, such as the need to alter treatment significantly, be communicated to the physician in a timely manner. However, this policy was not followed, as evidenced by the lack of documentation and communication regarding the resident's refusal of lab draws. This failure placed the resident at risk of having critical lab results that the facility would not have been aware of.
Failure to Protect Resident's Medical Record Privacy
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's medical records, specifically the Medication Administration Record (MAR), which was left visible and unattended by the Assistant Director of Nursing (ADON). During an observation, the ADON left the computer screen unlocked on top of the medication cart while attending to a resident's blood sugar check. This action exposed the resident's MAR to staff, residents, and visitors passing by, compromising the resident's privacy. The ADON acknowledged the oversight, admitting it was a violation of HIPAA regulations. The resident involved was a female with a history of stroke, diabetes, and high blood pressure, who was moderately cognitively impaired and required extensive assistance with daily activities. The Director of Nursing (DON) and the Administrator both stated their expectations for maintaining privacy and confidentiality of resident information, emphasizing that staff had been educated on HIPAA violations. However, the facility's policy on privacy practices did not specifically address the protection of residents' health information.
Failure to Report Alleged Neglect
Penalty
Summary
The facility failed to implement its written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, specifically for one resident reviewed for abuse. The incident involved a resident with dementia, diabetes mellitus, major depression, and chronic kidney disease, who was left in bed beyond soiled and shaking. A CNA reportedly stated that she did not attend to the resident because the resident hits her. The facility's policy required immediate reporting of such allegations to the state, but this was not done. The Social Worker received the grievance report from the resident's family member and notified the administrator immediately. However, the Director of Nursing (DON) and the Administrator did not consider the incident as an allegation of neglect and did not report it to the state as required by policy. The DON believed it was merely a grievance and was unsure of what should have been reported, while the Administrator also viewed it as a grievance rather than a reportable incident. This failure to report placed the resident at risk for further neglect or potential harm.
Failure to Report Allegation of Neglect in Timely Manner
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident within the required timeframe. The resident, a female with dementia, diabetes mellitus, major depression, and chronic kidney disease, was found by a family member to be in bed shaking and beyond soiled. The family member reported that a CNA stated she did not attend to the resident because the resident hits her. This incident was reported to the facility in May 2024, but the facility did not report it to the State Agency within the required 24-hour timeframe. Interviews with facility staff revealed a misunderstanding of the incident's severity. The Social Worker reported the grievance to the Administrator immediately, but the Administrator and the DON did not consider it an allegation of neglect. They viewed it as a grievance and did not report it to the appropriate authorities. The facility's policy requires immediate reporting of such allegations, but this was not followed, placing residents at risk for ongoing neglect.
Failure to Include MRSA Diagnosis in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with MRSA infection in a wound on his right hip. Despite the resident's complex medical history, including depression, emphysema, anxiety, and heart failure, the care plan did not address the MRSA diagnosis. This omission was identified during a review of the resident's care plans, which were last revised before the MRSA diagnosis was confirmed by a lab report. Interviews with facility staff, including the ADON, MDS Nurse, DON, and Administrator, revealed that the MRSA diagnosis was not included in the care plan due to a lack of awareness and communication. The MDS Nurse, responsible for updating care plans, was unaware of the MRSA diagnosis until the day of the interview. The staff acknowledged that the absence of the MRSA diagnosis in the care plan posed a risk of miscommunication and inadequate care for the resident.
Unsecured Oxygen Cylinder at Nurse's Station
Penalty
Summary
The facility failed to ensure the proper storage of an oxygen cylinder, which was observed unsecured at the nurse's station. During an observation, a Licensed Vocational Nurse (LVN) acknowledged the unsecured cylinder and mentioned it belonged to a resident who had gone out to smoke. The LVN admitted to being unaware of the cylinder's presence at the nurse's station and confirmed that oxygen cylinders should always be secured. Further interviews revealed that the Activity Director had placed the oxygen cylinder at the nurse's station but got distracted and forgot to secure it. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both emphasized that oxygen cylinders should be stored in a designated closet and secured to prevent accidents. The Administrator reiterated that it was everyone's responsibility to ensure the cylinders were secured, as leaving them unattended could pose a danger to residents and staff. The facility's policy on oxygen administration also stated that oxygen cylinders must be secured in a cart or bracket at all times.
Failure to Ensure Proper Dialysis Orders and Monitoring
Penalty
Summary
The facility failed to provide dialysis services in accordance with professional standards of practice for a resident with end-stage renal disease. The resident, who was cognitively intact and required hemodialysis, did not have a physician's order for dialysis treatment. The facility's policy allowed for dialysis instructions to be placed under special instructions rather than as a formal order, which led to the absence of a documented physician's order for the resident's dialysis treatment. Additionally, the facility did not monitor the resident's dialysis catheter as required. The resident had a dialysis catheter in the right groin due to a clotted access in the arm, but there were no orders to monitor the catheter for complications. Although the LVN reported monitoring the catheter, there was no formal order in place to ensure consistent monitoring every shift, as required by the facility's policy. This oversight placed the resident at risk for potential complications, such as infection. Interviews with facility staff, including the LVN, DON, and Administrator, revealed a misunderstanding of the necessity for formal physician orders for dialysis treatment and catheter monitoring. The DON and Administrator acknowledged the importance of having such orders and recognized the risk of infection due to the lack of monitoring. The facility's policy on dialysis care emphasized the need for physician orders and regular monitoring of dialysis catheters, which was not adhered to in this case.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Specifically, the facility did not conduct behavior monitoring for Bupropion HCL ER (Wellbutrin) and Sertraline (Zoloft), which were prescribed for depression, nor did it monitor side effects for Clonazepam (Klonopin), prescribed for anxiety. This oversight was identified for one resident among those reviewed for unnecessary medications. The resident in question was a male with a history of spinal stenosis, schizophrenia, depression, and PTSD. He was cognitively intact, as indicated by a BIMS score of 15, and required assistance with various activities of daily living. Despite being on a regimen of psychotropic medications, there was no documentation of behavior or side effect monitoring in his medication administration records over a specified period. Interviews with facility staff, including LVNs, the ADON, the DON, and the Administrator, revealed a lack of awareness and adherence to the facility's policy on psychotropic medication monitoring. The staff acknowledged the importance of such monitoring to assess medication effectiveness and detect side effects, but it was not implemented. The facility's policy required behavior and side effect monitoring for residents on psychotropic medications, but this was not followed in the case of the resident, leading to the identified deficiency.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs were only accessible by authorized personnel, as observed with the medication cart on hall 100. During an observation, the medication cart was found unlocked and unattended, with staff, residents, and visitors walking by. The Assistant Director of Nursing (ADON) admitted responsibility for leaving the cart unlocked, stating she was in a hurry and forgot to lock it. She acknowledged that leaving the cart unlocked could allow anyone to access the medications. Interviews with various staff members, including an LVN, the Director of Nursing (DON), and the Administrator, confirmed that the medication cart should always be locked when unattended to prevent unauthorized access. The facility's policy on the storage of medications also mandates that medication carts be locked when not attended by authorized personnel. The failure to secure the medication cart could lead to unauthorized access to medications, posing a risk to residents and staff.
Failure in Infection Control for MRSA Case
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the case of a resident with a MRSA infection in his right hip wound. The resident, who had a history of depression, emphysema, anxiety, and heart failure, was not placed on transmission-based precautions (TBP) for the MRSA infection, despite having an order for antibiotics. The resident's medical records did not include an order for isolation, nor was there a care plan addressing the MRSA diagnosis. Additionally, the resident's quarterly MDS did not reflect the MRSA diagnosis or antibiotic treatment, and his roommate was moved out and back into the room without proper precautions. Interviews with staff revealed a lack of communication and understanding regarding the necessary precautions for the resident's MRSA infection. The Treatment Nurse indicated that the resident was on enhanced-barrier precautions (EBP) rather than TBP, and staff were not notified of the specific infection. The Assistant Director of Nursing (ADON) acknowledged that the facility should have implemented TBP, including signage, PPE placement, and staff notification, but these measures were not taken. The Director of Nursing (DON) believed that EBP was sufficient and did not require staff to be informed of the infection, which contradicted the facility's policy. The facility's policy on transmission-based precautions was not followed, as the resident was not placed in a private room or on contact precautions as required for MRSA infections. The Administrator confirmed that the resident should have been on TBP, and the failure to do so posed a risk of MRSA transmission within the facility. The lack of proper precautions and communication among staff members contributed to the deficiency in infection control practices.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to adhere to its established smoking policy for a resident who was reviewed for smoking. The deficiency was identified when it was observed that the facility did not complete a smoking screen assessment quarterly for the resident, as required by their policy. The resident, a male with a history of stroke and high blood pressure, was cognitively intact and required limited assistance with daily activities. His comprehensive care plan indicated that he was a smoker and required supervision for smoking, with assessments to be conducted quarterly. However, the last smoking assessment was completed over a year ago, which was not in compliance with the facility's policy. Interviews with facility staff, including the ADON, DON, and Administrator, revealed that the responsibility for completing smoking assessments lay with the nursing staff. The ADON acknowledged that the assessments were supposed to be generated in the resident's electronic medical records but were not being done, posing a risk of burns to residents. The DON admitted that the system in place for checking smoking assessments failed to trigger, leading to the oversight. The Administrator, who was new to the facility, was unaware of the specific timeframe for smoking assessments but recognized the potential risk of injury due to the lack of assessments. The facility's policy, revised in November 2023, clearly outlined the requirement for quarterly smoking assessments, which was not followed in this case.
Failure in Pharmaceutical Services and Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the accurate acquiring, receiving, dispensing, and administering of Hydrocodone-Acetaminophen tablets. The resident, who had severe cognitive impairment and required pain management for chronic pain, was supposed to receive 115 tablets of Hydrocodone-Acetaminophen. However, a discrepancy was noted when a card of 30 tablets was missing, despite the medication administration record indicating no missed doses. The issue arose when LVN C signed for the delivery of the medication without noting the date or time and placed the medications on the counter in the medication room instead of securing them in the controlled box on the medication cart. This oversight allowed for the possibility of unauthorized access to the medications. CMA H and RN F later discovered the discrepancy during a routine count, but the medication cart had not been counted the previous night, and the missing card of tablets could not be accounted for. Interviews with staff revealed that the medications were not properly counted upon receipt, and there was a lack of adherence to the facility's procedures for handling controlled substances. The Director of Nursing acknowledged the failure in the process and the risk it posed, while the Administrator confirmed that an investigation was conducted, but the missing tablets were never found. The facility's policy on abuse prevention and prohibition emphasizes the importance of protecting residents from misappropriation of property, which was not upheld in this instance.
Failure to Coordinate Hospice Care and Use Mechanical Lift
Penalty
Summary
The facility failed to coordinate hospice care planning for Resident #9, who was receiving hospice services. This lack of coordination was evident in the failure to communicate with hospice representatives, including the hospice medical director and the resident's attending physician, regarding the care plan for Resident #9. The deficiency was identified during a review of the resident's records and interviews with facility and hospice staff. Resident #9, a female with diagnoses including unspecified dementia and Parkinson's disease, was dependent on staff for all activities of daily living (ADLs) and required the use of a mechanical lift for transfers, as per her care plan and physician's orders. However, on a specific date, Hospice Aide A transferred Resident #9 from her wheelchair to her bed without using the mechanical lift, contrary to the care plan. Hospice Aide A was not informed by the facility staff about the requirement for a mechanical lift, and her hospice aide care plan only mentioned assistance with transfers. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) C, revealed a lack of communication with the hospice regarding the change in Resident #9's transfer needs. The DON acknowledged that the charge nurse should have informed the hospice about the need for a mechanical lift, but LVN C admitted she did not notify the hospice of such changes. This communication breakdown placed Resident #9 at risk for falls and injuries due to improper transfer methods.
Inadequate Hand Hygiene During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a CNA during perineal care for a resident. The CNA did not perform hand hygiene between glove changes while providing care, which is a critical step in preventing cross-contamination and the spread of infection. This lapse was observed during a care procedure for a resident who was dependent on staff for personal hygiene due to conditions such as dementia, high blood pressure, chronic obstructive pulmonary disease, and diabetes mellitus. The resident's care plan indicated a need for assistance with activities of daily living, including toileting. During the observation, the CNA changed gloves multiple times without washing hands or using hand sanitizer, despite acknowledging the importance of this practice in preventing the transmission of germs and bacteria. Interviews with the CNA, the Director of Nursing (DON), the Administrator, and the Assistant Director of Nursing (ADON) confirmed the expectation for CNAs to perform hand hygiene between glove changes. The facility's policy on perineal care also outlined the requirement for handwashing or the use of hand sanitizer between glove changes. The failure to adhere to these protocols placed the resident at risk for contamination and infection.
Failure to Include Restorative Care in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. This deficiency was identified during a review of the care plans and interviews with staff and residents. The care plans for both residents did not include their restorative care programs, which were necessary to address their mobility and strength issues. Resident #1, an elderly female with severe cognitive impairment, required maximum assistance with daily activities and was involved in a restorative care program aimed at improving her ability to ambulate and transfer safely. However, her care plan did not reflect this program, and there were no orders for it in her records. During an interview, the resident mentioned inconsistencies in receiving therapy, indicating a lack of proper implementation of her restorative care. Resident #2, who had moderate cognitive impairment and functional limitations in her extremities, also had a restorative care program to enhance her strength and range of motion. Similar to Resident #1, her care plan did not include this program, and there were no corresponding orders. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed a lack of communication and understanding of responsibilities, leading to the omission of the restorative care programs in the residents' care plans.
Failure to Provide Restorative Care for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide appropriate restorative care to two residents with limited range of motion, as required by their Nursing Restorative Care Program plans. Resident #1, an elderly female with severe cognitive impairment, was admitted with diagnoses including muscle weakness and reduced mobility. Her care plan, initiated in January 2024, did not address a restorative program, and there were no orders or documentation for such a program in her records. Despite having a plan to increase her ability to ambulate and transfer, there were significant gaps in the documentation of restorative care provided, with several days showing no record of care being offered or completed. Resident #2, who had moderate cognitive impairment and functional limitations in both upper extremities and one lower extremity, also did not have a restorative program documented in her care plan. Her records similarly lacked orders or documentation for a restorative program. Although her plan included exercises to maintain strength and range of motion, there were multiple days without documentation of care being provided. Interviews revealed that the CNA responsible for restorative care did not consistently offer or document the care, citing reasons such as being occupied with other tasks or residents not having documentation areas in their electronic health records. Interviews with staff, including the Director of Nursing (DON) and the MDS Coordinator, highlighted a lack of oversight and understanding of responsibilities regarding the restorative program. The DON admitted to not routinely reviewing the restorative program logs and assumed the MDS Coordinator was responsible for adding restorative care to the residents' electronic health records. The MDS Coordinator, new to the position, was unaware of the residents receiving restorative care and uncertain about his role in ensuring it was included in care plans. The facility's policy indicated that the DON or their designee should manage the program, but this was not effectively implemented, leading to the deficiency.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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