The Colonnades At Reflection Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Pearland, Texas.
- Location
- 12001 Shadow Creek Parkway, Pearland, Texas 77584
- CMS Provider Number
- 676207
- Inspections on file
- 46
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 11 (3 serious)
Citation history
Health deficiencies cited at The Colonnades At Reflection Bay during CMS and state inspections, most recent first.
Surveyors found that several medication carts were left unlocked and unattended, with drawers open and keys accessible, while multiple insulin and heparin vials were undated and unlabeled. Staff interviews confirmed that carts should be locked and medications properly labeled, but these practices were not consistently followed.
Sharps containers in two resident bathrooms were found filled above the full line, with staff interviews revealing unclear responsibility and lack of a specific policy for timely replacement. Nursing staff indicated they were responsible for monitoring and changing the containers, while housekeeping staff did not have access. The absence of clear procedures led to overfilled sharps containers, increasing the risk of exposure to used sharps.
A medication cart was found to contain an expired insulin vial that had not been removed as required by facility policy. Staff interviews revealed inconsistent practices regarding the dating and disposal of insulin, and the expired medication remained accessible on the cart.
A resident with dementia, end stage renal disease, and impaired mobility was able to leave the facility unsupervised on two occasions, including crossing a busy street and being found at a nearby apartment complex. Staff failed to complete elopement risk assessments or implement appropriate supervision, and there was a lack of communication and documentation regarding the incidents.
A resident with a feeding tube was laid flat by a CNA while the feeding pump was running, leading to visible aspiration of formula. The LPN present did not promptly stop the feeding or reposition the resident, and there was a significant delay in providing suctioning and assessment. Staff actions did not follow established protocols for enteral feeding and aspiration precautions, resulting in a deficiency related to failure to prevent complications of enteral feeding.
A resident with a feeding tube and multiple complex conditions was laid flat by a CNA while her feeding pump was running, leading to possible aspiration. The LPN present did not promptly intervene, failed to stop the feeding pump, and delayed suctioning, while staff interviews revealed inconsistent knowledge of enteral feeding protocols and aspiration precautions.
A resident with cognitive impairment and multiple medical conditions eloped from the facility on two occasions, but staff failed to report these incidents to the State Survey Agency as required. The facility did not complete elopement assessments or incident reports prior to the second event, and staff interviews revealed inconsistencies in recognizing and reporting the incidents, resulting in noncompliance with regulatory reporting requirements.
A resident with severe cognitive impairment and multiple complex medical conditions repeatedly refused prescribed medications, including anticonvulsants and antihypertensives, over an extended period. Although staff were aware of the refusals and communicated them internally and to the provider, the facility did not update the care plan to include measurable objectives or interventions addressing the medication refusals, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not receive several prescribed medications and enteral feedings on multiple occasions, as shown by blank entries in the eMAR. Nursing staff and management confirmed that these blanks indicated missed doses, and facility policy requires both administration and documentation of all medications. There was no evidence that the resident refused the medications or that the physician was notified of the omissions.
A resident repeatedly refused multiple prescribed medications, including seizure medications and supplements, over an extended period. While these refusals were recorded in the eMAR, nursing staff did not document the refusals or notify the MD, NP, or responsible party in the resident's progress notes as required. Interviews confirmed that staff were aware of the documentation and notification expectations, but these actions were not completed or recorded, and the facility could not provide a relevant documentation policy.
A resident with a documented tracheostomy was admitted without appropriate orders or documentation for tracheostomy care, despite clear hospital discharge instructions. Nursing staff and leadership could not confirm that tracheostomy care or suctioning was provided, and facility records did not reflect any such care or recent staff training on the procedure.
A resident with severe cognitive impairment and multiple wounds experienced a deterioration of a sacral pressure ulcer from stage 2 to stage 4, with delayed wound care interventions, inconsistent administration of prescribed treatments, and inadequate documentation and performance of repositioning. The wound became infected and required hospitalization for sepsis. Similar lapses in repositioning and documentation were observed for two other residents, reflecting a pattern of deficient care.
Three residents who were dependent on staff for ADLs did not consistently receive scheduled showers or bed baths, resulting in missed hygiene care over multiple days. Residents reported grievances and described staff not returning to assist with bathing, while staff interviews revealed issues with documentation and unclear responsibilities for recording care provided.
A resident with a Foley catheter and ostomy was not provided with appropriate catheter care, as the catheter bag was observed lying on the bed and hanging on the floor instead of being secured below the bladder. The resident experienced discomfort and embarrassment due to the lack of proper strapping and positioning, and staff confirmed that required practices for catheter care and resident education were not consistently followed.
A resident with severe cognitive impairment and a gastrostomy received new physician orders for tube feeding, which were administered as directed, but the care plan was not updated to include this intervention until several days later. Staff interviews revealed gaps in interdisciplinary communication and timely care plan updates, resulting in the care plan not reflecting the resident's current nutritional needs.
Two residents in a LTC facility experienced significant medication errors. One resident received morphine more frequently than prescribed, leading to excessive sedation and Narcan administration. Another resident, who was immunocompromised, missed four doses of Posaconazole due to unavailability, resulting in a hospital readmission with a fever. Staff interviews revealed communication failures and non-adherence to medication protocols.
A facility failed to maintain accurate clinical records for two residents, leading to potential delays in necessary interventions. A nurse documented nebulizer treatment details for a resident without administering the treatment, and another nurse estimated a resident's post-treatment oxygen saturation without using a pulse oximeter. The facility's policy requires accurate documentation to ensure effective communication and care.
The facility failed to adhere to Enhanced Barrier Precautions for residents requiring such measures, as staff did not wear gowns during high-contact care activities. A resident with a G-tube was transferred without proper PPE, and two residents received incontinent care without staff wearing gowns, despite the presence of precautionary signs. Interviews with facility staff confirmed the requirement for gowns during these activities to prevent MDRO transmission.
The facility failed to provide adequate respiratory care for two residents, leading to improper oxygen monitoring and documentation. A resident with COPD was documented as being on room air despite needing continuous oxygen, and low oxygen saturation levels were not reported to the physician. Another resident's oxygen saturation was inaccurately documented post-nebulizer treatment. These deficiencies highlight a lack of adherence to care protocols.
A resident with severe cognitive impairment and a history of diabetes and skin infections did not receive wound care as ordered. The Wound Care Nurse applied betadine to the resident's foot but failed to cover it with a kerlix bandage, contrary to the treatment plan. This oversight was acknowledged by the nurse and could lead to further complications.
A resident's call light was found out of reach, violating their right to reasonable accommodation. The resident, who was bedfast and had muscle weakness, could not call for assistance. Interviews with staff confirmed the oversight, and facility policies were not followed.
A resident's room was found with soiled sheets and a strong urine odor, indicating a failure to maintain a clean and homelike environment. The resident, who needed assistance due to medical conditions, was left waiting for linens to be changed. Staff interviews revealed a lack of awareness and distraction, leading to unmet needs and a breach of facility policies on resident dignity and consistent care.
The facility failed to maintain an effective pest control program, resulting in roaches being observed in a resident's room. The resident frequently saw roaches, especially when the lights were off, and expressed fear of them crawling into her bed. Despite pest control treatments in November, the issue persisted, particularly in certain halls, as acknowledged by the Administrator. The facility's policy required an ongoing pest control program to keep the building free of pests, which was not effectively implemented.
A resident with severe cognitive impairment and multiple medical conditions did not consistently receive scheduled showers and clothing changes during the 2:00 p.m. - 10:00 p.m. shift, leading to body odors and family complaints. Despite being dependent on staff for ADLs, the resident's hygiene needs were not met, and documentation did not accurately reflect the care provided. The facility's administrator acknowledged the issue but claimed showers were given the next day.
A resident with severe cognitive impairment and an indwelling catheter was found without a catheter stabilizer, risking catheter dislodgement. The CNA noted the stabilizer's adhesive was ineffective, and the LVN relied on CNAs for updates on catheter security. The DON confirmed nursing staff's responsibility to ensure catheter stabilization, as per facility policy to prevent infections.
A facility failed to maintain an effective infection prevention and control program when a CNA did not perform hand hygiene after removing soiled gloves during incontinence care for a resident with severe cognitive impairment and an indwelling catheter. The CNA touched various items in the resident's environment with soiled gloves, risking cross-contamination. Additionally, another staff member improperly used double gloves, contrary to facility policy. Interviews confirmed these actions were against infection control protocols.
A resident with severe cognitive impairment and total dependence on assistance for transfers was improperly transferred by a CNA, who lifted the resident under the arms without using a gait belt, despite another staff member being present. This incident, captured on video, violated the facility's policy requiring gait belts for transfers and was acknowledged as improper by the DON. The CNA was terminated following the incident.
A facility failed to provide proper incontinent care for a resident with dementia, leading to a deficiency. The resident required substantial assistance and was always incontinent. During care, a CNA did not properly clean the resident, failing to spread the labia and clean the urinary meatus, increasing the risk of infection. The CNA admitted to the oversight due to nervousness, and the DON confirmed expectations for complete care, though no policy was provided upon exit.
A CNA failed to perform proper hand hygiene during incontinence care for a resident with dementia and incontinence, leading to potential cross-contamination. The CNA did not wash or sanitize hands between glove changes, despite the facility's policies requiring such practices. The CNA had not completed infection control training at the facility, contributing to the deficiency.
The facility failed to maintain an effective pest control program, with observations of roaches, gnats, and flies in the kitchen, dining area, and resident rooms. Despite regular pest control treatments, staff and contractors confirmed ongoing pest issues, placing residents at risk of infection and food-borne illnesses.
Medication Carts Left Unlocked and Medications Unlabeled
Penalty
Summary
Surveyors observed that seven out of fourteen medication carts were left unlocked and unsecured when not in use, with drawers open and the key lock visibly protruding. Multiple medication carts on both the first and second floors were unattended by staff, and in one instance, the cart keys were found inside a binder on top of a cart. Staff interviews confirmed that medication carts should be locked when not in use to prevent unauthorized access. Additionally, several biologicals, including various types of insulin and heparin, were found on multiple carts without proper labeling or dating, contrary to facility policy and accepted pharmaceutical practices. Staff members, including CMAs and LVNs, acknowledged during interviews that insulins should be dated when opened and that medication carts should remain locked if not in immediate use. The facility's policy requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified. Despite this, surveyors found undated and unlabeled insulin and heparin on several carts, and staff were not always present to monitor the carts, increasing the risk of improper medication handling.
Sharps Containers Overfilled in Resident Bathrooms
Penalty
Summary
Surveyors observed that two resident bathrooms contained sharps containers that were filled above the designated full line. Multiple staff interviews confirmed that the containers should be emptied when they reach the full line, but the containers in these bathrooms had not been changed as required. The responsibility for monitoring and changing the sharps containers was unclear among staff, with nursing staff indicating they were responsible, while housekeeping staff stated they did not have access to the containers. The Executive Director acknowledged there was no specific policy for emptying sharps containers and that the infection control policy did not address this issue. Staff interviews revealed inconsistent practices regarding the monitoring and replacement of sharps containers, with some staff stating they should be checked daily and changed at the full line to prevent exposure to body fluids. The lack of a clear policy and defined responsibility led to the containers being overfilled, creating an environment where residents could potentially be exposed to used sharps. The deficiency was identified through direct observation and staff interviews, with no mention of any resident being harmed at the time of the survey.
Expired Insulin Found on Medication Cart
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring that a medication cart was free of expired insulin. During an early morning observation, a surveyor found an insulin vial on one medication cart that was dated as opened on 09/07, indicating it was expired. Multiple staff interviews confirmed that insulin vials are required to be dated when opened and should be removed from the cart once expired. Staff members, including LVNs and the ADON, acknowledged that expired medications should not remain on the cart and should be disposed of according to facility policy. A review of the facility's policy on medication labeling and storage indicated that outdated medications should be returned or destroyed per pharmacy instructions. Despite this policy, the expired insulin remained on the cart, and staff interviews revealed inconsistent practices regarding the handling and disposal of expired insulin. The failure to remove the expired insulin from the medication cart constituted a lapse in the facility's procedures for the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with multiple risk factors, including end stage renal disease, unspecified dementia, repeated falls, and impaired mobility. The resident, who used a wheelchair or scooter and was cognitively impaired, was able to independently ambulate and had a history of confusion and memory loss. Despite these risks, the resident was able to leave the facility without staff knowledge or supervision on two separate occasions. On one occasion, the resident was found attempting to cross a four-lane street with a posted speed limit of 50 mph, and on another, the resident was located at an apartment complex across the street after being missing for a period of time. The facility's records and staff interviews revealed that there were no elopement risk assessments completed for the resident prior to the second incident, and no interventions or increased supervision were in place despite the resident's known cognitive impairment and previous attempt to leave the premises. Staff failed to recognize or respond to the resident's elopement risk, and there was a lack of communication and documentation regarding the incidents. Multiple staff members, including nurses and the receptionist, were unaware of the resident's risk for elopement and did not have clear protocols for monitoring or restricting the resident's movements. Interviews with staff and administration indicated inconsistencies in the recognition and reporting of the elopement events. Some staff were unaware of previous incidents, and there was confusion about whether the events constituted reportable elopements. Incident reports were not completed for any of the occurrences, and there was no evidence of a thorough investigation or timely notification to facility leadership. The lack of appropriate assessment, supervision, and response to the resident's behavior directly led to the resident being able to leave the facility unsupervised on multiple occasions.
Failure to Ensure Safe Positioning and Timely Intervention During Enteral Feeding
Penalty
Summary
A deficiency occurred when a resident with a feeding tube was laid flat by a CNA while the feeding pump was actively running, contrary to the care plan and facility policy that required the head of the bed to be elevated at least 30 degrees during and after enteral feeding. The resident had significant medical conditions, including severe cognitive impairment, dysphagia, gastrostomy status, and chronic respiratory disease, making her particularly vulnerable to complications from improper tube feeding management. Video evidence showed the CNA lowering the bed and the feeding pump remaining on, with no immediate intervention to pause the feeding or reposition the resident. Shortly after being laid flat, the resident began to have a moderate amount of white fluid coming from her mouth, which appeared to be formula. The LPN present did not immediately stop the feeding pump or reposition the resident, and there was a delay in providing suctioning. The LPN was observed searching for suction equipment and did not act with urgency, resulting in a significant delay before suctioning was performed. Throughout this period, the feeding pump continued to run, and the resident was not promptly assessed for vital signs or lung sounds as required by protocol. Interviews with facility staff, including the DON and ADM, confirmed that the actions taken by the CNA and LPN did not follow established protocols for enteral feeding management and aspiration precautions. The staff failed to demonstrate a sense of urgency, did not properly assess the resident after signs of aspiration, and did not document the incident accurately. The incident was identified as Immediate Jeopardy due to the failure to provide appropriate treatment and services to prevent complications of enteral feeding, specifically aspiration.
Failure to Ensure Competency in Enteral Feeding Care Leads to Resident Harm
Penalty
Summary
Nurse aides and licensed nurses failed to demonstrate the necessary competencies and skills to safely care for a resident with a feeding tube, as identified through the resident's assessment and care plan. The resident, who had multiple complex medical conditions including gastrostomy status, severe cognitive impairment, hemiplegia, and dysphagia, required her head of bed to be elevated at least 30 degrees during and after enteral feedings to prevent aspiration. Despite these requirements, a CNA was observed lowering the resident to a flat position while the feeding pump was running, contrary to the care plan and facility policy. Video evidence showed that after the resident was laid flat, white fluid began coming from her mouth, consistent with possible aspiration of tube feeding formula. The LPN present did not immediately intervene to stop the feeding pump or reposition the resident, and there was a significant delay in providing suctioning. The LPN was also observed searching for equipment and not demonstrating a sense of urgency, and the feeding pump remained on for an extended period after the resident showed signs of aspiration. The LPN did not perform a thorough assessment, such as checking vital signs or lung sounds, and post-mortem care was initiated before a registered nurse pronounced death, as required by protocol. Interviews with staff revealed inconsistent and incorrect knowledge regarding the care of residents with enteral feedings, including who is authorized to operate feeding pumps and the importance of head-of-bed elevation. Some CNAs believed it was acceptable to lay residents flat or to pause the pump themselves, while others were unaware of the risk of aspiration. The facility's own policies required head-of-bed elevation and nurse oversight of feeding pumps, but these were not followed, resulting in actual harm to the resident.
Failure to Timely Report Resident Elopement Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by regulation. Specifically, the facility did not report two separate elopement incidents involving a resident with significant cognitive impairment and multiple medical conditions, including end stage renal disease, dementia, and altered mental status. The first incident occurred when the resident was found outside the facility attempting to cross the street, and the second incident involved the resident being found across the street at an apartment complex. In both cases, there was no evidence that the incidents were reported to the State Survey Agency (SSA) as required. The resident in question had a documented history of confusion, memory loss, and impaired decision-making, and was assessed as being at risk for elopement. Despite this, there were no elopement assessments completed prior to the second incident, and the care plan interventions for elopement risk were not implemented until after the resident was found outside the facility. Staff interviews revealed inconsistencies in the recognition and reporting of the elopement events, with some staff unaware of previous incidents and others unsure of the reporting requirements. There were also no incident reports or witness statements completed for either elopement event. Facility policy required immediate reporting of suspected abuse, neglect, or elopement to the appropriate authorities, but review of records and staff interviews confirmed that these procedures were not followed. The events were not documented in the facility's reporting system, and the required notifications to the SSA were not made. The lack of timely reporting and investigation of these incidents constituted a failure to comply with regulatory requirements for the protection of residents.
Failure to Care Plan for Medication Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's repeated refusal of medications over an extended period. The resident, a male with a history of traumatic subdural hemorrhage, generalized idiopathic epilepsy, and other significant medical conditions, was admitted with multiple medication orders, including anticonvulsants, antidepressants, supplements, and antihypertensives. Despite frequent and documented refusals of these medications, the care plan did not include measurable objectives, timetables, or interventions specifically addressing the resident's medication refusal behavior. Record reviews showed that the resident consistently refused various prescribed medications, as documented in the electronic Medication Administration Record (eMAR) by multiple medication technicians and nurses. These refusals were noted for critical medications such as seizure medications, blood pressure medications, and supplements, with refusals occurring on numerous dates across several months. Interviews with staff, including medication technicians, nurses, the MDS Coordinator, and administrative personnel, confirmed that the resident's refusals were well known among staff and were communicated during staff meetings and to the medical provider. However, these refusals were not incorporated into the resident's care plan, and there was no evidence of individualized interventions or strategies to address the refusals. Facility policy required that comprehensive, person-centered care plans include measurable objectives and timetables to meet residents' needs, and that care plans be updated as new information became available. Staff interviews revealed an understanding that medication refusals should be care planned, as this would inform all caregivers of the issue and guide appropriate interventions. Despite this, the care plan for the resident did not reflect the ongoing medication refusals, resulting in a lack of documented strategies or goals to address the resident's non-compliance with medication administration.
Failure to Administer and Document Prescribed Medications and Enteral Feedings
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident with multiple complex medical conditions, including a history of traumatic subdural hemorrhage, epilepsy, and seizure disorders. Record review revealed that the resident did not receive several prescribed medications and enteral feedings on multiple occasions, as evidenced by blank spaces in the electronic Medication Administration Record (eMAR) for various dates. The medications not administered included a nicotine patch, folic acid, a multivitamin, vitamin B1, docusate sodium, levetiracetam, Tylenol, and enteral nutrition, all of which were ordered by the physician and documented in the resident's care plan and medical orders. Interviews with nursing staff, including charge nurses and the DON, confirmed that blank entries in the eMAR indicated that medications were not administered, constituting medication errors and poor quality of care. Staff acknowledged that it was their responsibility to ensure proper documentation and administration of medications, and that failure to do so could result in the resident not receiving necessary treatment. The administrator and nurse managers also stated that they were ultimately responsible for ensuring accurate documentation and that if it was not documented, it was not done. The facility's own policies on medication administration and refusal of treatment require that medications be administered as prescribed and that any refusals or omissions be thoroughly documented, including the reason for refusal, the resident's response, and notification of the physician. However, there was no documentation in the medical record to indicate that the resident refused the medications or that the physician was notified of missed doses. The lack of documentation and administration of prescribed medications and enteral feedings represents a failure to meet the pharmaceutical needs of the resident as required by facility policy and regulatory standards.
Failure to Document Medication Refusals and Notify Providers
Penalty
Summary
The facility failed to ensure accurate documentation of medication refusals and appropriate notification to medical providers and responsible parties for one resident. Over a period spanning from May to June, the electronic Medication Administration Record (eMAR) showed multiple instances where the resident refused various prescribed medications, including seizure medications, antihypertensives, vitamins, and supplements. Despite these refusals being recorded in the eMAR, there was no corresponding documentation in the resident's progress notes indicating that the physician (MD), nurse practitioner (NP), or responsible party (RP) had been notified of these refusals. Interviews with nursing staff, including LVNs and the ADON, confirmed that the facility's expectation was for nurses to document medication refusals in the progress notes and to notify the MD, NP, and RP each time a refusal occurred. Staff acknowledged that failure to document these actions constituted a gap in care and could result in a lack of follow-up or intervention. The interviews also revealed that the responsibility for documentation rested with both the charge nurse and the nurse administering the medication, and that the absence of documentation implied that the required notifications likely did not occur. Further, the facility was unable to provide a policy on documentation when requested. The administrator and DON both stated that proper documentation and notification were essential for ongoing patient care and that medication refusals should be treated as a change in condition, requiring thorough documentation and communication. The lack of documentation in this case meant that the medical team was not fully informed about the extent of the resident's medication refusals, particularly for critical medications such as those for seizure control.
Failure to Provide Tracheostomy Care Due to Lack of Orders and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required tracheostomy care. Upon admission, the resident had a documented tracheostomy, as indicated in the hospital discharge instructions, which specified the need for portable trach suctioning and identified the presence of a Shiley trach. However, the facility's admission records, care plans, and assessments did not reflect the presence of a tracheostomy, and no orders for tracheostomy care or suctioning were entered into the system. As a result, there was no evidence that tracheostomy care was provided during the resident's stay. Interviews with nursing staff and facility leadership revealed inconsistent practices and a lack of recall regarding the resident's tracheostomy status. Staff members described standard procedures for admitting residents with tracheostomies, including the expectation to enter standing or provider-verified orders for tracheostomy care and suctioning. Despite these protocols, none of the staff interviewed could confirm that such orders were entered or that care was provided for this resident. The facility's documentation and in-service records also did not show any recent training or education on tracheostomy care for staff. The resident's medical history included hypertensive heart disease, chronic kidney disease, and thyroid cancer, and he was alert and oriented at the time of admission. The lack of tracheostomy care orders and documentation of care, despite clear hospital discharge instructions, resulted in the resident not receiving necessary respiratory care during his stay. This deficiency was identified through record review and staff interviews, which confirmed the absence of required orders and care.
Failure to Provide Timely and Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to promote healing and prevent new pressure ulcers for one resident with significant risk factors and existing wounds. The resident, an elderly female with severe cognitive impairment, bowel incontinence, immobility, and multiple comorbidities, was admitted with a stage 2 sacral pressure ulcer, deep tissue injury to the left heel, and a surgical abdominal wound. Despite being identified as high risk for pressure ulcers, the facility did not ensure timely wound care interventions, as there was a delay between the physician's referral to wound care and the first visit by the wound care specialist. Documentation showed that wound treatments were not consistently administered, and there were gaps in the administration of prescribed nutritional supplements and vitamins intended to support wound healing. The sacral wound deteriorated from a stage 2 to a stage 4 ulcer, eventually measuring 7 cm by 13 cm by 3 cm, and required debridement for necrotic tissue. The facility did not implement new interventions when the wound failed to heal, and there was no evidence of regular wound assessment or timely notification to the provider when the wound worsened. Additionally, the care plan lacked specific details about the location of wounds, and interventions such as turning and repositioning were not consistently documented or performed. Staff interviews revealed confusion and inconsistency in documentation practices, with some staff unable to verify if repositioning was done as required, and others reporting that documentation systems did not allow for accurate recording of care provided. Observations and interviews indicated that the resident was often found in the same position for extended periods, and there was a persistent odor in the room, suggesting inadequate hygiene and wound care. Family members reported not being informed about the wound's condition and had to intervene to secure emergency medical attention when the resident became lethargic and the wound appeared significantly worsened. The resident was subsequently hospitalized with fever and sepsis, and the hospital assessment found the sacral wound to be larger and more severe than previously documented by the facility. Similar failures in repositioning and documentation were observed for two other residents, indicating a pattern of deficient care.
Failure to Provide Scheduled Showers and Bed Baths for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, for three residents who were dependent on staff for these tasks. Scheduled showers and bed baths were not consistently provided according to the facility's own shower schedule and care plans. For example, one resident who was dependent for all ADLs and had significant medical needs, including pressure ulcers and cognitive impairment, did not receive scheduled bed baths on multiple occasions, with documentation showing only two bed baths in a 30-day period. Another resident, who was cognitively intact but physically impaired and required maximal assistance for bathing and dressing, did not receive scheduled showers for extended periods, including gaps of up to 12 days without a shower. This resident reported to surveyors that she had not refused showers, had filed grievances, and sometimes experienced body odor due to missed showers. She also expressed concerns about staff not returning to assist her after promising to do so, particularly when two staff members were needed for safe transfers. A third resident, who was totally dependent on staff for bathing due to impaired balance and limited mobility, also missed multiple scheduled showers and filed grievances about not receiving them. Interviews with staff revealed inconsistencies in documentation, issues with access to the electronic charting system, and a lack of clarity regarding responsibility for entering shower records. Observations confirmed that shower documentation was incomplete and not consistently entered into the electronic system, with paper records left unfiled. The facility's own ADL policy required daily documentation and regular monitoring, which was not followed.
Failure to Provide Proper Catheter Care and Positioning
Penalty
Summary
A deficiency occurred when a resident with a Foley catheter and ostomy was not provided with appropriate catheter care to prevent urinary tract infections. Observations revealed that the resident's Foley catheter bag was found lying on the bed near his left calf and later hanging on the floor, rather than being secured below the bladder as required. The resident reported that the catheter was not strapped down, causing discomfort and embarrassment, and that the bag would become heavy and painful. Staff interviews confirmed that the catheter bag was not consistently positioned correctly and that the resident had not been educated on the risks associated with improper placement of the catheter bag. The resident, a 59-year-old male with diagnoses including malignant neoplasm of the rectosigmoid junction, infection of a continent stoma, chronic kidney disease, and an artificial urinary opening, was dependent for all functional abilities and cognitively intact. The care plan included maintaining the functionality and dignity of the ostomy, but did not address the Foley catheter. Staff acknowledged that the catheter bag should be kept below the bladder to prevent infection and that the bag should be secured to the resident's thigh, but these practices were not consistently followed. Facility policy also required the catheter to be secured and the drainage bag to be positioned lower than the bladder at all times.
Failure to Timely Update Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, specifically omitting information regarding newly ordered tube feedings. The resident, a male with a history of muscle weakness, traumatic brain injury, and gastrostomy status, was admitted with severe cognitive impairment as indicated by a BIMS score of 3. Physician orders documented the initiation of Isosource tube feeding, and clinical notes confirmed administration began as ordered. However, review of the resident's care plan on multiple dates showed no inclusion of tube feeding information until several days after the order was implemented, despite the resident actively receiving tube feedings during this period. Interviews with facility staff revealed that the process for updating care plans involved multiple roles, including the MDS nurse, ADON, and Patient Care Coordinator, but there was a lack of timely interdisciplinary communication and action to ensure the care plan reflected the resident's current needs. The Director of Nursing acknowledged that the care plan should be updated promptly to guide staff in providing appropriate care and confirmed the delay in updating the care plan to include tube feeding instructions. Facility policy requires ongoing assessment and timely revision of care plans as resident conditions change, which was not followed in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure the accurate administration of medications for two residents, leading to significant medication errors. One resident, a male with a history of prostate cancer, urethral stricture, and a stage 4 pressure ulcer, was administered morphine more frequently than prescribed. The resident was supposed to receive morphine ER 30 mg every 12 hours and morphine IR 15 mg every 6 hours as needed. However, the resident received morphine IR 15 mg more frequently than ordered, leading to excessive sedation and the need for Narcan administration to counteract the overdose. Another resident, who was immunocompromised due to acute myeloblastic leukemia and neutropenia, missed four doses of Posaconazole, an antifungal medication, because it was unavailable. Despite the resident's representative offering the medication, the facility declined to administer it, insisting on using their pharmacy. The resident was readmitted to the hospital with a fever, indicating a potential infection due to the missed doses. Interviews with staff revealed a lack of communication and adherence to medication administration protocols. Staff members were aware of the discrepancies and missing medications but failed to take appropriate actions, such as notifying the physician or ensuring timely delivery from the pharmacy. The facility's policies on medication administration and communication with the pharmacy were not effectively implemented, contributing to the deficiencies observed.
Removal Plan
- An Emergency QAPI was held to review the findings of the citations and the community's present practices and processes.
- The DON and administrator will have a collaborative effort with respect to monitoring medications upon admission, and daily thereafter for established residents regarding missing or unavailable medications.
- Ongoing monitoring by DON or designee, to review medications for compliance.
- 100% audit of all residents receiving both immediate release and extended-release medications will have MAR to Cart audits to ensure appropriate medications are being given.
- Initiation of the Medication Availability Log, in which each Nurse/Med-Aide validates that they have all available medications for Administration each shift.
- Report will be reviewed in clinical stand up for morning and afternoon shift to review communication with physician on medications not available.
- A New order report will be printed by the DON/Nurse Managers, this will be cross-referenced to validate physical availability of new medications in the community.
- Pharmacy Delivery Sheets will be reviewed by DON/Nurse Managers for medications that were delivered.
- The Clinical Smart Board, which is within our EMR, displays missed medications, will be reviewed by the DON/Nurse managers, in clinical stand up for both morning and afternoon shift to review medications given, missed medications.
- The DON/Nurse Management will communicate with pharmacy regarding medications not available and get estimated time of arrival or need to STAT medications.
- The DON/Nurse Management will communicate with physician and/or medical director on medications missed or not available on patients that issues were identified.
- The DON/Nurse Management will communicate all with physician and/or medical director on medication errors.
- The DON/Nurse Management will notify the Administrator on all issues identified with pharmacy and medication delivery, availability and missed doses as well as medication errors.
- In addition to education on utilizing the Pyxis and Pharmacy Service in-services, a review of current policies and procedures were completed with the QAPI team determining that the current policy was sufficient and new protocols were put into place to achieve compliance.
Inaccurate Documentation of Nebulizer Treatments
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to potential delays or omissions in necessary interventions. For one resident, a nurse documented pre- and post-nebulizer oxygen saturation levels, despite not administering the nebulizer treatment. Additionally, the nurse did not document the resident's vital signs at the time they were obtained, which is against the facility's documentation policy. The Director of Nursing (DON) confirmed that vital signs should be documented at the time they are obtained or, if documented later, the time should be noted. Another resident received a nebulizer treatment, but the nurse documented a post-nebulizer oxygen saturation level without actually checking the resident's oxygen saturation. The nurse admitted to estimating the oxygen saturation based on observation rather than using a pulse oximeter, which is required to ensure the treatment's effectiveness. The DON confirmed that the nurse should have used the pulse oximeter to monitor pre- and post-nebulizer treatment oxygen saturation levels. The facility's policy on charting and documentation emphasizes the importance of complete and accurate medical records to facilitate communication among the interdisciplinary team regarding the resident's condition and response to care. The failure to adhere to this policy could result in inaccurate data, potentially leading to delays or omissions in necessary interventions for the residents involved.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, staff members entered rooms of residents on EBP without wearing the required personal protective equipment (PPE) such as gowns, which is necessary during high-contact care activities. This was observed in the case of Resident #44, who required total assistance for transfers and had a G-tube, necessitating EBP. A staff member, CNA C, assisted in transferring the resident without donning a gown and failed to perform hand hygiene after removing gloves. In another instance, two staff members provided incontinent care to Resident #92, who also required EBP due to having a G-tube and pressure ulcers, without wearing gowns. Despite the presence of an EBP sign on the door, the staff members only wore masks and gloves. One of the staff members, CNA B, acknowledged forgetting to wear a gown, while CNA C expressed frustration with the precautionary measures. Interviews with facility staff, including the Charge Nurse, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Infection Control Preventionist, confirmed that the staff should have been wearing gowns during these high-contact activities. The Enhanced Barrier Precautions sign clearly indicated the requirement for gowns and gloves during specific care activities to prevent the transmission of multidrug-resistant organisms (MDROs).
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, CR #2 and Resident #10, as per professional standards and their care plans. CR #2, a female resident with COPD and other respiratory conditions, had an order for continuous oxygen at 3L/min. However, documentation showed she was on room air multiple times, and her oxygen saturation levels were not consistently monitored or reported to the physician when they fell below the target level. Notably, an oxygen saturation of 84% was recorded without notifying the physician, and there was a lack of continuous supervision during nebulizer treatments. Interviews with staff revealed discrepancies in documentation and a lack of adherence to protocols. LVN T admitted to errors in documenting CR #2's oxygen status and nebulizer treatments, and the DON confirmed that the physician should have been notified of the low oxygen saturation. The ADON and DON highlighted the importance of monitoring changes in condition, especially for residents with respiratory issues, but these protocols were not followed, leading to a failure in addressing CR #2's needs. For Resident #10, the facility also failed to properly assess and document oxygen saturation levels following nebulizer treatments. LVN Z did not use a pulse oximeter post-treatment and inaccurately documented a 98% oxygen saturation based on observation rather than measurement. This lack of proper monitoring and documentation could have compromised the resident's care, as the effectiveness of the treatment was not accurately assessed.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not follow the treatment orders for a resident's left distal/medial foot as prescribed by the Nurse Practitioner. The resident, who has a history of type 2 diabetes mellitus, local infection of the skin, and pressure-induced deep tissue damage of the left heel, was supposed to have betadine applied to the affected area and covered with a kerlix bandage daily. However, on one occasion, the Wound Care Nurse applied betadine but failed to cover the wound with the bandage as ordered. The resident, who is severely cognitively impaired and dependent on staff for personal care, was observed sitting in a wheelchair with a pressure-relieving boot on her left leg. Despite the resident expressing satisfaction with her care, the failure to follow the treatment order was noted during an observation of wound care. The Wound Care Nurse acknowledged not following the doctor's order, which could potentially lead to damage to the arterial wound if the resident moved with the wound exposed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a violation of the resident's rights to reasonable accommodation of their needs and preferences. The deficiency was identified during an observation and interview process, where it was noted that the call light for a resident was hung on the bed headboard, out of the resident's reach. This was confirmed during two separate observations on the same day. The resident, who was bedfast and had a history of general muscle weakness and cerebral infarction, was unable to answer questions, indicating a potential communication barrier. Interviews with the unit manager and the facility administrator revealed that it was the responsibility of the nurses and CNAs to ensure that call lights were within reach of residents. The unit manager acknowledged that the call light might have been left on the headboard after care was provided, and confirmed that the resident would not be able to call for assistance due to the call light's inaccessibility. The facility's policy on answering call lights and the call system emphasized the importance of ensuring that residents have a means to call for assistance, which was not adhered to in this instance.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the presence of soiled sheets and a strong urine odor in the resident's room. The resident, who required assistance with activities of daily living due to conditions such as muscle weakness, dementia, and epilepsy, was found sitting in his wheelchair in a room with a noticeable urine smell and stained sheets. The resident reported waiting for staff to change his bed linens for about 30 minutes. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) was unaware of the soiled sheets and acknowledged that they should have been changed immediately. The Certified Nursing Assistant (CNA) responsible for changing the linens admitted to being distracted by another resident's request and leaving the room without completing the task. The CNA acknowledged that the resident's needs were not met and that other staff could have assisted. The facility's policies emphasize treating residents with dignity and ensuring consistent care, which was not adhered to in this instance.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in resident rooms. On December 4, 2024, a live brown roach was observed in a resident's room between the laundry basket and bedside nightstand. The resident reported seeing roaches frequently, especially when the lights were off, and expressed fear that the roaches might crawl into her bed. This indicates that the pest control measures in place were insufficient to keep the resident rooms free from pests. The facility's pest control vendor had visited and treated the facility for roaches on two occasions in November 2024. Despite these treatments, the problem persisted, particularly in the 500 and 1000 halls, as acknowledged by the Administrator. The Administrator noted that the issue worsened during rainy conditions and emphasized that all staff were responsible for reporting insect sightings. The facility's policy, revised in May 2008, stated that an ongoing pest control program should ensure the building is free of insects and rodents, which was not effectively implemented in this case.
Failure to Provide Consistent ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This deficiency was observed in a resident who was physically impaired and dependent on staff for assistance with ADLs, including bathing and clothing changes. The resident, who had severe cognitive impairment and multiple medical conditions, was supposed to receive showers on specific days during the 2:00 p.m. - 10:00 p.m. shift. However, records indicated that the resident did not consistently receive these showers, leading to body odors and complaints from the resident's family. Interviews with staff revealed that the 2:00 p.m. - 10:00 p.m. shift often failed to provide the scheduled showers and clothing changes for the resident. A CNA from the 6:00 a.m. - 2:00 p.m. shift reported taking the initiative to give the resident showers due to concerns about the lack of care from the later shift. The resident's family also expressed concerns about the resident not receiving showers and being found in the same gown for multiple days, which sometimes resulted in odors. Despite these issues, the facility's documentation did not consistently reflect the missed showers or clothing changes. The facility's administrator acknowledged that the resident's family had complained about missed showers and clothing changes. However, the administrator claimed that the showers were given the next day after a missed appointment. The lack of proper documentation and accountability for the 2:00 p.m. - 10:00 p.m. shift contributed to the ongoing issue, as the resident's hygiene needs were not consistently met, leading to grievances from the family and potential risks for the resident.
Failure to Secure Catheter Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections. The resident, an elderly female with severe cognitive impairment and a history of cerebral infarction, acute kidney failure, and urinary retention, was observed without a catheter stabilizer in place. This oversight was noted during a care session where the CNA attempted to reapply the stabilizer but found the adhesive was not sticking. The CNA acknowledged the importance of the stabilizer in preventing the catheter from being pulled out or displaced. Interviews with facility staff, including an LVN and the DON, revealed a lack of consistent monitoring and communication regarding the resident's catheter care. The LVN admitted to relying on CNAs to inform him if the catheter stabilizer was not secured, while the DON emphasized that it was the nursing staff's responsibility to ensure the catheter was anchored properly. The facility's policy on catheter care, which aims to prevent catheter-associated urinary tract infections, specifies that catheters should be secured with a leg strap to reduce friction and movement at the insertion site.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA B during the provision of incontinence care to Resident #1. CNA B did not perform hand hygiene after removing soiled gloves and before applying new gloves, which led to cross-contamination. While wearing soiled gloves, CNA B touched various items in the resident's environment, including the bedside drawer, barrier cream container, clean dress, brief, and sheets. This lapse in protocol could potentially place residents at risk for the spread of infection. Resident #1, a female with severe cognitive impairment, was dependent on an indwelling catheter and required substantial assistance with personal hygiene. Her care plan highlighted the risk of complications such as recurrent urinary tract infections. During the observation, CNA/Activity also failed to adhere to proper infection control practices by double-gloving, which is against the facility's policy. Interviews with the staff, including the Administrator and DON, confirmed that these actions were not in line with the facility's infection control policies, which emphasize the importance of hand hygiene as the primary means to prevent the spread of infections.
Inadequate Supervision and Improper Transfer Technique
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices during the transfer of a resident, leading to a deficiency in accident prevention. The resident, who was severely cognitively impaired and totally dependent on two-person physical assistance for transfers, was inappropriately transferred by a CNA. The CNA lifted the resident under the arms and placed him into a wheelchair without using a gait belt, despite the presence of another staff member in the room who could have assisted. This improper transfer technique was captured on video and reported by the resident's family member. The resident's care plan indicated the need for extensive to total assistance with activities of daily living, including transfers, and the facility's policy required the use of a gait belt for all assisted transfers. Interviews with staff confirmed that they were trained to use gait belts to reduce the risk of injury during transfers. The Director of Nursing acknowledged the improper transfer and confirmed that staff were not trained to perform such transfers. The CNA involved was terminated following the incident.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in care. The resident, a female with dementia, insomnia, and constipation, was admitted to the facility and required substantial assistance with activities of daily living, including toileting and personal hygiene. The resident was always incontinent of both bowel and bladder, as noted in her care plan, which aimed to maintain her dignity by keeping her clean, dry, and odor-free. However, during an observation, a CNA did not properly clean the resident during incontinent care, failing to spread the labia and clean the urinary meatus, which is a necessary step to prevent infections. The CNA, who worked on a PRN basis, admitted to not performing the task correctly due to nervousness, acknowledging that this failure placed the resident at risk for infections. The Director of Nursing stated that staff were expected to provide complete and proper incontinent care and that training and competency checks were provided upon hire and quarterly. Despite this, the facility did not provide a policy on incontinent care upon exit, and the Incontinent Care Skills Checklist indicated the proper procedure was not followed.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a CNA during incontinence care for a resident. The CNA did not perform hand hygiene before entering the resident's room or before donning clean gloves. During the care process, the CNA removed soiled gloves without washing or sanitizing her hands and donned new gloves, continuing to provide care and touch clean items with potentially contaminated hands. This lapse in proper hand hygiene could lead to cross-contamination and the spread of infection. The resident involved was an elderly female with dementia, insomnia, and constipation, requiring substantial assistance with activities of daily living, including toileting and personal hygiene. The resident was always incontinent, necessitating careful and hygienic care. The CNA, who worked PRN and had not completed competency checks or in-service training on infection control at this facility, acknowledged the risk of cross-contamination due to improper hand hygiene. The facility's policies on infection control and hand hygiene were not adhered to, as evidenced by the CNA's actions and the lack of documented training.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches, gnats, and flies in various areas, including the kitchen, dining area, and resident rooms. Observations on multiple occasions revealed gnats flying in the kitchen, flies in the dining area, and roaches climbing on the kitchen walls. Interviews with the Dietary Manager and aides confirmed the ongoing issue with pests, despite regular visits from a local pest control company. The Dietary Manager acknowledged the presence of gnats and was informed by staff about roaches, although she had not personally seen them. The facility's pest control policy, dated 2008, stated that the building should be kept free of insects and rodents, yet the maintenance log recorded multiple instances of roach sightings in resident rooms over several months. During an interview with the local pest control contractor, it was noted that a fly light bulb near the kitchen entrance was out, which could have contributed to the fly and gnat problem. The contractor suggested changes in handling fruit deliveries to reduce pest attraction. Despite these efforts, the presence of pests persisted, as evidenced by the state investigator's observation of roaches during the interview. The facility's failure to effectively control pests placed residents at risk of infection and food-borne illnesses, as acknowledged by the Dietary Manager and Administrator.
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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