The Crescent
Inspection history, citations, penalties and survey trends for this long-term care facility in Sugar Land, Texas.
- Location
- 11353 Sugar Park Lane, Sugar Land, Texas 77478
- CMS Provider Number
- 676323
- Inspections on file
- 47
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 12 (5 serious)
Citation history
Health deficiencies cited at The Crescent during CMS and state inspections, most recent first.
A resident with multiple complex conditions and a sacral pressure injury had an updated wound care order for zinc plus collagen powder written by an NP, but the wound care LVN did not transcribe and initiate this new treatment for several days, continuing the prior calcium alginate regimen instead. The LVN cited system issues and competing obligations, the NP expected the written order to be promptly carried out, and the DON and ADON described shared but unclear responsibilities for ensuring timely transcription of wound care orders. Review of clinical records confirmed the delay between the date the new order was written and the date it was implemented, contrary to facility policy requiring timely transcription of consulting practitioner orders.
A nurse failed to follow infection control protocols while administering IV antibiotics to a resident on enhanced barrier precautions for MRSA, including not wearing a gown or gloves, not performing hand hygiene, and not sanitizing the overbed table before or after the procedure. These actions were observed on video and confirmed by staff interviews, indicating a lapse in required infection prevention measures.
A resident with a Foley catheter was observed without a required leg strap, despite care plans and facility policy mandating its use to prevent catheter pulling or dislodgement. Staff interviews confirmed the omission, and the resident reported that a secure strap was never attached.
Staff did not wear required gowns while providing Foley catheter care and wound dressing changes for a resident with chronic wounds and an indwelling catheter, despite clear signage and available PPE. The involved staff acknowledged they were aware of the need for full PPE but failed to comply, resulting in a breach of the facility's infection control protocols.
A resident with upper extremity impairment and requiring total assistance with eating was given hot water for soup by a CNA, who left the room after warning the resident that the water was hot. The resident accidentally spilled the hot water, resulting in severe burns. The care plan lacked interventions for hot liquids, staff did not consistently check liquid temperatures, and there was no clear process or responsibility for monitoring hot liquid safety, leading to the incident.
A resident with cognitive intactness and upper extremity impairment was left unattended with a hot beverage, resulting in second-degree burns to her leg. The incident was not documented in the facility's incident log or reported to the state agency within the required timeframe, despite facility policy and regulatory requirements for immediate reporting of such events.
The facility did not have effective or consistently enforced policies and procedures to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and oversight, resulting in inadequate protection for residents.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents did not receive their prescribed blood pressure medications according to physician-ordered parameters, and staff failed to document when medications were held or not administered. Nursing staff acknowledged errors in both medication administration and documentation, and facility policy requiring proper documentation was not followed.
A facility failed to notify the ombudsman and ensure a safe discharge for a resident with complex medical conditions. The resident was not properly informed of her rights and options, and the facility did not adequately assist her in exploring alternatives. Staff interviews revealed a lack of awareness about notifying the ombudsman, contributing to the deficiency.
Two residents did not have their prescribed medications properly documented as administered, with multiple medications missing documentation on the MARs and no explanations provided in nursing notes. Staff interviews confirmed that all medication administration should be recorded, and the facility's policy requires this, but it was not followed in these cases.
A resident with multiple medical conditions who required assistance with ADLs was observed with long and dirty fingernails after refusing nail care. The CNA did not report the refusal to the nurse, and required documentation and follow-up were not completed, resulting in a failure to maintain the resident's grooming and hygiene.
The facility failed to conduct PASRR Level 2 evaluations for residents with mental illness, as five residents were incorrectly marked negative for mental illness in their PASRR Level 1 screenings. This oversight could risk residents not receiving necessary care. The facility relied on hospital PASRR information and did not reassess or audit these screenings, leading to the deficiency.
The facility failed to ensure physician orders for oxygen administration for two residents requiring respiratory care. One resident with a tracheostomy and respiratory failure was observed receiving oxygen without an order, and another resident's oxygen tubing and humidifier were not labeled or dated. Staff interviews revealed confusion with a new EMR system and a lack of adherence to procedures, risking respiratory complications.
A facility failed to develop a baseline care plan for a newly admitted resident with rhabdomyolysis, UTI, and bipolar disorder. The care plan did not address the resident's PASRR diagnosis or bipolar disorder, as required by facility policy. Staff interviews confirmed the importance of baseline care plans for guiding care and ensuring coordination, but the admitting nurse did not complete the necessary documentation.
A facility failed to implement a comprehensive care plan for a resident, omitting care for a rectal tube placed prior to documentation. The resident, with multiple serious diagnoses, was at risk due to this oversight. Staff interviews revealed confusion over care plan responsibilities, contributing to the deficiency.
A facility failed to secure a resident's indwelling catheter, as required by their care plan and facility policy, leading to a deficiency. The unsecured catheter posed a risk of trauma and improper drainage. Staff interviews revealed uncertainty about how long the catheter had been unsecured, despite the facility's policy mandating the use of a leg strap.
The facility failed to ensure that the lids of two dumpsters were secured, leaving garbage exposed. The Nutrition Director and staff acknowledged the requirement to keep lids closed, but some staff struggled to do so due to their height. The facility's protocol mandates that dumpster doors remain closed at all times.
A resident with quadriplegia and an indwelling catheter was found without a catheter stabilizer, risking dislodgement and trauma. Observations showed the catheter tube improperly positioned under the resident's leg, contrary to facility policy. Staff acknowledged the oversight, noting the importance of securing the catheter to prevent movement and ensure proper urine drainage.
The facility failed to ensure safe and orderly discharges for five residents, lacking proper care planning and involvement in the process. One resident with significant medical needs was discharged without necessary home health services or medical supplies, and family members were not adequately informed. The facility's actions led to multiple appeals, highlighting a pattern of unethical discharge practices.
A facility failed to create a comprehensive baseline care plan within 48 hours of admission for a resident with multiple health issues, including cerebral infarction and colon cancer. The care plan did not address essential health and safety concerns or involve the interdisciplinary team. Interviews revealed a lack of communication and care planning meetings during the resident's nearly three-month stay, leading to unmet needs and disappointment.
A resident admitted with multiple medical conditions, including wounds on the left foot and sacrum, did not receive timely wound care orders due to the admitting nurse's failure to document the wounds and obtain temporary treatment orders. The resident refused assessments from wound care nurses, contributing to the delay. Facility staff interviews revealed that the deficiency was not identified through the facility's audit process, which should have ensured accuracy and prevented delays in care.
A resident admitted with a sacral wound did not receive timely wound care orders due to a failure in documentation and communication by the admitting nurse. Despite the resident's refusal of assessments, facility policy required obtaining treatment orders at admission, which was not done, leading to a delay in care.
A resident with multiple medical conditions was found with a bruise on his left arm, which was not reported by RN A to the facility's Abuse Coordinator as required. Despite the family's inquiry, RN A did not document or notify the appropriate authorities, believing the bruise was old. The facility's policy mandates immediate reporting of such injuries to initiate an investigation, which was not followed.
A facility failed to develop a baseline care plan for a newly admitted resident with multiple health issues, including unhealed pressure ulcers, within 48 hours of admission. The admitting nurse did not include wound care in the plan, and there was no audit to catch the oversight. Interviews with staff indicated a lack of clear processes to ensure accurate admission procedures, risking inappropriate care for the resident.
A facility failed to implement a comprehensive person-centered care plan for a resident with complex medical needs, including epilepsy, oxygen therapy, and a feeding tube. Despite these needs being identified in the resident's MDS, the care plan lacked focus, goals, or interventions for these areas. Interviews revealed confusion among staff about responsibility for care plan completion and updates, with the DON and ADON expected to ensure accuracy. The oversight could result in the resident not receiving appropriate care.
A resident with terminal cancer experienced a significant change in condition, but the facility failed to notify the physician. Despite staff recognizing the resident's distress, the responsible nurse contacted the wrong NP and did not follow up. The resident was later transported to the hospital by EMS and passed away. The facility's protocol for notifying physicians was not followed, leading to a deficiency.
A resident with terminal cancer experienced a change in condition, including weakness and inability to speak, but the LTC facility staff failed to assess, document, or notify the physician appropriately. Despite low oxygen saturation, no standing order for oxygen was present, and emergency services were not contacted in a timely manner. The resident was eventually taken to the hospital by EMS and passed away two days later.
A resident was discharged from an LTC facility without a comprehensive discharge plan, lacking essential information such as home health services and durable medical equipment. The resident and family were not adequately informed or involved in the discharge planning process, and the facility failed to follow its policies for discharge planning, resulting in a deficiency in transfer and discharge rights.
A resident with Alzheimer's and functional quadriplegia received incontinence care from two CNAs who failed to adhere to proper hand hygiene protocols. CNA JJ did not wash or sanitize her hands between glove changes, contrary to the facility's policy. The DON confirmed the expectation for proper hand hygiene, but CNA JJ admitted to washing hands only after every third glove change, highlighting a lapse in infection control practices.
Delayed Transcription and Implementation of Updated Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident was an elderly female with multiple complex diagnoses, including hypoxic encephalopathy, cerebral infarction, emphysema, acute respiratory failure with hypoxia, pulmonary edema, type 2 diabetes mellitus, morbid obesity, dysphagia, hemiplegia and hemiparesis, seizures, intracranial hemorrhage, anemia, elevated white blood cell count, myocardial infarction, heart failure, pneumonitis due to aspiration, rhabdomyolysis, hyponatremia, gastrostomy, and hypothermia. Her admission MDS showed severely impaired cognition with a BIMS score of 3, dependence in toileting and personal hygiene, and functional impairments in upper and lower extremities. She was initially identified as having no pressure ulcers but at risk for development, and was care planned for pressure ulcer prevention with interventions such as barrier cream, turning and repositioning every two hours and as needed, and use of suspension devices to reduce pressure on heels and bony prominences. Subsequently, a clinically unavoidable pressure injury form dated 01/25/26 documented a stage 2 coccyx blister. On 01/28/26, a wound treatment order was in place for the sacral area using calcium alginate with TRIAD cream, to be applied daily. On 01/29/26, the Wound Care Specialist NP assessed the sacral wound, identified as a sacral pressure injury, and issued a new written order for zinc plus collagen powder as the wound treatment. This new order was intended to be transcribed and carried out by facility staff. However, review of the resident’s February MAR and TAR showed that the zinc plus collagen powder order was not initiated until 02/04/26, and the completed order summary reflected that the calcium alginate order was not discontinued and the new collagen with TRIAD order not started until 02/03/26, indicating a delay in implementing the updated wound care regimen. Interviews clarified the actions and inactions leading to the delay. The wound care LVN stated he discovered the sacral redness on 01/28/26, notified the family and NP, and received the initial calcium alginate order. He reported that the new wound care order from 01/29/26 was not transcribed the same day, citing internet issues and other obligations such as calling families about new orders, and acknowledged he did not see the new order until 02/03/26. The Wound Care Specialist NP confirmed she provided the zinc plus collagen powder order on 01/29/26 and expected it to be transcribed and implemented, and was unaware it had not been started until 02/04/26. The DON stated that the LVN was responsible for transcribing treatment orders and that the ADON shared an office with him and was responsible for ensuring all orders, including wound care orders, were transcribed in a timely manner, while the ADON reported she was not aware the new wound care orders had not been transcribed and that overseeing wound care orders had not been specifically assigned to her. Facility policies required that consulting practitioner orders be noted and transcribed to the medication or treatment administration record in a timely manner, which did not occur in this case.
Failure to Follow Infection Control Protocols During IV Medication Administration
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow infection prevention and control protocols while administering intravenous (IV) antibiotics to a resident. The resident had a history of osteomyelitis in the left foot and ankle, Type 2 diabetes, muscle weakness, and was on enhanced barrier precautions (EBP) due to wounds and a feeding tube. The care plan also indicated the resident required isolation for MRSA in a wound, with interventions specifying hand washing and the use of protective equipment. On the observed occasion, the LVN entered the resident's room wearing only a mask, without donning a gown or gloves, and did not sanitize or wash hands upon entry. The LVN proceeded to hang the IV medication, handled supplies, and used the overbed table without sanitizing it before or after the procedure. The LVN also failed to wash hands upon exiting the room. These actions were captured on video and confirmed through interviews with facility staff, who stated that proper protocol required hand hygiene, use of gown and gloves, and sanitizing surfaces before and after procedures involving IV medications. Facility policies reviewed included requirements for enhanced barrier precautions and infection control, but the intravenous therapy policy did not specifically address infection control guidelines. Staff interviews confirmed that the observed practices did not align with facility expectations or infection control standards, placing the resident at risk for infection and cross-contamination.
Failure to Secure Foley Catheter with Leg Strap
Penalty
Summary
A resident with a history of paraplegia, neuromuscular bladder dysfunction, and other significant medical conditions was admitted and care planned for a Foley catheter. The care plan included monitoring for pain or discomfort due to the catheter and checking the tubing for kinks each shift. Physician orders specified the use of a Foley catheter, and facility policy required that the catheter be secured with a leg strap to reduce friction and movement at the insertion site. During observation of catheter care, it was noted that the resident did not have a Foley catheter leg strap in place. Interviews with nursing staff confirmed that the resident was supposed to have a secure leg strap to prevent pulling or dislodgement of the catheter, but the strap was not present. The resident reported that staff never attached a secure strap to the catheter tubing. Facility policy and staff interviews confirmed the expectation that all residents with Foley catheters should have a leg strap to prevent dislodgement.
Failure to Use Required PPE During High-Risk Resident Care
Penalty
Summary
Staff failed to follow established infection prevention and control protocols for a resident with significant medical needs, including chronic wounds and an indwelling Foley catheter. During direct care activities, including Foley catheter care and wound dressing changes, the Assistant Director of Nursing (ADON), a Certified Nursing Assistant (CNA), and a Registered Nurse (RN) entered the resident's room without donning the required disposable gowns, despite clear signage and the availability of personal protective equipment (PPE) at the entrance. All three staff members only wore gloves while providing care, contrary to the facility's Enhanced Barrier Precautions policy, which mandates both gowns and gloves for high-contact care activities involving residents with wounds or indwelling devices. The resident involved had a complex medical history, including paraplegia, chronic wounds to the sacrum and right lower ischium, an intraspinal abscess, osteomyelitis, and an indwelling Foley catheter. The care plan and physician orders specified the need for enhanced infection control measures, and the resident's room was clearly marked with instructions for staff to use gowns and gloves. Observations confirmed that the required PPE was available outside the room, and the staff acknowledged during interviews that they were aware of the need for full PPE but failed to comply due to distraction or forgetfulness. Facility policy, as well as the revised Enhanced Barrier Precautions guidelines, require the use of gowns and gloves during high-contact care for residents with chronic wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms. The staff's failure to adhere to these protocols was confirmed through observation, interviews, and record review, and was acknowledged by the Director of Nursing as a breach of infection control standards.
Failure to Prevent Resident Burns Due to Inadequate Hot Liquid Safety and Supervision
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but had upper extremity impairment and required total staff assistance with eating, was provided with hot water for soup by a CNA. The CNA obtained the hot water from a dispenser in the coffee room, which was later measured to be 167.6 degrees Fahrenheit. The CNA informed the resident that the water was hot and left the room. While the CNA was away, the resident accidentally spilled the hot water on her leg, resulting in second and third degree burns. The incident was reported to the LVN, who assessed the resident and initiated treatment, but the resident was not sent to the emergency room despite her request and the severity of the burns. The resident's care plan did not include interventions or precautions related to being served hot liquids, despite her need for total assistance with eating and her physical impairment. Staff interviews revealed inconsistent practices regarding the testing of hot liquid temperatures before serving to residents, and there was no clear process or designated responsibility for ensuring the safety of hot liquids dispensed from the coffee machine. Some staff relied on subjective methods, such as touching the outside of the cup, and there was no thermometer available for checking temperatures. Additionally, the facility's incident log did not reflect the burn incident, and staff were not uniformly aware of protocols for hot liquid safety. Observations confirmed that the hot water dispenser was accessible to all residents, and there was a lack of oversight or monitoring of the area. Interviews with facility leadership, including the DON and Nutritional Director, indicated uncertainty about who was responsible for monitoring hot liquid temperatures and ensuring resident safety in the coffee room. The facility's policy required immediate reporting and documentation of accidents, but this was not followed in the case of the burn incident. These actions and inactions led to a situation where a resident suffered significant burns due to inadequate supervision and lack of safety measures regarding hot liquids.
Failure to Timely Report Resident Burn Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported within the required timeframes to the administrator and State Survey Agency. Specifically, an incident occurred in which a cognitively intact female resident with multiple medical conditions, including anxiety disorder, rheumatoid arthritis, muscle wasting, hypertension, and heart failure, was left unattended with a hot cup of liquid. This resulted in the resident sustaining second-degree burns to her right leg and experiencing pain. The incident was not documented in the facility's incident log, nor was it reported to the state agency as required. Record reviews revealed that the resident required total staff assistance with eating and had upper extremity impairment, yet was left alone with a hot beverage. After the incident, the resident was found in pain with a burn to her leg, and treatment was provided, including medication and wound care. However, the incident was not reported to Health and Human Services within the mandated 24-hour period, and there was no evidence of timely notification to the appropriate authorities. Interviews with staff indicated a lack of recall regarding the specifics of the incident and uncertainty about reporting responsibilities. Further interviews with facility leadership confirmed that the incident was not reported as required, with the current administrator and DON stating that the event occurred prior to their tenure and acknowledging the potential for additional harm due to the lack of reporting. Review of facility policies confirmed the requirement for immediate reporting of such incidents, but these protocols were not followed in this case.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and interviews, which revealed gaps in staff training and oversight related to the prevention of abuse, neglect, and theft. The lack of clear and enforced procedures contributed to an environment where residents were not adequately protected from potential harm.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Accurately Administer and Document Medications with Parameters
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications as ordered by physicians for two residents. For one resident with multiple diagnoses including hypertension, muscle weakness, and severe cognitive impairment, the prescribed blood pressure medication, metoprolol, was not documented as held when the resident's blood pressure was below the physician-ordered parameters. There was no documentation in the nurse's progress notes explaining why the medication was not held, and the responsible RN acknowledged that the medication should have been held and properly documented on the MAR and in the nurse's notes. Another resident, with diagnoses such as essential hypertension, heart failure, and cognitive awareness, had physician orders for both midodrine and metoprolol with specific blood pressure parameters for administration. The MAR indicated that midodrine was not held on several occasions when the resident's systolic blood pressure exceeded the ordered threshold, and metoprolol was not held when the blood pressure was below the required parameters. There was no documentation in the nurse's notes to explain why these medications were administered or not held as per the orders. The RN involved admitted to documenting in error and not following the required procedure for medications with parameters. Interviews with nursing staff and the DON confirmed that medications with parameters must be administered according to the physician's orders and that any medication held or not given should be clearly documented with the reason. The facility's policy also requires that withheld medications be properly documented on the MAR. The lack of adherence to these procedures resulted in the failure to ensure accurate medication administration and documentation for the residents involved.
Failure to Notify Ombudsman and Ensure Safe Discharge
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a resident's safe and orderly transfer or discharge. The resident, who had a range of complex medical conditions including myasthenia gravis, diabetes, and chronic heart failure, was not properly informed of her rights and options regarding her discharge. The facility did not notify the Office of the State Long-Term Care Ombudsman about the resident's transfer or discharge, which is a requirement to ensure residents have an advocate to inform them of their rights and options. The resident was informed that her Medicare coverage for skilled nursing facility services would end, and she expressed a desire not to remain in long-term care due to financial concerns. Despite this, the facility did not adequately assist her in exploring alternative options or ensure she was fully prepared for the transition. The resident was eventually discharged to an assisted living facility, but the process lacked proper documentation and communication with necessary parties, including the ombudsman. Interviews with facility staff revealed a lack of awareness and understanding of the requirement to notify the ombudsman, which contributed to the deficiency. The Business Manager admitted to not knowing that the ombudsman needed to be informed, and the Executive Director acknowledged the need for staff training on the proper transfer and discharge process. This oversight placed the resident at risk of an unsafe transfer and discharge, as she was not provided with the necessary support and advocacy during the transition.
Failure to Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and documentation of medications for two residents. For one resident, who had multiple complex diagnoses including hyperthyroidism, dementia, depression, pain, insomnia, hypotension, and quadriplegia, there were multiple instances where prescribed medications such as levothyroxine, midodrine, melatonin, sertraline, ascorbic acid, ciprofloxacin, gabapentin, and doxycycline were not documented as administered on several days. There was no documentation in the medication administration records (MARs) or nurse's progress notes to indicate whether the medications were given, withheld, or refused, nor any explanation for the omissions. A confidential interview also revealed that the resident had to request her thyroid medication, suggesting lapses in routine medication administration. Another resident, with diagnoses including hypertension, diabetes, depression, hyperlipidemia, peripheral vascular disease, GERD, insomnia, and Alzheimer's disease, also had multiple medications not documented as given on several days. These included furosemide, atorvastatin, melatonin, omeprazole, ascorbic acid, and gabapentin. The MARs showed numerous blanks, and there was no documentation in the nurse's progress notes to explain the missing entries or to indicate if the resident had refused the medications. Interviews with facility staff, including the unit manager, RN, DON, and LVN, confirmed that medications should be documented as given or not given, with reasons for any omissions. Staff acknowledged that blanks on the MARs make it impossible to determine if medications were administered, which could result in residents being overmedicated or not receiving their medications. The facility's policy requires that all physician orders, including medications, be maintained and documented per regulations, but this was not followed in these cases.
Failure to Provide and Document Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain good grooming and personal hygiene for a resident who was unable to perform activities of daily living independently. Specifically, the resident, who had diagnoses including hypertension, hyperlipidemia, muscle weakness, renal insufficiency, dementia, and anxiety, required supervision or assistance for most ADLs. On the date of observation, the resident was found in bed with long and dirty fingernails. The resident had received a bed bath that morning and refused nail care, which was documented on the ADL shower sheet. However, the section for the charge nurse's assessment and intervention was left blank. Interviews revealed that the CNA who provided care did not clean the resident's nails because the resident refused, and the CNA did not report this refusal to the nurse as required by facility policy. The DON confirmed that nail care is the responsibility of both CNAs and nurses, and that refusals of care should be reported to the nurse for follow-up. The facility's policy states that residents unable to carry out ADLs independently should receive necessary services to maintain grooming and hygiene, with refusals documented and communicated appropriately. The failure to ensure the resident's nails were cleaned and trimmed, and the lack of communication and documentation regarding the refusal, led to the deficiency.
Failure to Conduct PASRR Level 2 Evaluations for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level 1 residents with mental illness received a PASRR Level 2 evaluation. This deficiency was identified for five residents who were reviewed for assessments. These residents were not correctly identified as having mental illness in their PASRR Level 1 screenings, which could place them at risk of not receiving the necessary care and services in the appropriate setting. Resident #4, a female with diagnoses including schizophrenia, psychosis, and major depressive disorder, was incorrectly marked as negative for mental illness in her PASRR Level 1 screening. Her care plan indicated verbal behavioral symptoms and interventions to manage these behaviors. Similarly, Resident #5, with diagnoses of anxiety disorder and major depressive disorder, was also marked negative for mental illness in her PASRR Level 1 screening. Her care plan included interventions for anxiety and physical manifestations of anxiety. The facility's process for handling PASRR screenings was flawed, as indicated by interviews with MDS Coordinators. They relied on PASRR information from hospitals and did not conduct audits on these screenings. The MDS Coordinators admitted to not reassessing residents who were admitted with other diagnoses or if the PASRR was already completed by the hospital. The facility's policy required all new admissions to be screened for mental disorders, but this was not effectively implemented, leading to the deficiency.
Failure to Ensure Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as evidenced by the lack of physician's orders for oxygen administration prior to providing oxygen. Resident #240, a male with a history of cerebral infarct, pneumonia, and acute and chronic respiratory failure, was observed with an oxygen concentrator set at 5 liters per minute via tracheostomy without a corresponding physician's order. Similarly, Resident #73, a female with diagnoses including osteomyelitis, epilepsy, cardiac arrest, and sepsis, was also receiving oxygen therapy at 5 liters per minute without a physician's order. Additionally, the oxygen tubing and humidifier for Resident #73 were not labeled or dated, which is against the facility's policy. Interviews with staff revealed a lack of clarity and adherence to procedures regarding respiratory care. LVN O mentioned that the respiratory therapist should initiate orders and treatment for tracheostomy residents, but there was confusion due to a new electronic medical record (EMR) system. The respiratory therapist admitted to being unfamiliar with the new EMR system, which led to difficulties in entering orders. LVN C emphasized the importance of having physician orders for tracheostomy care and oxygen therapy, noting that the absence of such orders could lead to respiratory distress. The Director of Nursing (DON) confirmed that all humidifiers should be dated and initialed to prevent infection, and that residents with tracheostomies should have orders for oxygen on admission. The Interim Administrator also stated that physician orders are necessary to ensure proper care. The facility's policy on oxygen administration requires verification of a physician's order before the procedure, highlighting the facility's failure to adhere to its own protocols.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a female with a history of rhabdomyolysis, urinary tract infection, and bipolar disorder, was admitted without a care plan addressing her PASRR diagnosis or her bipolar disorder. This omission was identified during a record review and interviews with facility staff, who acknowledged the importance of baseline care plans in guiding care and ensuring coordination among staff. Interviews with various staff members, including LVNs and the Director of Nursing, revealed that the responsibility for initiating baseline care plans lies with the admitting nurse. However, in this case, the baseline care plan was incomplete, lacking critical information necessary for the resident's care. The facility's policy mandates that a baseline care plan should include initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, if applicable. The absence of a comprehensive care plan could lead to staff not knowing how to adequately care for the resident.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan did not address the care for the resident's rectal tube, which was placed prior to the date it was documented in the care plan. This oversight could potentially place the resident at risk for not receiving appropriate interventions to meet their care needs. The resident, a female with multiple diagnoses including osteomyelitis of the vertebra, epilepsy with status epilepticus, cardiac arrest, and sepsis due to Streptococcus pneumoniae, was admitted to the facility with a stage 4 pressure ulcer and incontinence. Despite these conditions, the comprehensive care plan was not updated to reflect the rectal tube placement until a later date. Interviews with facility staff, including an LVN, the DON, and the MDS Coordinator, revealed a lack of clarity and responsibility regarding the initiation and updating of care plans, which contributed to the deficiency.
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. Specifically, the facility did not maintain the catheter stabilizer, which is a strap or secure device attached to the resident's thigh to prevent the catheter tube from moving. This deficiency was observed during a survey when the catheter tube was found unsecured, posing a risk of trauma or improper drainage. The resident involved was an elderly male with a history of bladder dysfunction and a Foley catheter in place. His care plan indicated a risk for increased urinary tract infections and required that the catheter be secured with a leg strap. However, during an observation, the catheter was found unsecured, and staff interviews revealed uncertainty about how long it had been unsecured. The resident did not report any pain, and there was no observed trauma at the time of the survey. Interviews with staff, including an LVN and CNA, confirmed that the catheter should have been secured and that it was their responsibility to ensure this. The Director of Nursing and the Interim Administrator acknowledged the importance of securing the catheter to prevent trauma and ensure proper drainage. The facility's policy, updated in 2019, also required the use of a leg strap to secure the catheter tubing.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that the lids of two dumpsters were secured. During an observation and interview, it was noted that both dumpsters had their lids completely open, exposing the garbage. The Nutrition Director acknowledged that the housekeeping, kitchen, and nursing staff used the dumpsters and that the trash had not been taken out that morning. He mentioned that some housekeeping staff struggled to close the lids due to their height, requiring them to use a stick to secure the lids. Interviews with the Nutrition Director and another staff member revealed that all kitchen staff were aware of the requirement to keep dumpster lids closed and were responsible for ensuring this. However, the staff member interviewed did not know the specific risks to residents if the lids were left open. The facility's Dumpster Protocol, dated December 2023, stated that dumpster doors should remain closed at all times and that any staff bringing trash to the dumpster should ensure all doors are closed.
Failure to Secure Indwelling Catheter
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, a male with quadriplegia, a stage four pressure ulcer, and neuromuscular dysfunction of the bladder, was observed without a catheter stabilizer in place. This stabilizer is crucial for preventing the catheter from moving, which could lead to accidental dislodgement and trauma to the bladder and urethra. During observations, it was noted that the catheter tube was not secured to the resident's thigh and was positioned incorrectly, running under the resident's leg. Multiple staff members, including LVNs and CNAs, acknowledged the absence of the catheter strap and the improper positioning of the catheter tube. They confirmed that the facility's policy required the catheter to be secured to prevent movement and ensure proper urine drainage. Interviews with the staff, including the RN DON and the Administrator, revealed that the facility's policy was not followed, as the catheter was not secured. The staff members were aware of the risks associated with unsecured catheters, such as potential trauma and interference with urine flow, yet the deficiency occurred. The facility's urinary catheter care policy emphasized the importance of securing the catheter to prevent infections and ensure unobstructed urine flow.
Failure to Ensure Safe and Orderly Discharge of Residents
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the safe and orderly transfer or discharge of five residents. The facility did not arrange a safe discharge through care planning and failed to involve the residents in the process. Specifically, the facility did not secure a home health agency for one resident prior to discharge, placing the resident at risk of not receiving necessary care and services upon leaving the facility. One resident, who had a history of cerebral infarction, hemiplegia, and colon cancer, was discharged without a proper care plan or involvement in the discharge process. The resident was dependent on staff for various activities of daily living and required assistance with a colostomy bag. Despite these needs, the facility discharged the resident to a group home without home health services or necessary medical supplies, such as extra colostomy bags and a helmet. The resident's family was not adequately informed or involved in the discharge planning, and the resident was transferred without her belongings. Interviews with staff and family members revealed a pattern of unethical discharge practices, including harassment of family members to remove residents due to financial issues. The facility failed to provide required discharge notices and summaries, and there was no evidence of care plan meetings or discharge conferences. The facility's actions led to multiple appeals being filed and won by the residents, indicating a failure to follow regulatory requirements for safe and orderly discharges.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered baseline care plan within 48 hours of admission for a resident, identified as CR#1, who was reviewed for care plans. The baseline care plan did not address the resident's initial goals based on admission orders, physician orders, therapy services, social services, or PASRR recommendations. This omission could place newly admitted residents at risk of not receiving services to meet their needs. The resident, who had diagnoses including cerebral infarction, hemiplegia, and colon cancer, was totally dependent on staff for various activities of daily living and required assistance with positioning and transferring. The report highlights that CR#1's baseline care plan was inadequate, failing to address specific health and safety concerns such as fall risk, supervision needs, and assistance with activities of daily living. Additionally, there was no documentation of a care plan conference with the resident or involvement of the interdisciplinary team. Interviews with family members and the resident revealed that there was no communication or care planning meeting held during the resident's stay, which lasted almost three months. The resident expressed disappointment at not receiving physical therapy or having any interaction with the social worker or other staff members.
Failure to Obtain Timely Wound Care Orders for Resident
Penalty
Summary
The facility staff failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. The deficiency involved a resident who was admitted to the facility with multiple medical conditions, including metabolic encephalopathy, peripheral vascular disease, and an amputation above the knee. Upon admission, the resident had wounds on the left foot and sacrum, but the facility did not obtain wound care orders for these areas until several days later. The admitting nurse, RN A, did not document the wounds in the admission progress note or include them in the baseline care plan. Additionally, RN A failed to obtain temporary orders to treat the wounds at the time of admission. The resident refused assessments from wound care nurses on multiple occasions, which contributed to the delay in obtaining treatment orders. However, the facility's policy required that a head-to-toe skin assessment be completed and documented on the day of admission, and that the physician be notified of any identified areas requiring treatment. Interviews with facility staff, including the DON, ADON, and wound care nurses, revealed that the lack of documentation and failure to obtain timely treatment orders were not identified through the facility's audit process. The facility's policy dictated that audits of newly admitted residents should be conducted to ensure accuracy and prevent delays in care, but it was unclear if such an audit was performed for this resident. The delay in obtaining wound care orders could have placed the resident at risk for further injury or complications.
Failure to Obtain Timely Wound Care Orders for Resident
Penalty
Summary
The facility staff failed to ensure that a resident received appropriate wound care upon admission, leading to a deficiency in care. The resident, a male with multiple medical conditions including metabolic encephalopathy and peripheral vascular disease, was admitted with a sacral wound. However, the facility did not obtain wound care orders for this wound from the time of admission until several days later. This lapse in obtaining timely treatment orders was compounded by the resident's refusal to allow wound assessments on multiple occasions. The admitting nurse, RN A, did not document the presence of the sacral wound in the admission progress note or the baseline care plan, nor did she obtain temporary treatment orders for the wound. This oversight was not communicated to the wound care nurses or the subsequent shifts, resulting in a delay in wound care treatment. The facility's policy required a head-to-toe skin assessment and notification of the physician for any identified areas, which was not adhered to in this case. Interviews with facility staff, including the DON, ADON, and wound care nurses, revealed that the lack of documentation and failure to obtain treatment orders were attributed to the resident's refusal of assessments. However, the facility's policy and staff interviews indicated that orders should have been in place regardless of the resident's refusal to prevent delays in care. The deficiency was identified during a review of the resident's medical records and interviews with staff, highlighting a failure in the facility's admission and wound care processes.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an alleged violation involving a resident, identified as CR#1, who was found with a bruise on his left arm. The bruise was brought to the attention of RN A by the resident's family on 07/04/2024. Despite the family inquiring about the cause of the bruise, RN A did not report the incident to the facility's Abuse Coordinator or document it in the progress notes, as she believed the bruise was old and not indicative of abuse. This inaction was contrary to the facility's policy, which requires immediate reporting of injuries of unknown origin to the appropriate authorities. CR#1 was a male resident with multiple medical conditions, including metabolic encephalopathy, peripheral vascular disease, and chronic diastolic congestive heart failure. He was moderately impaired cognitively, with a BIMS score of 10. On the day the bruise was discovered, CR#1 experienced a change in condition, leading to his transfer to a local hospital where he was diagnosed with pneumonia and COVID-19. The hospital records did not document the bruise, and subsequent observations did not reveal its presence. Interviews with facility staff, including RN A, CNA E, the DON, and the ED, revealed a lack of awareness and communication regarding the bruise. RN A initially acknowledged the family's report of the bruise but later denied any recollection of it. The facility's policy mandates that any injury of unknown origin should be reported immediately to the ED, who serves as the abuse coordinator, to initiate an investigation and report to the State Survey Agency. However, this protocol was not followed, resulting in a failure to ensure the safety and well-being of the resident.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, which is necessary to provide effective and person-centered care. The resident, a male with multiple diagnoses including metabolic encephalopathy, peripheral vascular disease, and unhealed pressure ulcers, was admitted without a baseline care plan addressing his wound care needs. The admitting nurse acknowledged the oversight, stating that the resident was not planned for wounds, and there was no clear process in place to ensure the accuracy of the admission process. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and other staff revealed that the baseline care plan should have included skin impairments and that audits should be conducted to ensure accuracy. However, it was unclear if the admission was audited, and the error was not corrected. The facility's policy requires the baseline care plan to include necessary instructions for care, but this was not followed, leading to a risk of inappropriate care for the resident.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, identified as Resident #2, who was reviewed for comprehensive care plans. The resident, a male with multiple complex medical conditions including epilepsy, dysphasia, aphasia, quadriplegia, and others, was admitted to the facility with specific care needs such as oxygen therapy and a feeding tube. Despite these needs being identified in the resident's quarterly MDS, the care plan did not include focus, goals, or interventions to address these critical areas. Interviews with various staff members, including LVNs, RNs, the DON, ADON, and the ED, revealed a lack of clarity and responsibility regarding the completion and updating of comprehensive care plans. The staff indicated that the care plans were supposed to be completed by the DON and ADON, but there was confusion about who was responsible for ensuring their accuracy and completeness. The MDS Nurse could initiate the care plan based on MDS assessments, but the finalization and updates were expected to be done by the DON and ADON. The oversight in Resident #2's care plan was acknowledged by the DON, who admitted that the care plan did not address the resident's seizures, oxygen therapy, and feeding tube needs. This lack of a comprehensive care plan could lead to the resident not receiving appropriate care, as the care plan is essential for guiding clinical nursing staff in providing necessary care. The facility's policies and procedures emphasize the importance of developing and implementing a comprehensive, person-centered care plan for each resident, but this was not adhered to in this case.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant need to alter treatment. This deficiency was identified during a review of a case involving a resident with terminal cancer who experienced a change in condition. On the day of the incident, the resident was found to be weak and unable to speak, prompting concerns from both the private nurse and the transporter. Despite these observations, the resident's physician was not notified of the change in condition, and the resident was eventually transported to the hospital by EMS, where he passed away two days later. Interviews with staff revealed that RN B, who was responsible for notifying the physician, mistakenly contacted the wrong nurse practitioner via text message and did not make further attempts to reach the correct physician. The Director of Nursing (DON) was present during the incident but was unaware that the wrong physician had been contacted. The facility's protocol required nurses to notify the physician, family, management, and the DON in case of an unstable resident, but this protocol was not followed. Additionally, the facility's policy did not require documentation of who was contacted or the mode of communication used, which contributed to the oversight. The resident's medical records did not show any orders for oxygen use, and there was no documentation of the physician being notified of the resident's change in condition. The facility's failure to notify the physician and document the change in condition put the resident at risk, as noted by the staff interviews and the facility's own policies. The incident highlighted a breakdown in communication and adherence to established protocols, which ultimately led to the resident not receiving timely medical intervention.
Neglect in Responding to Resident's Change in Condition
Penalty
Summary
The facility failed to ensure the resident's right to be free from neglect, as evidenced by the inadequate response to a change in condition for one resident. The resident, who had terminal cancer and was typically alert and vocal, experienced a significant change in condition, including weakness and inability to speak. Despite these symptoms, the facility staff did not appropriately assess, document, or notify the physician, nor did they provide timely emergency medical treatment. The resident was eventually transported to the hospital by EMS, where he passed away two days later. Interviews with facility staff revealed a lack of clear communication and documentation regarding the resident's condition. RN B, who was not familiar with the resident, failed to document an SBAR or notify the physician of the change in condition. Although the resident's oxygen saturation was low, RN B did not have a standing order for oxygen and relied on PRN orders. The DON and other staff members were present but did not take decisive action to contact emergency services, relying instead on the resident's apparent stability after initial assessments. The facility's documentation and monitoring practices were insufficient, as evidenced by the lack of recorded vital signs and assessments following the initial change in condition. The DON and LVN A did not ensure continuous monitoring or proper documentation of the resident's status. The facility's failure to follow established protocols for notifying physicians and documenting changes in condition contributed to the neglect of the resident's needs, ultimately leading to a delay in receiving necessary medical intervention.
Inadequate Discharge Planning for Resident
Penalty
Summary
The facility failed to adequately prepare and document a safe and orderly discharge for a resident, leading to a deficiency in transfer and discharge rights. The resident, who had intact cognition and required various levels of assistance for daily activities, was discharged without a comprehensive discharge plan. The resident's care plan included goals for discharge planning, but there was no evidence of an interdisciplinary team meeting or a developed discharge plan with the resident's involvement. The discharge plan of care provided to the resident was incomplete, lacking essential information such as home health services, durable medical equipment, and necessary contact information. Interviews revealed that the resident and her family were not adequately informed or involved in the discharge planning process. The resident, a former RN, expressed a desire to be informed about the discharge process and potential home health agencies but did not receive the necessary information. The family member also reported concerns about the lack of communication and the incomplete discharge plan. The facility staff, including the social worker and DON, failed to ensure that home health services were arranged prior to discharge, and the resident was discharged with a blank discharge plan document. The facility's failure to follow its policies and procedures for discharge planning was evident in the lack of a 30-day discharge notice, absence of a care plan meeting with the resident, and failure to notify the Ombudsman Office. The social worker admitted to not having a formal meeting with the resident to discuss discharge plans and did not ensure the accuracy and completeness of the discharge plan. The administrator acknowledged the oversight and expressed the need for improved verification of discharge services in the future.
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 two CNAs during the provision of incontinence care for a resident. The resident, a male with Alzheimer's disease, functional quadriplegia, and gastrostomy status, was dependent on staff for personal hygiene and was always incontinent. During an observation, CNA JJ did not perform hand hygiene before entering the resident's room or before donning clean gloves. She removed the resident's soiled brief and gloves without washing or sanitizing her hands and then donned clean gloves to continue care. CNA JJ admitted to washing her hands only after every third glove change, which contradicts the facility's hand hygiene policy. This policy requires hand hygiene before moving from a contaminated body site to a clean one and after removing gloves. CNA RR, who assisted in the care, acknowledged that CNA JJ should have performed hand hygiene before placing a clean brief on the resident. The Director of Nursing (DON) confirmed that staff are expected to perform proper hand hygiene to prevent infection. The facility's infection control policy mandates a system for preventing and controlling infections, which includes staff training. However, CNA JJ could not recall recent training at this facility, despite having signed an in-service training report on infection control. The DON stated that staff receive regular training and competency checks, but the observed failure in hand hygiene practices indicates a lapse in adherence to these protocols.
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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