The Enclave
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 18803 Hardy Oak, San Antonio, Texas 78258
- CMS Provider Number
- 676425
- Inspections on file
- 51
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at The Enclave during CMS and state inspections, most recent first.
Surveyors found a treatment cart unlocked and unattended in a resident area, with a bottle of betadine accessible in a side basket and no staff at the nurses’ station while residents were moving about. A Human Resources staff member confirmed the cart should not have been unlocked and indicated the TN had just arrived, while the TN stated the night nurse was responsible for the cart. The DON reported that carts must be locked when not in use or unattended, that mobile residents were present, and that the assigned nurse was responsible for securing the cart, consistent with the facility’s written policy requiring medication carts and storage bins to be kept closed, secured, and/or in line of sight when not in use.
A resident with vascular dementia, moderate cognitive impairment, hemiplegia, and dependence on staff for ADLs was subjected to kissing and intimate physical contact by a CNA, as captured on in-room video. The CNA was seen sitting close to the bed with his arm under the resident’s blanket near her chest, kissing the resident near the head, later holding her hand with both hands, kissing her near the mouth and then on the mouth, stating "I like you," and caressing her face. In a facility interview, the resident reported that a man had kissed and touched her, and an anonymous source stated the resident had said the CNA kissed her, prompting review of the video and its transmission to the Administrator and DON. Despite this, leadership characterized the conduct as unprofessional consoling behavior, did not treat it as an allegation of abuse, and did not report it to HHSC, even though facility policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required prompt reporting of all alleged or suspected violations.
A resident with vascular dementia, moderate cognitive impairment, and significant physical dependence reported that a male CNA had kissed and touched her. Video from the resident’s room showed the CNA seated close to the bed with his arm under the blankets near the resident’s chest, kissing her near the head, later holding her hand, kissing her near and then on the mouth, and caressing her face while she remained in bed. An anonymous source reported the resident’s statement, and the video was emailed to the Administrator and DON, who acknowledged receipt. Despite the resident’s documented statement and the video evidence, facility leadership concluded there was no reportable allegation and characterized the conduct as merely unprofessional, and the incident was not reported to HHSC as required by the facility’s abuse reporting policy and federal/state regulations.
A resident with dementia and GERD did not receive a scheduled dose of Famotidine because the medication was not found in the medication cart at the time of administration. The nurse searched for the medication, ordered a replacement from the pharmacy, and informed the resident of the delay, but the dose was missed. The medication was later found and administered by another nurse, revealing a lapse in the facility's medication management procedures.
The facility did not maintain complete and accurate medical records for several residents who were dependent on staff for bathing, as required by professional standards. Multiple instances were found where it was not documented whether a bath or shower was given or refused on scheduled days, despite care plans and schedules indicating the need for regular bathing. Interviews with the DON and CNAs confirmed that care was provided or refused but not properly recorded in the electronic system or nursing notes, resulting in incomplete records.
The facility failed to meet food service safety standards, with issues including improper hair restraint use by the CDM, incorrect storage of raw beef over cooked pies, uncovered foods in the cooler, and incorrect temperature logging for dishwashing and food items. Additionally, refrigerator temperatures were inadequately monitored, potentially risking foodborne illness for residents.
A resident with a history of atrial fibrillation and hypertension experienced significant medication errors at an LTC facility. Diltiazem HCl was administered outside prescribed parameters, with instances of missing documentation and incorrect administration despite low blood pressure readings. Staff interviews confirmed these discrepancies, highlighting a failure to adhere to the facility's medication administration policy.
The facility failed to implement a policy for the use and storage of foods brought by family and visitors, resulting in unsanitary conditions in personal refrigerators for several residents. Issues included dirty refrigerators, undated and expired foods, and a broken refrigerator door. Nursing staff acknowledged the need for routine checks and proper labeling to prevent potential food-borne illnesses.
The facility failed to ensure call lights were within reach for two residents, impacting their ability to request assistance. One resident with moderate cognitive impairment had her call light out of sight and reach, while another with severe cognitive impairment had her call light inaccessible from her wheelchair. Staff confirmed the improper placement, and the facility's policy requires call lights to be easily accessible.
The facility failed to ensure accurate MDS assessments for two residents. One resident's therapeutic diet was not documented correctly, and another resident's discharge status was inaccurately recorded. These errors were acknowledged by the MDS staff, highlighting the importance of accurate assessments for care and billing.
A facility failed to ensure accurate PASRR Level I assessments for residents with mental illness. A resident with PTSD was incorrectly marked as having no mental illness in their PASRR screening, risking missed services. The MDS Coordinator acknowledged the error, and the DON admitted to random monitoring, which may have led to the oversight.
A resident with severe cognitive impairment and dependency on staff for all ADLs was not provided with adequate personal and oral hygiene care. Observations showed long fingernails, dry patches on the face, and cracked lips with residue. Interviews with staff indicated that CNAs were responsible for ADL care, but there was a lack of consistent grooming and oversight by the nursing staff.
A resident receiving enteral feeding did not receive the correct water flush rate as prescribed by the physician. The LVN set the water flush to 175 milliliters every four hours instead of the prescribed 275 milliliters, due to not checking the physician's order. This error was confirmed by the DON and could potentially lead to dehydration.
A resident with asthma did not receive proper respiratory care as their nebulizer mask was found improperly stored and undated. The mask was left on the nightstand without a plastic bag, contrary to facility policy requiring weekly changes and proper storage. This was confirmed by both an LVN and the DON, highlighting a failure in adhering to the facility's respiratory equipment management policy.
The facility failed to periodically assess the safety of bed rails for two residents, leading to potential risks of entrapment. One resident with moderate cognitive impairment used side rails for repositioning, but her consent was outdated, and the last review was months prior. Another resident with dementia also used side rails, with consent dated years ago and the last review months before. Staff interviews revealed inconsistencies in policy implementation regarding assessment frequency.
A resident's Ciprofloxacin eye drops were left unsecured on a bedside table without a self-administration order, violating medication storage protocols. The resident confirmed the nurse left the drops for use after breakfast, but no assessment or order was documented. The DON acknowledged this breach of policy.
The facility did not follow the planned menu for a lunch meal, serving mixed vegetables and rice instead of the expected corn and broccoli, and failed to update the menu for residents. A resident, at risk for nutritional deficits, did not eat the meal provided due to the lack of preferred items and was offered an alternative. Staff interviews revealed the kitchen ran out of certain items, and the menu was not updated to reflect these changes.
The facility failed to meet the dietary needs of two residents, one of whom did not receive a proper protein source despite being at risk for nutritional deficits, and another who was served fish despite having a documented allergy. The staff failed to update meal tickets and adhere to dietary protocols, leading to deficiencies in care.
A facility failed to adhere to infection control protocols for two residents under Enhanced Barrier Precautions (EBP). An LVN did not wear a gown while applying cream to a resident with skin abrasions, and an ADON did not wash hands or wear a gown while handling a G-tube. Both incidents violated the facility's infection prevention policy, risking cross-contamination.
A resident, who required a Total Lift for transfers, experienced pain in her right ankle after a nursing assistant transferred her without the lift, despite the resident's request. The resident's care plan and Kardex indicated the need for a Total Lift, and the nursing assistant admitted to not using it because it was faster. The resident reported pain, and an x-ray showed no fracture. The nursing assistant had been trained on safe transfer equipment and resident safety.
A resident with Alzheimer's Disease was found outside the facility on two occasions without supervision. The facility failed to document or report these incidents as elopements and did not implement new interventions. The front doors were not locked until 8:00 PM, and there was no memory care unit. Staff were not adequately trained on elopement prevention, and the administration was not fully aware of the incidents.
A resident did not receive multiple critical medications upon admission due to the LVN's failure to access the emergency medication kit or seek assistance. The resident's medical history included type 2 diabetes, paroxysmal atrial fibrillation, and heart failure. The facility's policy on timely medication administration was not followed.
The facility failed to treat residents with dignity and respect, as observed in the interactions of an LVN with three residents. The LVN used terms of endearment like 'honey' and 'sweetheart' instead of their preferred names, which could make residents feel uncomfortable and disrespected. The DON confirmed that such terms should not be used, emphasizing the importance of respect and dignity.
The facility failed to report two incidents of a resident with Alzheimer's Disease eloping from the facility to the appropriate authorities within the required timeframe. Despite being aware of the incidents, the staff did not consider them as potential neglect and did not report them to the Administrator or the State Survey Agency.
A resident with a history of diabetes, atrial fibrillation, and heart failure did not receive critical medications upon admission due to the LVN's failure to access the emergency medication kit or seek assistance. The medications were administered several days later, against the facility's protocol.
The facility failed to maintain an infection control program when an LVN left wound care supplies unattended and improperly cleaned a resident's wound, increasing the risk of cross-contamination. The resident had a complex medical history, including acute respiratory failure and osteomyelitis.
Unlocked, Unattended Treatment Cart with Medications Accessible in Resident Area
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments under proper controls and that only authorized personnel had access to the keys for a treatment cart. During an observation at 6:59 a.m., Treatment Cart #1 was found unlocked and unattended, with a bottle of betadine in a basket affixed to the side of the cart. There were no staff present at the nurses’ station, and residents were moving about the facility at the time. The Human Resources staff member present acknowledged that the cart was not supposed to be unlocked and stated he did not know who was responsible for the cart because he worked in Human Resources, but indicated that the Treatment Nurse had just arrived. In a subsequent interview, the Treatment Nurse stated that the night nurse was responsible for the treatment cart, as that nurse worked the night shift and would have provided treatments for residents. An interview with the DON confirmed that her expectation was that medication and treatment carts be locked when not in use and unattended, and that medications and treatments must be secured and not left outside or on top of the cart. The DON stated that the facility had mobile residents and that any staff member could lock a cart if they passed by it, but the nurse assigned to the cart was responsible for ensuring it was locked when not in use. Review of the facility’s “Medication Cart Use and Storage” policy, revised January 2023, showed that licensed nurses and CMAs were responsible disciplines and that the medication cart and its storage bins should be kept closed, secured, and/or in the line of sight when not in use.
Failure to Protect Cognitively Impaired Resident From Sexualized Contact by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse when a CNA engaged in kissing and physical contact of a sexual and unprofessional nature with the resident, as captured on video and later corroborated by the resident’s own statement. The resident was an elderly female with vascular dementia, moderate cognitive impairment (BIMS 11/15), anxiety, memory deficits following a stroke, left-sided hemiplegia/hemiparesis, and dependence on staff for most ADLs including toileting and transfers. Her care plan identified memory problems affecting her ability to communicate needs, cognitive impairment impacting communication, and risk for emotional distress and behaviors, with interventions focused on reassurance, monitoring for emotional issues, and speaking in a calm tone. Video evidence from the resident’s room on the morning in question showed CNA A seated close to the resident’s bed with his right arm under the resident’s blanket near her chest while she lay in bed covered with blankets. The CNA leaned over the resident and appeared to kiss her near the head, with an audible kissing sound, while his arm remained under the blankets at her chest. In a subsequent video a few minutes later, the CNA was seen standing at the bedside holding the resident’s hand with both of his hands, then leaning down and kissing her near the side of her mouth, after which the resident said, “Thank you.” The CNA then again leaned down and kissed the resident on her mouth; the resident smiled and made a pecking sound. The CNA told the resident, “I like you,” continued to hold her hand, caressed the right side of her face several times with the back of his hand and fingers, and discussed returning later to check on her. Record review showed that during a facility interview conducted after the incident, the resident initially responded “Yes, some man kissed me and touched me” when asked if she had ever been treated in a rough, inappropriate, or unkind manner. In a later interview with surveyors, the resident stated she had been told by administration that the CNA was only trying to console her because she was sad, and she reported that he kissed her on the forehead, denied being kissed on the mouth, and said she did not feel threatened, though she was surprised anyone would want to kiss her at her age. An anonymous source reported that the resident had stated the CNA kissed her, which prompted review of the camera footage and transmission of the video to the Administrator and DON. The Administrator acknowledged there had been previous unsubstantiated concerns about inappropriate touching with another resident and an incident of the CNA holding this resident’s hand. The DON and Administrator characterized the conduct as unprofessional and stated it was not reported to HHSC because they believed there was no allegation and the resident felt safe, despite facility policy defining sexual abuse as non-consensual sexual contact of any type with a resident and requiring all alleged or suspected violations to be promptly reported to appropriate state agencies. Further review of CNA A’s personnel file showed he had completed competency training on privacy, dignity, resident rights, and abuse/neglect, and had been deemed competent in knowledge of abuse, neglect, and reporting. A disciplinary action was documented for rude, disrespectful, or unprofessional behavior and failure to maintain professional boundaries, categorized as a violation requiring written coaching. Time sheets confirmed that the CNA worked on the date of the incident and the following day, with no further shifts afterward. In a telephone interview, the CNA stated the resident had expressed loneliness, suicidal thoughts, and feelings of being forgotten by family, and that he hugged and kissed her on the cheek in what he described as a mutual, consoling interaction, while denying kissing her on the lips or being inappropriate. Despite these statements, the video evidence and the resident’s earlier report that a man had kissed and touched her demonstrate that the facility failed to protect the resident from abuse and failed to treat the conduct as an allegation requiring reporting and full recognition as potential sexual abuse under its own policy and regulatory definitions. The facility’s abuse policy, revised January 2024, stated that every resident has the right to be free from abuse and neglect and that residents should not be subjected to abuse by anyone, including team members and other residents. The policy required that all alleged or suspected violations and all substantiated incidents of abuse be promptly reported to appropriate state agencies per state and federal requirements. It also referenced the federal definition of sexual abuse as non-consensual sexual contact of any type with a resident and defined “willful” as deliberate action, not requiring intent to cause harm. In this case, the CNA’s deliberate kissing and intimate physical contact with a cognitively impaired, dependent resident, combined with the facility’s failure to recognize and report the conduct as an allegation of abuse despite video evidence and the resident’s statement that a man had kissed and touched her, formed the basis of the cited deficiency for failure to ensure the resident was free from abuse.
Failure to Timely Report Alleged Sexual Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively impaired resident to the State Survey Agency (HHSC) and other required authorities. The resident was an elderly female with vascular dementia, moderate cognitive impairment (BIMS score of 11/15), memory deficits following a stroke, left-sided weakness, and generalized anxiety disorder. She was dependent or required substantial/maximal assistance for most ADLs, including transfers, toileting, and bathing, and was frequently incontinent. Her care plan identified memory problems, difficulty communicating needs due to cognitive impairment, and risk for emotional distress and behaviors, with interventions focused on reassurance and monitoring for emotional issues. The events leading to the deficiency began when the resident reported that a male staff member had kissed and touched her. In a documented interview dated the day after the incident, when asked if she had ever been treated in a rough, inappropriate, or unkind manner, the resident responded, "Yes, some man kissed me and touched me." Video recordings from the resident’s room showed a CNA seated close to the resident’s bed with his arm under the blankets near her chest, leaning over and audibly kissing her near the head, and later standing at the bedside holding her hand, kissing her near the mouth, and then on the mouth while caressing her face. The resident verbally responded to the CNA, including thanking him after a kiss and engaging in conversation, but the videos documented repeated kissing and physical contact of an intimate nature while the resident was in bed and dependent on care. An anonymous source reported that the resident had stated the CNA kissed her, which prompted review of the room camera and the sending of the video to the Administrator and DON via email. The email with the video was sent the day after the incident, and the DON acknowledged receipt and stated they would address the issue. In subsequent interviews with surveyors, the Administrator and DON stated they did not consider the incident reportable because they believed there was no allegation by the resident or her family and characterized the conduct as unprofessional rather than abuse or exploitation. They also referenced a previous unsubstantiated allegation of inappropriate touching by the same CNA with another resident. Despite the resident’s documented statement that a man had kissed and touched her, the video evidence of kissing and intimate contact, and the facility’s own abuse policy requiring prompt reporting of all alleged or suspected violations, the facility did not report the allegation and incident to HHSC as required, resulting in the cited deficiency for failure to timely report suspected abuse. Additional interviews further illustrated conflicting accounts and the facility’s determination not to treat the incident as a reportable allegation. In an interview with surveyors, the resident later denied being kissed on the mouth and stated she was told by administration that the CNA was only trying to console her because she was sad, adding that she did not feel threatened and was surprised anyone would want to kiss her at her age. The DON reiterated to surveyors that there was no allegation from the resident or family member and that the video showed only unprofessional conduct. In a telephone interview, the CNA stated the resident had expressed loneliness and suicidal thoughts, asked for a hug, and that he hugged and kissed her on the cheek, describing the interaction as mutual and denying kissing her on the lips or being inappropriate. Despite these varying descriptions, the documented resident statement that a man kissed and touched her, combined with the video evidence and the facility’s policy defining and requiring reporting of all alleged or suspected abuse, formed the basis for the surveyors’ finding that the facility failed to ensure the alleged violation was reported immediately, but not later than two hours after the allegation was made.
Failure to Administer Prescribed Medication Due to Unavailable Stock
Penalty
Summary
A deficiency occurred when a nurse failed to administer a prescribed dose of Famotidine (Pepcid) 10 mg to a resident with dementia and GERD, as ordered for indigestion. The medication was not found in the medication cart during the scheduled administration time, despite being present the previous day. The nurse searched both the medication cart and the medication room but was unable to locate the medication. She subsequently ordered the medication from the pharmacy and informed the resident that it would be delivered later, but the dose was missed for that day. Further review revealed that the medication was listed as an over-the-counter (OTC) drug, which contributed to it not being refilled in a timely manner. The following day, another nurse located an opened box of the medication in the medication cart and administered it as ordered. The facility's policy requires medications to be administered accurately and as ordered by the physician, but this process was not followed, resulting in the resident missing a scheduled dose.
Failure to Accurately Document Bathing Care in Resident Medical Records
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with accepted professional standards and practices, specifically regarding the documentation of bathing or showering for four residents. For each of these residents, there were multiple instances over a one-month period where it was not documented whether a bath or shower was given or refused, despite scheduled bathing days and care plans indicating the need for 2-3 showers per week. The lack of documentation was identified through review of electronic clinical records, care plans, shower schedules, and nurses' notes, which did not reflect either the provision of care or resident refusals on numerous scheduled days. Resident records reviewed included individuals with significant medical conditions such as heart failure, stroke, hemiparesis, hemiplegia, high blood pressure, memory deficits, vascular dementia, morbid obesity, cognitive communication deficits, atrial fibrillation, kidney failure, lymphedema, and muscle wasting. These residents were all dependent on staff for bathing or showering, as indicated by their care plans and Minimum Data Set (MDS) assessments. Despite this dependency, the documentation in the electronic clinical record was incomplete, with several scheduled bathing days lacking any record of care provided or refusals, and no corresponding notes in the nursing progress records. Interviews with the DON revealed that, upon inquiry, CNAs reported having provided baths or showers or having received refusals from residents on the undocumented days. However, these actions or refusals were not entered into the electronic Point of Care Tasks or nursing notes as required by facility policy. The administrator confirmed that the absence of such documentation resulted in inaccurate medical records. The facility's policy, revised in January 2023, requires that a medical record be maintained for every resident, including documentation of services provided, in accordance with professional standards.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas within the kitchen. The Certified Dietary Manager (CDM) was observed wearing a hair restraint that did not cover all his hair, which is against the facility's policy and the U.S. Food Code requirements. Additionally, in the freezer, raw beef was improperly stored above fully cooked frozen pies, posing a risk of cross-contamination. In the walk-in cooler, there were uncovered trays of pie desserts, bowls of fruits, and plates of salad, as well as improperly stored cheese. The CDM admitted to not labeling prepared foods with a discard date, which is a violation of the facility's food storage policy and the U.S. Food Code. The dishwashing machine's temperature log was found to have incorrect temperatures recorded, with the machine's operational requirements not being met. The CDM revealed that the dishwasher staff recorded temperatures before the machine started, which did not reflect the actual temperature. This discrepancy could lead to contamination if the dishwashing machine does not reach the required temperature for sanitization. Furthermore, during a lunch service, the temperatures of fortified shakes and yogurt were taken incorrectly by touching the thermometer to the outside of the containers instead of inserting it into the food, contrary to the facility's policy. The facility also failed to monitor refrigerator temperatures adequately, as logs showed only one temperature check per day, despite the policy requiring checks once on the day shift and once on the night shift. This lack of monitoring could result in food spoilage if the refrigerators do not maintain the appropriate temperature. These deficiencies collectively indicate a failure to store, prepare, distribute, and serve food in accordance with professional standards, potentially placing residents at risk for foodborne illness.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Diltiazem HCl Oral Tablet 30 MG. The medication was prescribed to be given three times a day with specific parameters to monitor blood pressure and heart rate, holding the medication if systolic blood pressure was less than 110 or heart rate was less than 60 bpm. However, the medication was administered outside of these parameters on multiple occasions, and there were instances where the medication administration record was left blank, indicating potential missed doses. The resident involved was a female with a history of paroxysmal atrial fibrillation and essential hypertension, conditions that require careful management of heart rate and blood pressure. The resident's medical records showed several instances where the medication was given despite blood pressure readings being outside the prescribed parameters, and there were also times when the blood pressure was not documented at all. This inconsistent medication administration could have contributed to the resident's hospitalization for atrial fibrillation with rapid ventricular rate. Interviews with facility staff, including the Assistant Director of Nursing and a registered nurse, confirmed the discrepancies in medication administration. The staff acknowledged that the medication was given outside of the prescribed parameters and that this practice was unacceptable. The facility's policy on medication administration emphasized the importance of administering medications as ordered by the physician and documenting vital signs accurately, which was not adhered to in this case.
Failure to Implement Food Storage Policy in Resident Refrigerators
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsanitary conditions in personal refrigerators for several residents. Resident #29's refrigerator was found to be dirty with old and brown-colored food debris, which was confirmed by both the resident and LVN O. Despite the nurse's responsibility to check and clean the refrigerators, the debris was not cleaned due to the nurse being busy. The Director of Nursing (DON) confirmed that the refrigerator should have been cleaned to prevent potential food-borne illness. Resident #228 had undated soup with rice in his personal refrigerator, which was brought by his wife. The resident forgot to consume it, and the assigned nurse, LVN A, acknowledged that the undated food should have been discarded by the nursing staff. The Assistant Director of Nursing (ADON) G, responsible for overseeing personal refrigerators, confirmed the risk of food-borne illness from consuming undated food. Similarly, Resident #2's refrigerator had a broken door, causing improper closure and water leakage, along with an unlabeled and undated opened food container. The ADON RN I confirmed these issues and acknowledged that the facility nurses should have labeled and dated opened foods. Resident #100's refrigerator contained undated fried chicken brought by a friend, and the resident could not recall when it was brought. LVN A confirmed that the undated food should have been discarded. ADON G reiterated the risk of food-borne illness from undated food. Lastly, Resident #4's refrigerator contained expired foods, including Danishes and brownies, which were brought by a family member. LVN S confirmed that nursing staff should have checked and disposed of expired foods to prevent illness. The facility's policy required routine checks of personal refrigerators to ensure safe food storage, which was not adequately followed, leading to these deficiencies.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodation of their needs, specifically regarding the placement of call lights. Two residents were affected by this deficiency. Resident #4, who has moderate cognitive impairment and requires assistance with all activities of daily living (ADLs) except eating, was observed with her call light out of reach and out of sight, placed on top of the nightstand behind her. This was confirmed by LVN S, who acknowledged that the call light should have been within Resident #4's reach as she regularly used it to request assistance. Similarly, Resident #49, who has severe cognitive impairment and requires substantial assistance with ADLs, was observed with her call light pinned to her bed cover, making it inaccessible while she was seated in her wheelchair. CNA W confirmed that the call light was not within reach and adjusted its placement. Interviews with the ADON and DON revealed that all staff were responsible for ensuring call lights were within reach, and the facility's policy emphasized the importance of timely response to call lights and their placement within easy reach of residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care documentation. For one resident, the Quarterly MDS assessment did not reflect the therapeutic diet prescribed, despite the resident being on a regular soft and bite-sized diet with large protein portions due to conditions like type 2 diabetes mellitus, dysphagia, and protein-calorie malnutrition. The MDS coordinator acknowledged the error, stating the importance of accurate MDS assessments for care provision and billing purposes. Another resident's discharge MDS assessment inaccurately recorded the discharge status as to a short-term general hospital, while the resident was actually discharged to home with home health services. This discrepancy was confirmed by the MDS RN and LVN, who admitted the mistake and indicated the need for modification. The facility's policy and CMS MDS 3.0 Manual emphasize the necessity of accurate resident assessments, which were not adhered to in these cases.
Inaccurate PASRR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment. Specifically, the PASRR Level I assessment for a resident did not accurately capture the resident's diagnosis of mental illness. The resident, a female admitted to the facility with diagnoses including Post Traumatic Stress Disorder (PTSD), had a PASRR Level I screening that incorrectly indicated no evidence of mental illness. This oversight was acknowledged by the MDS Coordinator, who stated that the resident's PASRR screening should have been marked as positive. Additionally, the Director of Nursing (DON) admitted to overseeing PASRRs and monitoring them at random, which may have contributed to the missed assessment. The facility's policy on comprehensive assessments emphasizes coordination to maximize the resident assessment process, yet the failure to accurately complete the PASRR Level I assessment for the resident with PTSD indicates a lapse in this process. The resident risked missing out on potential services due to the inaccurate PASRR screening.
Failure to Provide Adequate ADL Care for a Resident
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADL) to a resident with severe cognitive impairment and dependency on staff for all ADLs. The resident, who had a traumatic brain injury and other medical conditions, was observed with long fingernails, dry patches on the face, and cracked lips with residue. These observations were made over several days, indicating a lack of consistent personal and oral hygiene care by the nursing staff. Interviews with staff, including a charge nurse and an occupational therapist, revealed that the resident was not well-groomed and that the responsibility for ADL care was assigned to the CNAs. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the nursing staff was responsible for maintaining the resident's grooming, including cutting nails. However, the DON stated she had not observed the resident's poor condition, suggesting a lack of oversight and communication among the staff.
Incorrect Water Flush Rate for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided with the appropriate treatment and services to prevent complications. Specifically, the facility did not administer the correct rate of water flush as prescribed by the physician for a resident with a gastrostomy tube. The resident, who had intact cognition, was supposed to receive a water flush of 275 milliliters every four hours, as per the physician's order. However, observations revealed that the water flush was set to 175 milliliters every four hours, which was confirmed by the LVN responsible for the resident's care. The LVN admitted to not checking the physician's order due to nervousness, leading to the incorrect setting of the water flush rate. The Director of Nursing confirmed that the resident should have received the prescribed 275 milliliters of water flush every four hours. This oversight could potentially lead to dehydration, as the resident was not receiving the proper hydration requirements as prescribed.
Improper Storage and Dating of Nebulizer Mask
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, specifically in the management of a nebulizer mask. The resident, who had a history of asthma and other medical conditions, was observed with a nebulizer mask that was not properly stored or dated. The mask was found on the nightstand without being bagged, and there was no indication of when it was last changed. This oversight was confirmed by both the resident and a Licensed Vocational Nurse (LVN), who acknowledged that the mask should have been covered and dated according to facility policy. Interviews with the LVN and the Director of Nursing (DON) further confirmed that the facility's policy required nebulizer masks to be changed weekly and stored in a plastic bag when not in use. The lack of proper storage and dating of the nebulizer mask could potentially lead to respiratory infections, as noted by the staff. The facility's policy on respiratory equipment management, revised in January 2022, mandates weekly changes and proper storage of respiratory tubing and equipment, which was not adhered to in this instance.
Failure to Periodically Assess Bed Rail Safety
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of residents using bed rails, which could lead to potential safety risks such as entrapment. Specifically, two residents, identified as Resident #4 and Resident #33, were not periodically assessed for the risk of entrapment from bed rails as per the facility's policy. Resident #4, who has a history of aphasia following cerebral infarction and moderate cognitive impairment, was observed using side rails for repositioning and assistance during care. However, the last documented consent for side rail use was dated over a year prior, and the side rail review tool was last updated several months before the observation. Resident #33, diagnosed with muscle wasting, atrophy, lack of coordination, and dementia, also used side rails as an enabler. Despite her moderate cognitive impairment and dependency on staff for daily activities, her consent for side rail use was dated several years prior, with the last update to the side rail review tool occurring months before the observation. Interviews with staff, including the ADON and DON, revealed inconsistencies in the understanding and implementation of the facility's policy regarding the frequency of side rail assessments, with some staff unsure of the specific timeframe for updates. The facility's policy on restraints and entrapment risk emphasizes the need for informed consent, regular assessments, and monitoring to ensure resident safety and prevent the use of restraints as a convenience. However, the lack of periodic assessments and unclear guidelines on assessment frequency contributed to the deficiency, potentially affecting any resident using side rails and increasing the risk of entrapment incidents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly secured for a resident, leading to a deficiency in medication storage practices. Specifically, a bottle of Ciprofloxacin ophthalmic eye drops was observed on the bedside table of a resident who did not have an order to self-administer medications. The resident, who had intact cognition as indicated by a BIMS score of 15, confirmed that the nurse had left the eye drops for him to use after breakfast. However, there was no documented order or assessment allowing the resident to self-administer the medication. Interviews with the LVN responsible for the resident and the Director of Nursing (DON) revealed that the LVN had left the medication on the nightstand without a self-medication assessment or a signed physician order. The DON acknowledged that this practice was against the facility's policy, which requires a self-medication review by the clinical team if a resident wishes to self-administer medication. The facility's policy, revised in January 2023, emphasizes the need for such assessments to prevent residents from taking more than the prescribed dosage.
Failure to Follow Menu and Update Residents on Meal Changes
Penalty
Summary
The facility failed to adhere to the planned menu for residents on regular and modified diets during a lunch meal. On the specified date, the menu was supposed to include lemon pepper chicken, buttered corn, and roasted broccoli. However, the facility served mixed vegetables and rice instead of corn and broccoli, and a resident's meal tray lacked protein. This deviation from the menu was not communicated to the residents, and the menu displayed was not updated to reflect the changes. A resident, who was at risk for nutritional deficits due to muscle wasting, atrophy, and mild protein-calorie malnutrition, did not consume the meal provided because it did not include the items he preferred and expected based on the posted menu. The resident expressed dissatisfaction with the meal provided, which led to him being offered peanut butter and jelly sandwiches as an alternative. Interviews with staff revealed that the kitchen ran out of corn and broccoli, and the Certified Dietary Manager (CDM) was aware of the shortage but did not update the menu. The Registered Dietitian (RD) confirmed the importance of updating the menu to ensure residents are informed and can adjust their meal choices accordingly.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to accommodate the dietary needs and preferences of two residents, leading to deficiencies in their care. Resident #79, who was at risk for nutritional deficits due to muscle wasting and mild protein-calorie malnutrition, did not receive an appropriate protein source during a lunch meal. Despite having a documented dislike for chicken, the resident was served a meal without any protein, and the staff incorrectly identified greens as a protein source. The resident expressed that he had not received a proper protein for a long time, and the dietary manager admitted difficulty in finding suitable protein options for him. Resident #35, who had a documented allergy to fish and seafood, was served fish for lunch, contrary to her medical record and cardiology prescription. Despite her moderate cognitive impairment, she was aware of her dietary restrictions and expressed frustration when served fish. The dietary staff and nursing staff failed to update her meal ticket to reflect her allergy, and the registered dietitian had not reviewed her cardiologist's note regarding her dietary needs. The resident's main entree was removed after she refused to eat the fish, highlighting a lapse in communication and adherence to dietary protocols. The facility's policies on menu substitutions and honoring food preferences were not followed, contributing to these deficiencies. The policy stated that menus should be served as planned unless an emergency arises, and substitutions should ensure a well-balanced meal. However, the facility did not adhere to these guidelines, resulting in inadequate nutrition and potential health risks for the residents involved.
Infection Control Breach in EBP Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving residents under Enhanced Barrier Precautions (EBP). In the first incident, a Licensed Vocational Nurse (LVN) entered the room of a resident with multiple medical conditions, including muscle wasting, type 2 diabetes, and a pressure ulcer, without donning a gown as required by EBP protocols. The LVN applied a cream to the resident's legs, which had skin abrasions, without wearing a gown, potentially risking contamination. The LVN later acknowledged forgetting to wear a gown due to nervousness, and the Director of Nursing (DON) confirmed the breach in protocol. In the second incident, the Assistant Director of Nursing (ADON) entered the room of another resident, who had a traumatic brain injury and was on EBP due to a gastrostomy tube, without washing or sanitizing her hands or wearing a gown. The ADON handled the resident's G-tube without following proper hand hygiene or gowning procedures, despite the posted EBP sign on the resident's door. The ADON admitted to not being sure about the gown requirement and acknowledged the importance of following EBP and hand hygiene to prevent cross-contamination. Both incidents highlight the facility's failure to adhere to its own infection prevention and control policies, specifically regarding the use of gowns and hand hygiene during high-contact resident care activities. The facility's policy, revised in April 2024, clearly outlines the need for gloves and gowns during such activities, yet these protocols were not followed, potentially placing residents at risk for infections.
Failure to Use Assistive Device During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident. The resident, a cognitively intact female with a history of muscle wasting, diabetes, cognitive communicative disorder, recurrent depression, a history of a right femur fracture, hyperlipidemia, and dementia, required assistance from one or two staff members with a Total Lift for transfers. On the date of the incident, a nursing assistant (NA E) did not use the required Total Lift when transferring the resident from her bed to a wheelchair, despite the resident's request to use the lift. Instead, NA E used a gait belt and transferred the resident alone, resulting in the resident experiencing pain in her right ankle. The resident reported hearing and feeling a pop in her right ankle during the transfer, and subsequently experienced pain rated at 10/10. An x-ray was ordered, which revealed no fracture. Interviews with other staff members confirmed that the resident's care plan and Kardex indicated the need for a Total Lift during transfers. The Director of Nursing (DON) revealed that NA E admitted to not using the Total Lift because it was faster, despite being trained and in-serviced on safe transfer equipment and resident safety. NA E's competency records showed she had completed training on safe lift and movement, fall prevention, and accessing the Kardex for safety needs.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident diagnosed with Alzheimer's Disease. On two separate occasions, the resident was found outside the facility without supervision. The first incident occurred when the resident was found outside the front doors of the facility, and the second incident happened when the resident was found outside the building in the late evening. Both incidents were not properly documented or reported as elopements, and no new interventions were implemented after the first incident. The resident's care plan indicated that she was at risk for elopement and wandering due to her Alzheimer's Disease. Despite this, the facility did not have adequate measures in place to prevent her from leaving the premises. The front doors of the facility were not locked until 8:00 PM, and there was no locked or memory care unit to provide additional security. Staff interviews revealed that the incidents were not considered elopements, and no elopement assessments or incident reports were completed. The facility's failure to provide adequate supervision and implement appropriate interventions placed the resident at risk of harm. The facility's elopement response policy was not followed, and staff were not adequately trained on elopement prevention. The facility's administration was not fully aware of the incidents, and there was a lack of communication and proper documentation regarding the resident's elopement risk and incidents. This deficiency led to the identification of Immediate Jeopardy, which was later removed after corrective actions were implemented, but the facility remained out of compliance due to incomplete staff training on elopement prevention.
Removal Plan
- Staff immediately re-directed resident #1 from the community's porch, sidewalk area and nursing assessed Resident #1. There were no negative outcomes identified.
- Front entrance lock pad system activated by [company name] to continuously require a code to get in or out at all times.
- Director of Nursing/Designee initiated in-service training to all licensed nurses and direct care team members on utilizing/accessing the Kardex Plan of Care system to identify residents who are at risk for elopement/wandering.
- Director of Nursing / Designee to conduct retraining for all team members as well as agency staffers (nurses/CNAs) prior to assuming next shift. DNS/Designee will ensure that all newly hired team members receive the training as part of the onboarding.
- The 3 residents identified to have a high risk for elopement in the community were provided with a watch like bracelet to identify the risk for wandering/elopement. In-service initiated by Director of Nursing/SW/Designee to all team members on the watch like bracelet placed on residents to identify the risk for wandering and elopement.
- Resident #1 placed on a one to one monitoring to maintain safety.
- Resident #2 placed on q15 minute monitoring to maintain safety.
- Resident #3 placed on q15 minute monitoring to maintain safety.
- Nursing/IDT will continue to monitor resident to ensure resident's safety and wellbeing.
- Nursing notified MD (PCP) and family representative of incident and resident's status.
- VP of Clinical Operations and VP of Operations conducted in-service training to the identified Director of Clinical Operations, Director of Nursing and Administrator regarding identifying and responding to exit seeking and elopement risk or events, implementing appropriate interventions; thus, ensuring the residents' safety and well-being.
- VP of Clinical Operations and VP of Operations conducted in-service training to the identified Director of Clinical Operations, Director of Nursing and Administrator regarding: Missing Person & Elopement / Exit Seeking Response. Additional education provided reviewed the process for reviewing the TXHHSC PL for reporting criteria of missing resident/elopement in order to ensure compliance with state and federal regulations: Preventing, Identifying and Reporting Abuse and Neglect, Facility's process for identifying potential risks of elopement; implementing appropriate interventions and updating the plan of care as indicated.
- Administrator/Social Worker/Director of Nursing/Designee will conduct in-service training to all staff prior to their next shift training regarding: Identifying and responding to missing person, exit seeking and elopement risk and/or incidents, and ensuring that appropriate interventions are implemented to ensure the residents' safety and well-being.
- Director of Nursing/Designee will conduct an audit of all recent new admissions and readmission, reviewing the exiting seeking assessment in order to identify any concerns with exiting seeking or elopement risks and the IDT will review the plan of care to ensure it appropriately reflects potential elopement/exit seeking risks and/or will update the plan of care as indicated.
- Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of exiting seeking / elopement behaviors. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential exiting seeking / elopement risk noted.
- Director of Nursing / Assistant Director of Nursing conducted re-education to the IDT and all licensed nurses regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being.
- Director of Nursing / Designee to conduct retraining for all team members as well as agency staffers (nurses/CNAs) prior to assuming next shift. DNS/Designee will ensure that all newly hired team members receive the training as part of the onboarding.
- Director of Nursing / Designee conducted in-service training to all licensed nurses as well as agency staffers (nurses) prior to assuming next shift. DNS/Designee will ensure that all newly hired nurses receive the training as part of the onboarding.
- Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented.
- ADMIN/DNS/SW/ Designee will conduct random daily rounds on various shifts to validate the safety and well-being of our residents.
- Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified elopement risk are noted in the plan of care and appropriate interventions are in place.
- Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly.
- Administrator/Director of Nursing/Designee will conduct Elopement / Missing Person Response Drills on random shifts to identify competency of TMs or to identify additional education needs.
- This plan will remain in place and findings will be reported to the QAPI committee during monthly meeting. The QAPI committee will then determine compliance or identify a need for additional training.
Failure to Administer Medications on Admission
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, resulting in multiple missed doses of critical medications. Specifically, the resident did not receive Amiodarone, Alprazolam, Latanoprost, Gemtesa, and Loratadine on various dates. The resident's medical history included type 2 diabetes, paroxysmal atrial fibrillation, and acute on chronic combined systolic and diastolic heart failure. The missed doses were due to the medications not being available upon the resident's admission and the failure of the LVN to access the emergency medication kit or seek assistance from other nurses who had access to it. The resident was admitted to the facility from a hospital without medications on hand. The LVN on duty submitted the prescription to the contracted pharmacy but did not see the delivery of the medications, resulting in the resident not receiving the medications on time. The Director of Nursing (DON) confirmed that the facility maintained an emergency kit of medications that nurses could access in such instances, but the LVN did not utilize this resource or contact other nurses for assistance. Interviews with the DON, the Director of Clinical Operations (DCO), and the Administrator confirmed that the LVN's actions were against protocol. The emergency medication kit inventory showed that some of the required medications were available, but the LVN failed to access them. The facility's policy on medication administration emphasized the importance of administering medications accurately, safely, and timely, which was not adhered to in this case.
Failure to Address Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect, as observed in the interactions of LVN A with three residents. LVN A addressed the residents using terms of endearment such as 'honey' and 'sweetheart' instead of their preferred names. This behavior was observed during visits to the rooms of three residents, all of whom had varying degrees of cognitive function. Resident #1, with intact cognition, was addressed as 'honey.' Resident #2, also with intact cognition, was addressed as 'honey' and 'sweetheart.' Resident #3, who was moderately cognitively impaired, was addressed as 'honey.' These observations were made on the same day during different times in the morning. During an interview, LVN A admitted to using terms of endearment and acknowledged that not using the residents' preferred names could diminish their respect and dignity. The Director of Nursing (DON) confirmed that LVN A should not be using such terms to address the residents, emphasizing that it was a respect and dignity issue. The report highlights that this failure could affect residents by making them feel uncomfortable and disrespected, thus failing to protect and promote their rights.
Failure to Report Elopement Incidents
Penalty
Summary
The facility failed to report incidents of elopement involving a resident with Alzheimer's Disease to the appropriate authorities within the required timeframe. On two separate occasions, the resident was found outside the facility, but these incidents were not reported to the Administrator or the State Survey Agency as required by law. The first incident occurred on 02/25/2024, when the resident was found outside the front doors of the facility. The second incident occurred on 04/28/2024, when the resident was again found outside the facility in the evening. Despite these occurrences, the facility staff did not report these incidents as potential neglect to the Administrator or the State Survey Agency. Interviews with staff and record reviews revealed that the facility did not have adequate measures in place to prevent the resident from eloping, especially during times when the front doors were not magnetically locked. The Director of Nursing (DON) and other staff members were aware of the incidents but did not consider them as elopements or potential neglect, and thus did not report them. The Administrator was only aware of the second incident and did not report it to the State Survey Agency, believing it did not meet the criteria for neglect as the resident was found on the sidewalk and not in the parking lot. The facility's failure to report these incidents as required could affect any resident with a high risk for wandering or elopement. The lack of reporting and subsequent investigation into these incidents of elopement indicates a deficiency in the facility's adherence to regulatory requirements for reporting potential neglect. This deficiency could result in similar incidents not being properly investigated or addressed, potentially compromising resident safety.
Failure to Administer Critical Medications Upon Admission
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, Resident #4 did not receive several critical medications, including Amiodarone, Alprazolam, Latanoprost, Gemtesa, and Loratadine, upon admission. The resident, who had a history of type 2 diabetes, paroxysmal atrial fibrillation, and heart failure, was admitted without these medications being administered as ordered by the physician. The medications were not provided until several days after admission, which could have posed a significant risk to the resident's health. The deficiency was identified through a combination of record reviews, observations, and interviews. The resident's medication administration record indicated that the medications were not administered on the dates they were ordered. Interviews with the Director of Nursing (DON) and the Licensed Vocational Nurse (LVN) who admitted the resident revealed that the medications were not available initially and that the LVN did not access the facility's emergency medication kit or seek assistance from other nurses to obtain the medications. Further investigation showed that the facility's emergency medication kit did contain some of the required medications, but the LVN failed to utilize it. The DON confirmed that this was against the facility's protocol and expectations. The facility's policy on medication administration emphasized the importance of administering medications accurately, safely, and timely, which was not adhered to in this case.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection control program, as evidenced by the actions of LVN A during wound care for Resident #14. LVN A prepared wound care supplies and left them unattended in the resident's room, covered only with wax paper. This action posed a risk of cross-contamination. Additionally, during the wound care procedure, LVN A used a single wet gauze to clean the resident's wound, wiping from the top of the wound through to the bottom, which further increased the risk of cross-contamination. Resident #14 had a complex medical history, including acute respiratory failure with osteomyelitis of the vertebra, malignant neoplasm of the thymus, intraspinal abscess, and granuloma. The resident also had an indwelling catheter and ostomy and was cognitively intact. The Director of Nursing (DON) confirmed that LVN A's actions were inappropriate and acknowledged the potential for cross-contamination during wound care.
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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