The Lev At San Antonio
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 7703 Briaridge Drive, San Antonio, Texas 78230
- CMS Provider Number
- 455742
- Inspections on file
- 37
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at The Lev At San Antonio during CMS and state inspections, most recent first.
Surveyors found one of four medication carts, the MA Med Cart for 500 Hall, unlocked while a medication aide was putting items away and preparing for shift change, despite facility policy requiring all drugs and biologicals to be stored in locked compartments accessible only to authorized personnel. The MA acknowledged the cart should not have been left unlocked due to resident safety concerns, and the ADON confirmed the cart should have been locked to prevent unauthorized access.
Surveyors found that medication and treatment carts containing drugs and biologicals were left unlocked and unattended by nursing staff, contrary to facility policy and professional standards. Interviews with LVNs and the DON confirmed that carts should have been locked when not in use, but this protocol was not followed, resulting in unsecured access to medications.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Two residents experienced a lack of dignified care and communication when staff failed to communicate in a language understood by a quadriplegic resident during personal care, and nursing staff did not document or respond to another resident's reports of numbness and chest pain. Both residents felt ignored and disrespected, with one questioning her importance after her health concerns were not addressed.
A resident with intact cognition and multiple psychiatric and neurological diagnoses was not informed about the care plan for a facial laceration sustained during surgery. Despite expressing concern about scarring and a preference for ointment, the resident was not told by the Wound Care Nurse that no new treatment orders were in place. Facility policy requires residents to be informed and involved in their care, but this did not occur in this case.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
A resident with a new diagnosis of Bipolar II Disorder did not receive a required PASARR Level I screening after admission. The initial PASARR did not reflect the mental health diagnosis, and staff interviews revealed uncertainty about the need for a new screening when new diagnoses are identified. Facility policy requires prompt referral for further review when a serious mental disorder is newly evident.
A resident with moderate cognitive impairment and multiple diagnoses experienced uncontrollable nausea and vomiting during her menstrual cycles, but this was not reflected in her comprehensive care plan. Despite staff awareness and a standing order for Zofran, the care plan was not updated by the interdisciplinary team after assessments, and the facility could not provide a policy on care plan updates when requested.
Two residents did not receive care in accordance with professional standards and their preferences: one resident's facial laceration was not treated or communicated about despite her concerns, and another resident's reports of numbness and chest pain were not properly assessed, documented, or reported by LVNs, resulting in missed physician notification and lack of follow-up.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A medication aide administered prescribed medications to a resident 51 minutes past the scheduled time without notifying the charge nurse, resulting in a medication error rate of 7.14%, which exceeds the required threshold. The resident had diabetes with neuropathy and GERD, and the late administration was due to the resident receiving a bath at the scheduled time.
A nurse failed to disinfect a glucometer between uses on two residents, both with diabetes and sepsis, despite facility policy requiring disinfection after each use. The nurse performed hand hygiene but did not clean the device before attempting to use it on a second resident, and the DON confirmed that staff are expected to use approved chemical wipes for bloodborne pathogens between each use.
The facility did not post the most recent survey results in a location accessible to residents, family members, and legal representatives. The survey results binder available in the public area contained outdated information, omitting the latest recertification survey findings, despite facility policy requiring the most current results to be posted.
A facility failed to maintain a clean and comfortable environment due to persistent adhesive glue seeping from under the flooring, resulting in dirty, sticky floors and matted debris on medication cart wheels. Despite repeated cleaning efforts and contractor interventions, the issue persisted, affecting a resident who used a wheelchair and leading to ongoing unsanitary conditions.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with multiple complex diagnoses was discharged without a physician's order or a completed discharge summary. Staff confirmed that required documentation was missing, and facility policy requiring a discharge summary to the receiving provider was not followed.
A resident with multiple diagnoses, including autistic disorder and diabetes, was discharged to another facility without the required notification being sent to the State Long-Term Care Ombudsman. The social worker responsible for this task was unaware of the notification requirement, and the administrator confirmed that the Ombudsman had not been informed, contrary to facility policy.
The facility failed to ensure timely follow-up medical care for two residents, leading to significant health complications. One resident experienced a delay in esophageal stent removal, resulting in the stent migrating into the stomach, while another resident missed a cardiology follow-up, leading to hospitalization for heart issues. The deficiencies were due to inadequate processes for managing medical appointments.
The facility failed to store, prepare, and serve food according to professional standards, with deficiencies noted in the storage of cookies, shortening, and coffee filters on the floor, uncovered condiment cups in the cooler, and improperly sealed and labeled food items in the walk-in cooler and freezer. These lapses could risk foodborne illnesses.
The facility failed to provide education and offer influenza vaccinations to three residents during the designated period, despite having a policy to do so. This oversight was confirmed through interviews and record reviews, revealing a lack of documentation in the residents' immunization records. The residents had various medical conditions, increasing their vulnerability to influenza.
A facility failed to support a resident's transportation needs for non-medical appointments, impacting his ability to explore benefits related to his blindness. Despite having intact cognition and being dependent on staff, the resident missed several important appointments due to the facility's policy of only arranging transportation for medical appointments. Staff interviews revealed concerns about the lack of support, and the facility's actions were inconsistent with the resident's rights as outlined in the admission agreement.
A resident with COPD, anxiety, and mood disorder expressed concerns about not receiving information on an oncology appointment. Despite communicating this to staff, including an LVN and a medication aide, no grievance report was initiated. The facility's grievance policy was not followed, leading to the resident's grievance being unaddressed.
A resident's drug regimen was not properly monitored for side effects and behaviors associated with their prescribed medications, including olanzapine, busPIRone, and sertraline. Despite the care plan's requirement for monitoring every shift, the medication administration record lacked sections for such monitoring. Interviews confirmed no observed side effects, but the facility's failure to adhere to its policy placed the resident at risk.
A facility failed to maintain accurate clinical records for a resident when an LVN did not document the administration of hydrocodone-acetaminophen on the medication administration record, despite recording it on the narcotic counting sheet. The LVN attributed this oversight to her inexperience and workload. The resident, who was cognitively intact, had a history of multiple health conditions. This documentation failure posed a risk of incorrect medication administration.
A facility failed to accurately reflect a resident's behavioral symptoms in the MDS assessment. Despite a documented incident of aggression, the MDS was coded as if no such behavior occurred. The resident, with a history of schizoaffective and anxiety disorders, was cognitively intact. The social worker admitted to the coding error, and the MDS nurse acknowledged the potential for inadequate care due to this inaccuracy.
A facility failed to properly secure a narcotic box containing Lorazepam in the medication room's refrigerator, as it was not permanently affixed. This oversight was confirmed by the DON and violated the facility's policy for storing Schedule II controlled medications. The resident involved had a prescription for Lorazepam to manage anxiety and agitation.
Unlocked Medication Cart on 500 Hall
Penalty
Summary
Surveyors identified a deficiency related to medication storage when, during observation of one of four medication carts (the MA Med Cart for 500 Hall) on 3/16/2026 at 1:54 p.m., the cart was found unlocked. In an interview at 1:56 p.m., the medication aide assigned to that cart confirmed it was unlocked and explained it was left that way because she was putting items away and preparing for a shift change to another hall. She acknowledged that the cart should not be unlocked because it would be unsafe for residents to have access to the medications. In a subsequent interview on 3/19/2026 at 10:04 a.m., the ADON stated the medication cart should have been locked to prevent unauthorized access and for resident safety. Review of the facility’s “Medication Storage” policy showed that all drugs and biologicals are required to be stored in locked compartments, with access to keys limited to authorized personnel, indicating the unlocked cart was not in compliance with facility policy. No specific residents, medical histories, or clinical conditions were mentioned in relation to this incident in the report.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored securely in accordance with professional standards. Specifically, the nurse treatment cart was found unlocked, unattended, and unsupervised, containing various wound care medications such as miconazole antifungal powder, collagenase enzyme paste, hypochlorous acid solution, and other wound care products. Interviews with two LVNs confirmed that the cart was left unlocked, with one stating the keys were left by the nurse’s station and acknowledging that the cart should have been locked. The facility’s own policy requires all medications to be stored in locked compartments, but this was not followed in these instances. Additionally, a medication cart on the 400 hall was observed unlocked and unattended while a nurse was administering medications in a resident’s room. The nurse admitted the cart should have been locked when unattended. The Director of Nursing confirmed the expectation that medication carts be locked when not in use and acknowledged the risk if this protocol is not followed. These observations and staff interviews demonstrate a failure to adhere to the facility’s medication storage policy.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Ensure Dignified Care and Communication for Residents
Penalty
Summary
The facility failed to ensure that residents' rights to a dignified existence, self-determination, and effective communication were upheld for two residents. One resident, who was completely dependent on staff due to quadriplegia and had no cognitive impairment, reported feeling disrespected and demoralized when staff providing incontinent care communicated only in Spanish, a language she did not understand. Despite her care plan specifying that staff should converse with her during care, bilingual and Spanish-only speaking CNAs conversed with each other in Spanish and did not translate their communication for the resident. The resident expressed frustration and a sense of isolation, as she was unable to communicate her needs or preferences effectively, particularly regarding the quality of her care. Another resident, with a history of cardiomyopathy, diabetes, and moderate cognitive impairment, reported experiencing numbness in her left arm and leg, as well as chest pain, to both day and night nursing staff. Despite these reports, there was no documentation in the resident's progress notes regarding these symptoms, nor evidence that nursing staff assessed her, notified a physician, or took further action. The resident expressed feelings of sadness and questioned whether she mattered, as she had not received feedback or follow-up from the nursing staff regarding her health concerns. Interviews with facility leadership confirmed that staff did not follow established policies requiring communication in a language residents understand and prompt reporting and documentation of changes in condition. The Director of Nursing acknowledged that the lack of action in response to the resident's reported symptoms was inappropriate and could have jeopardized the resident's health. The facility's own policies emphasized the importance of respect, dignity, and communication, but these were not followed in the care of the two residents involved.
Failure to Inform Resident of Care Plan for Facial Laceration
Penalty
Summary
The facility failed to ensure that a resident was informed and involved in decisions regarding care for a facial laceration sustained during a surgical procedure. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and Parkinson's disease but demonstrated intact cognition with a BIMS score of 14, reported not being told about the care plan for the cut on her face. She expressed concern about potential scarring and a preference for ointment, but stated that the nurse had not communicated any plan of care. The Wound Care Nurse confirmed that while the resident's physician was notified and no new orders were given, she did not inform the resident about the absence of new treatment orders for the laceration. The Director of Nursing (DON) indicated that the facility's process should include completing a risk management form and notifying relevant parties, but acknowledged that she was not informed about the laceration because it was considered a scab. Facility policy requires that residents be informed of and participate in their treatment, including being told about risks, benefits, and alternatives. In this instance, the resident was not provided with information or choices regarding the treatment of her facial laceration, resulting in a failure to honor her right to self-determination and informed participation in her care.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident complaints in a timely and non-retaliatory manner.
Failure to Complete PASARR Screening After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who was newly diagnosed with a serious mental disorder. Specifically, a resident was admitted with diagnoses including Bipolar II Disorder, end stage renal disease, and type 2 diabetes mellitus. The resident's diagnosis of Bipolar II Disorder was documented after the initial PASARR screening, which did not reflect this mental health diagnosis. Despite the new diagnosis, there was no evidence that a subsequent PASARR Level I screening was completed as required by facility policy. Interviews with facility staff revealed uncertainty regarding the need for a new PASARR screening when a new mental health diagnosis is identified after admission. The social worker, who recently assumed responsibility for PASARR oversight, was unsure if a new screening was necessary in such cases. The DON stated that it was expected for PASARR screenings to be completed upon receipt of a new diagnosis and acknowledged that failure to do so could result in residents not receiving appropriate services. Review of the facility's policy confirmed that residents with newly evident or possible serious mental disorders should be promptly referred for a Level II review.
Care Plan Not Updated for Resident's Menstrual-Related Nausea and Vomiting
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a female resident with a history of hypoglycemia, bipolar disorder, and type 2 diabetes mellitus was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly reviews. Specifically, the care plan did not include information regarding the resident's uncontrollable nausea and vomiting during her menstrual cycles, despite this being a recurring issue noted by both nursing and medical staff. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and there was a standing order for Zofran to address her symptoms. Interviews with facility staff, including an LVN, a nurse practitioner, and the DON, confirmed that the resident experienced frequent uncontrollable nausea and vomiting during her menstrual cycle, and that this should have been documented in her care plan. The absence of this information in the care plan meant that other staff might not be aware of the resident's symptoms, potentially leading to misdiagnosis. Additionally, when requested, the facility was unable to provide a policy on updating care plans prior to the survey team's exit.
Failure to Provide Timely Care and Notification for Change of Condition and Wound Management
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and residents' preferences for two residents. One resident with a history of schizoaffective disorder, bipolar disorder, and Parkinson’s disease developed a facial laceration after surgery. Although the wound care nurse assessed the injury and was aware of the resident’s concern about potential scarring, no wound care orders were documented or implemented, and the resident was not informed of the care plan. The resident expressed a preference for ointment to prevent scarring, but her concerns were not addressed, and the physician was not properly notified until after surveyor intervention. Another resident with diagnoses including cardiomyopathy and type 2 diabetes with diabetic polyneuropathy reported episodes of numbness in her left arm and leg, as well as chest pain, to multiple nurses. Despite these symptoms representing a significant change in condition, the nursing staff did not document the events, notify the physician or responsible party, or complete a change of condition evaluation. Interviews revealed that the nurses believed the concerns had been addressed by other staff or by lab orders, but there was no communication or documentation to confirm this. The nurse practitioner stated she was not informed of the numbness or chest pain and would have taken further action if she had been notified. The facility’s policy requires prompt notification of the physician and responsible party in the event of significant changes in a resident’s condition, including life-threatening symptoms or clinical complications. In both cases, the required notifications, assessments, and documentation were not completed, resulting in a lack of appropriate care and communication regarding the residents’ conditions and preferences.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Medication Error Rate Exceeds 5% Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, during medication administration observations. Out of 28 medication administration opportunities, there were 2 errors, resulting in a 7.14% medication error rate. Specifically, a medication aide administered metoclopramide and gabapentin to a resident 51 minutes past the prescribed administration window. The aide did not notify the charge nurse about the late administration, which was outside the facility's policy of administering medications within one hour before or after the scheduled time. The resident involved had diagnoses including diabetes mellitus with diabetic neuropathy and gastro-esophageal reflux, and was assessed as having intact cognition. The resident's care plan and physician orders specified the timing and dosage for the medications. The delay occurred because the resident was receiving a bath at the scheduled time, and the aide chose to return later without informing supervisory staff. Facility policy and interviews confirmed that this timing exceeded the acceptable administration window and constituted a medication error.
Failure to Disinfect Glucometer Between Residents
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding the disinfection of glucometers between resident uses. During an observation, an LVN used a glucometer to assess the blood sugar level of one resident and, without disinfecting the device, proceeded to use the same glucometer on another resident. The LVN performed hand hygiene but did not disinfect the glucometer before attempting to assess the second resident. The state surveyor intervened before the second resident's blood was drawn. During interviews, the LVN acknowledged the failure to disinfect the glucometer and recognized the risk of cross contamination. The DON confirmed that the facility's expectation was for staff to disinfect glucometers between each resident use with an approved chemical wipe for bloodborne pathogens. Record reviews showed that both residents involved had diagnoses including diabetes and sepsis, and both were receiving insulin injections per physician orders. The facility's policy on glucometer disinfection required cleaning and disinfecting the devices after each use and according to the manufacturer's instructions for multi-resident use. The deficiency was identified through observations, interviews, and record reviews, which confirmed that the facility did not follow its own written standards, policies, and procedures for infection control regarding glucometer disinfection.
Failure to Post Most Recent Survey Results in Accessible Location
Penalty
Summary
The facility failed to post the results of its most recent recertification survey in a location that was readily accessible to residents, family members, and legal representatives. During an observation and record review, it was found that the survey results binder, located by the receptionist desk in the public common area, only contained survey results up to February 2024. However, a review of the Texas Unified Licensure Information Portal (TULIP) indicated that the most recent recertification survey was conducted in August 2024, and these results were not included in the binder. During an interview, the Administrator confirmed that it was facility policy to keep the most recent survey results in the binder and accessible to the public. The Administrator acknowledged responsibility for ensuring the binder was up to date and stated she was unaware that the most recent survey results were missing. The facility's policy was reported to follow HHSC guidelines, but the omission of the latest survey results was confirmed through both observation and record review.
Failure to Maintain Clean and Sanitary Environment Due to Flooring Adhesive Issues
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment due to ongoing issues with flooring adhesive seeping from under the tiles, resulting in dirty and sticky floors. Observations over several days revealed that the glue was oozing out, causing the floors to collect hair and debris, which also accumulated on the wheels of medication carts. The Housekeeping Director confirmed that cleaning and mopping efforts were ineffective in containing the glue, and that the problem had persisted since the flooring was installed about a year prior. The issue was further corroborated by a resident who reported that the sticky floors caused debris to stick to his wheelchair and hands as he propelled himself. A review of the facility's correspondence with the flooring contractor documented multiple unsuccessful attempts to address the adhesive problem, including cleaning, buffing, and re-gluing the floors. The contractor acknowledged that the glue provided by the manufacturer was faulty and that the issue had not been resolved despite repeated interventions. The Administrator confirmed awareness of the problem and ongoing coordination with the contractor to find a solution. The deficiency was identified through observations, interviews, and record reviews, and was found to affect the cleanliness and safety of the facility's environment.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Document Physician Discharge Order and Summary
Penalty
Summary
The facility failed to properly document the discharge of a resident, as required by policy and regulatory standards. Specifically, there was no physician's order for the resident's discharge, nor was there a completed discharge summary by either the physician or nursing staff. The resident, who had diagnoses including autistic disorder, trisomy 21-mosaicism, and type 2 diabetes with hyperglycemia, was discharged with only a brief progress note indicating the resident left in good spirits via gurney with EMT and that all belongings were taken. However, the electronic medical record lacked both the required discharge order and summary. Interviews with facility staff, including the ADON and MDS Nurse, confirmed that the necessary documentation for the discharge was not completed. The ADON acknowledged awareness of the requirements for a physician's discharge order and a discharge summary, but these were not present in the resident's record. Review of facility policy indicated that a discharge summary should be provided to the receiving care provider, including an overview of the resident's stay and a final summary of their status at discharge, but this was not done in this case.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide required notification to the Office of the State Long-Term Care Ombudsman regarding the discharge of a resident. Record review showed that the resident, who had diagnoses including autistic disorder, trisomy 21-mosaicism, and type 2 diabetes with hyperglycemia, was cognitively intact and had requested alternate nursing facility placement. The resident was discharged to another nursing facility, but the Ombudsman did not receive written notification of this discharge. Interviews with facility staff revealed that the social worker, who was responsible for sending discharge notifications to the Ombudsman, was unaware of the notification requirement at the time of the resident's discharge. The administrator confirmed that the Ombudsman had not been notified, and acknowledged the importance of this notification for proper discharge procedures. Facility policy required that discharge summaries be available for release to authorized persons and agencies, with the resident's consent, but this process was not followed in this instance.
Failure to Schedule Timely Medical Follow-Ups
Penalty
Summary
The facility failed to ensure that two residents received timely follow-up medical care as recommended by their healthcare providers, leading to significant health complications. Resident #22, a male with a history of esophageal obstruction and other related conditions, was discharged with instructions to have an esophageal stent removed within 4-6 weeks. However, the facility did not schedule the follow-up appointment until 10 weeks later, by which time the stent had migrated into the stomach, necessitating an unplanned removal procedure that caused traumatic dilation of the esophagus. Similarly, Resident #5, a female with a history of hypertension, atrial fibrillation, and myocardial infarction, was discharged with instructions to follow up with a cardiologist within 1-2 weeks. The facility failed to schedule this appointment, and the resident did not see a cardiologist until a hospitalization several months later for heart health issues. The delay in follow-up care was attributed to a failure in the facility's process for managing medical appointments, as the necessary paperwork was not uploaded correctly, and the appointment was not rescheduled after being canceled. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed a lack of clarity and responsibility in scheduling follow-up appointments. The DON acknowledged that the facility should have intervened to ensure timely appointments and that the nursing staff should have been responsible for making these appointments. The failure to adhere to professional standards of practice in scheduling necessary medical follow-ups placed residents at risk for delayed treatment and diminished quality of care.
Removal Plan
- Resident #22 was assessed by licensed nurse, no adverse reactions noted.
- Resident #5 was assessed by licensed nurse, no adverse reactions noted.
- Licensed nurses physically present were educated in person regarding the community process for scheduling consults and medical appointments. Training conducted by DON and/or ADON.
- Licensed nursing staff not physically present, to include those that are PRN and on leave, were contacted by the Administrator, ADON and/or DON via phone and provided education regarding the communities process on scheduling consults and medical appointments.
- All licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities.
- Licensed nurse, ADON and/or DON will review documentation from the hospital to confirm appointments are scheduled in the timeframe requested for new residents.
- Upon return from appointments, Licensed nurse, ADON and/or DON will review documentation from resident appointments to confirm appointments are scheduled in the timeframe requested if follow up is documented for current residents.
- Once documentation is reviewed, the Licensed Nurse, ADON or DON will enter an order into Point Click Care that will include the appointment details per the documentation received from the hospital and/or the appointment.
- DON and/or ADON will review orders the following business day and ensure that appointments are made per the recommendations of the physician.
- DON, ADON or Licensed Nurse will enter progress note after appointment is confirmed to ensure staff have the details for the appointment.
- If doctor/clinic is unable to coordinate in the specified timeframe, DON, ADON or Licensed Nurse will work with the resident/family and physician to locate a different provider that can accommodate their needs if physician deems necessary.
- If an appointment is made outside of the timeframe requested by the physician, the DON, ADON or Licensed Nurse will enter a progress note explaining the reason for the delay and confirm attending physician.
- The DON, ADON, MDS Coordinator or other designee will review re-admission paperwork as a secondary review from admitting nurse to ensure that residents care is followed up.
- When the community is notified of a cancelled appointment, they will follow the process and enter a new order into PCC, stating that appointment was cancelled and needs to be rescheduled.
- Appointments will be maintained in a calendar book to be located at nurses' station for appointment tracking.
- DON, ADON or other designee will be responsible for ensuring calendar is up to date and will be reviewed no less than three times a week.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- The Administrator will complete an audit no less than one time per month and a report of findings will be reported to the facility's QAPI committee no less than one time per month for six months.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Several deficiencies were noted, including improper storage of food items in the dry storage room, where cases of cookies, shortening, and coffee filters were found on the floor. This was contrary to the facility's policy, which requires items to be stored at least six inches above the floor to prevent contamination. Interviews with staff revealed that the items were not on the floor when the dietary manager last checked, indicating a lapse in maintaining proper storage practices. In the reach-in cooler, disposable condiment cups of salsa and butter were found uncovered, lacking lids or plastic wrap. This oversight could lead to potential cross-contamination, as confirmed by the dietary manager during an interview. Additionally, in the walk-in cooler, several food items, including a pan of cake, a bag of sliced turkey breast, a container of whipped topping, and a bag of boiled eggs, were not covered or labeled with a use-by date. The facility's policy mandates that all refrigerated foods be tightly sealed and labeled to ensure freshness and prevent contamination. Further inspection of the walk-in freezer revealed two bags of food, identified as biscuits and chocolate chip cookies, that were not properly sealed or labeled. The facility's policy requires that all frozen foods be stored in moisture-proof wrap or containers with appropriate labeling. The dietary manager acknowledged that the responsibility for labeling and sealing these items lay with the dietary aide or cook who returned them to the freezer. These lapses in food storage and labeling practices could place residents at risk for foodborne illnesses.
Failure to Offer Influenza Vaccination and Education
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure that residents or their representatives received education regarding the benefits and potential side effects of the influenza immunization. This deficiency was identified for three residents who were reviewed for the influenza vaccine offering. The facility did not provide the necessary education to these residents, which is a critical step before offering the vaccine. The report highlights that the facility did not offer the influenza immunization to the three residents during the designated period from October 1 through March 31. This oversight was confirmed through interviews and record reviews, which showed that the residents' immunization records lacked documentation of the vaccine being offered or declined. Additionally, the facility's policy, which mandates offering the influenza vaccine annually, was not followed for these residents. The residents involved had various medical conditions, including dementia, chronic kidney disease, and type II diabetes, which could increase their vulnerability to influenza. Despite the facility's policy to minimize the risk of influenza by offering annual immunizations, the failure to adhere to this policy placed the residents at potential risk of exposure to the influenza virus.
Failure to Support Resident's Transportation Needs for Non-Medical Appointments
Penalty
Summary
The facility failed to support and accommodate a resident's needs and choices regarding transportation for non-medical appointments, which led to a deficiency in honoring the resident's right to self-determination. The resident, who has diagnoses including blindness and glaucoma, requested assistance with transportation to explore benefits related to his condition. Despite having intact cognition and being dependent on staff for various needs, the facility did not arrange transportation for the resident's non-medical appointments, which were necessary for exploring potential benefits and improving his quality of life. Interviews with facility staff revealed that transportation arrangements were only made for medical or health-related appointments, and the facility's transportation van was not in use due to registration issues. The resident missed several appointments with an organization that could assist with benefits due to the facility's refusal to arrange transportation. Staff members expressed concerns about the lack of support for the resident's transportation needs, noting that the appointments were important for the resident's health and quality of life. The facility's actions were inconsistent with the resident's rights as outlined in the admission agreement, which emphasized the importance of supporting residents in exercising their rights and achieving the highest possible level of health.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without discrimination or reprisal, as evidenced by the case of Resident #16. Resident #16, a female with diagnoses including Chronic Obstructive Pulmonary Disease, anxiety, and mood disorder, expressed concerns about not receiving information regarding an oncology appointment ordered by her physician. Despite her attempts to communicate this issue to various staff members, including LVN A and MA O, no grievance report was initiated on her behalf. On two separate occasions, Resident #16 communicated her grievance to staff members. On the first occasion, she informed LVN A during the night shift about her concern regarding the lack of information on her oncology appointment. LVN A did not generate a grievance report, believing the resident's expression was a concern rather than a complaint. On the second occasion, Resident #16 expressed her grievance to MA O, who then reported it to the ADON. However, the ADON stated that MA O did not report it as a complaint, and thus no grievance report was generated. The facility's grievance policy requires staff to report grievances on a designated form and forward it to a grievance official. However, in this case, the staff failed to adhere to this policy, resulting in Resident #16's grievance not being documented or addressed. This failure could potentially lead to unresolved issues and feelings of not being heard among residents.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring the side effects and behaviors associated with the resident's prescribed medications. The resident, who was cognitively intact, was taking olanzapine for schizoaffective disorder, busPIRone for anxiety disorder, and sertraline for depression related to schizoaffective disorder. Despite the comprehensive care plan requiring monitoring of side effects and behaviors every shift, the medication administration record lacked sections for such monitoring. Interviews with the resident, an LVN, and the DON confirmed that there were no observed side effects or adverse behaviors related to the medications. However, the facility's failure to monitor these aspects as per the care plan and facility policy placed the resident at risk of side effects and adverse reactions. The facility's policy on the use of psychotropic medications emphasized ongoing evaluation of the effects on a resident's well-being, which was not adhered to in this case.
Incomplete Documentation of Narcotic Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the administration of hydrocodone-acetaminophen. The Licensed Vocational Nurse (LVN) administered the medication on several occasions as ordered and documented these administrations on the narcotic counting sheet. However, the LVN did not document these administrations on the resident's medication administration record, which is a requirement according to professional standards and the facility's policy. This oversight was attributed to the LVN's inexperience and workload, as she had been working as a floor nurse for only three weeks and was very busy during the dates in question. The resident involved had a history of type 2 diabetes mellitus, atherosclerotic heart disease, hypertension, pain in the left arm, and anxiety disorder. The resident was cognitively intact, as indicated by a recent assessment. The failure to document the administration of the narcotic medication on the medication administration record posed a risk of incorrect medication administration due to incomplete and inaccurate medical records. The facility's Director of Nursing confirmed the documentation failure and noted the potential harm of incorrect dosing due to this inaccuracy.
Inaccurate MDS Assessment of Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident, leading to a deficiency. Specifically, a resident's quarterly MDS assessment indicated no physical behavioral symptoms directed toward others, despite a nursing note documenting an incident where the resident hit another resident. The MDS assessment, dated 05/08/2024, inaccurately coded the resident's behavior as not exhibited, even though there was a documented incident of aggression on 05/03/2024. This discrepancy was acknowledged by the social worker responsible for coding the MDS, who admitted to mistakenly coding the behavior as not exhibited, believing the incident to be isolated. The resident involved had a history of end-stage renal disease, type 2 diabetes mellitus, schizoaffective disorder, and anxiety disorder. The resident was cognitively intact, as indicated by a BIMS score of 13/15. The MDS nurse confirmed that the assessment was inaccurate and expressed concern that such inaccuracies could lead to the facility missing patterns of aggressive behavior, potentially resulting in inadequate care. The facility's policy and the CMS MDS 3.0 Manual require accurate and standardized assessments, which were not adhered to in this case.
Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by their policy. During an observation, it was noted that the narcotic box inside the medication room's refrigerator was not permanently affixed to the compartment. This box contained a bottle of Lorazepam 2mg/ml prescribed to a resident. The Director of Nursing (DON) confirmed that the narcotic box was not secured as per the facility's policy, which mandates that Schedule II controlled medications be stored within a separately locked, permanently affixed compartment when other medications are stored in the same area. The resident involved had been admitted with diagnoses including Alzheimer's disease, muscle wasting and atrophy, and anorexia. The resident had a physician's order for Lorazepam Oral Concentrate 2 mg/ml to be administered as needed for anxiety, agitation, or restlessness. The failure to secure the narcotic box could potentially result in the resident not receiving their medication as prescribed, due to the risk of the medication being removed from the refrigerator.
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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