The Oaks At Radford Hills Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Abilene, Texas.
- Location
- 725 Medical Dr, Abilene, Texas 79601
- CMS Provider Number
- 675330
- Inspections on file
- 49
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Oaks At Radford Hills Healthcare Center during CMS and state inspections, most recent first.
Three medication carts containing prescription and OTC drugs were found unlocked and unattended, with residents and staff nearby. RNs responsible for the carts admitted to leaving them unlocked or not maintaining visual contact, contrary to facility policy requiring all medication storage to be locked and accessible only to authorized personnel. Facility leadership confirmed the expectation for carts to be locked at all times when not in use.
Three residents with cognitive impairment and incontinence were not provided with timely assistance for hygiene needs, including brief changes and scheduled showers. Staff failed to respond to direct requests and call lights, and documentation showed that showers were consistently missed. Residents and their families reported these concerns to management, but no improvements were made. Staff interviews and resident council minutes confirmed ongoing issues with short staffing, lack of nurse participation in care, and inadequate documentation of hygiene services.
The facility did not provide enough nursing staff to meet resident needs, resulting in multiple residents missing scheduled showers and experiencing delays in assistance with hygiene and call lights. Staff and resident interviews, as well as documentation, confirmed that short staffing led to inadequate care, with residents often left in soiled briefs and reporting infrequent showers. Facility records and council meeting minutes further supported ongoing concerns about insufficient staffing and unmet care needs.
Two residents were found in possession of and attempting to use methamphetamine within the facility. Staff confiscated the drugs and notified police, but did not report the incident to the state agency as required by policy. Interviews revealed that facility leadership did not consider the event reportable since they believed no drugs were ingested and no harm occurred.
Two residents with behavioral health and substance use histories were involved in incidents where they attempted to smoke methamphetamine in the facility. Despite documentation of these events by nursing staff and notification of facility leadership, their care plans were not updated to address substance abuse or include new interventions, in violation of facility policy requiring comprehensive, measurable care planning.
A medication cart was found unlocked and unattended in a facility, with residents and visitors nearby. LVN A, responsible for the cart, admitted to leaving it unsecured while assisting with resident care. The facility's policy requires carts to be locked at all times when not in use to prevent unauthorized access.
A resident with severe cognitive impairment left the facility unnoticed despite an alarm sounding. Staff failed to perform a head count or respond adequately, assuming another resident triggered the alarm. The resident was found wandering outside by the public, highlighting a lack of training and communication regarding elopement procedures.
A resident with severe cognitive impairment and a wander guard left the facility unnoticed, despite an alarm sounding. Staff failed to perform a head count or follow emergency procedures, resulting in the resident being found by the public over two hours later. Interviews revealed staff were untrained in door codes and alarm response, contributing to the neglect.
A facility failed to provide adequate supervision for two residents, leading to one resident with severe cognitive impairment eloping and being found outside in the rain. The staff did not promptly respond to the alarm, and a headcount was not conducted immediately. Additionally, another resident was found with smoking materials not properly stored, posing a risk of accidents.
The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents. The DON worked the floor on several occasions due to staffing shortages, which prevented her from performing her administrative duties. Both the DON and the ADMN were unaware of the regulation prohibiting the DON from working as a charge nurse. The facility's policy for RN/DON coverage was requested but not provided.
The facility failed to resolve grievances for 12 residents, as concerns raised in Resident Council meetings were not addressed or communicated back. Issues included delayed call light responses and insufficient staff. Staff interviews revealed a lack of clarity in the grievance process, contributing to unresolved grievances.
The facility failed to develop comprehensive care plans for four residents, leading to deficiencies in addressing specific medical needs such as nebulized breathing treatments, oxygen therapy, trach care, and sleeping preferences. Observations and interviews revealed improper equipment management and a lack of staff awareness regarding care plans, resulting in potential risks to resident care.
The facility failed to provide adequate resident care due to a shortage of wipes, with supplies being locked in the DON's office and staff having to request them. This led to the use of paper towels for care, contrary to the facility's policy. Residents and staff reported issues with wipe availability, and the DON admitted to ordering failures, impacting care quality.
The facility failed to provide sufficient nursing staff, resulting in unmet care needs for residents, including missed bathing schedules and delayed call light responses. Staffing records showed consistent shortfalls, and resident council meetings documented numerous complaints. Additionally, a resident with severe cognitive impairment exited the facility unsupervised, requiring police intervention. Interviews revealed systemic staffing management issues.
A facility failed to ensure a licensed pharmacist conducted a monthly drug regimen review for a resident on anti-psychotic medication. The resident, with schizoaffective disorder and dementia, was prescribed Abilify, but there was no documentation of a medication review since the last survey. Despite a request for a gradual dose reduction, there was no evidence of pharmacy recommendations or physician review. Interviews revealed missing documentation and lack of notification to the medical director about the GDR recommendation.
The facility did not follow the posted menus for two consecutive meals, serving different meals without informing residents. The Dietary Manager changed the menu due to a few residents' requests but did not communicate this to all residents. A group of residents expressed dissatisfaction with the inconsistency, and the Administrator was unaware of the changes, acknowledging potential disruptions to meal planning.
The facility failed to label and date food items in the freezer and did not ensure proper hand hygiene among dietary staff during meal preparation. An employee was observed handling trash and preparing food without washing hands or changing gloves, contrary to facility policy. The Dietary Manager acknowledged these lapses, which could lead to serving expired food and cross-contamination.
Three CNAs failed to follow proper infection control practices during peri-care for two residents, including improper wiping techniques and inadequate hand hygiene. The CNAs did not wash hands or change gloves appropriately, risking cross-contamination. The DON acknowledged the lack of training and monitoring as contributing factors.
The facility failed to provide effective communication training for four staff members, including the DON and a CNA during orientation, and an RN and LVN annually. Interviews revealed systemic issues in monitoring training due to recent leadership changes, with HR and corporate HR responsible for ensuring training completion.
The facility failed to ensure that RN I and LVN F received the required annual training on resident rights, as evidenced by missing documentation in their files. Interviews revealed a lack of accountability and clarity regarding training responsibilities, with department heads and HR cited as responsible parties. Leadership changes were mentioned as a contributing factor to the oversight.
The facility failed to ensure that two employees, an RN and an LVN, received required annual training on abuse, neglect, exploitation, and dementia management. This oversight was attributed to recent leadership changes and inadequate monitoring of staff training responsibilities. The ADMN acknowledged the expectation for staff to receive necessary training but noted no significant negative effects on residents due to the deficiency.
The facility failed to ensure required infection prevention and control training for four employees, including the DON and a CNA during orientation, and an RN and LVN annually. Interviews revealed systemic issues in the training process, with staff placed on the floor without completing necessary training. Leadership changes were cited as a contributing factor to the oversight.
The facility failed to provide required compliance and ethics training to four staff members, including the DON and a CNA during orientation, and an RN and LVN annually. Interviews revealed systemic issues in the training process, with the CHRL and ADMN acknowledging oversight and recent leadership changes as contributing factors.
A resident with severe cognitive impairment was transferred to another facility without prior written notice to her guardian or the State Long-Term Care Ombudsman. The transfer was due to the resident being an elopement risk, but the guardian was not informed until days later. Facility staff interviews revealed a lack of communication and responsibility regarding the notification process.
A facility failed to transmit a resident's discharge MDS assessment to CMS within the required timeframe. The resident, with a history of chronic obstructive pulmonary disease and colon cancer, was discharged to another facility. The MDS Coordinator and Regional MDS Coordinator were unaware of the cause of the delay, and the DON was not informed of the issue. The facility's policy mandates timely transmission of MDS assessments, but this was not adhered to in this case.
A resident with severe cognitive impairment and on hospice care was inaccurately documented as having eaten 75-100% of her dinner, despite only consuming 1-2 bites. The CNA responsible admitted to the error, highlighting the importance of accurate documentation, especially for residents with specific dietary needs. Interviews with facility staff emphasized the expectation for accurate and timely documentation.
A resident's legal guardian was not informed of the resident's hospital transfer due to altered mental status, resulting in the resident lacking an advocate for decision-making at the hospital. The facility's staff acknowledged the failure, citing communication gaps, particularly with agency staff, as the cause. The facility's policy mandates prompt notification of changes in a resident's condition, which was not followed in this instance.
Two residents in a LTC facility were found to be living in unsanitary conditions due to the facility's failure to maintain a clean and homelike environment. One resident, who is legally blind, had a room with stained tiles, a wet floor, and a dirty oxygen machine. Another resident's bathroom had broken tiles and a loose toilet base. Staff interviews revealed issues with communication and maintenance, leading to persistent uncleanliness and disrepair.
A facility failed to notify the Ombudsman of a resident's discharge, as required by policy. The resident, with multiple health conditions, was discharged home against medical advice. The social worker, unaware of her responsibility, did not send the necessary notice, which had not been sent since March. This oversight could limit residents' access to advocacy services.
The facility failed to develop a comprehensive care plan for a resident with moderate cognitive impairment who frequently went out on pass for personal needs. Despite the resident leaving the facility 17 times, there was no care plan in place to address his outings, which could place residents at risk of not receiving the care required to meet their individualized needs.
The facility failed to obtain a physician's order for a resident to go out on pass daily, despite the resident leaving the facility 17 times. The resident had moderate cognitive impairment and diagnoses including respiratory failure and unsteadiness on feet. The physician was not informed, and the facility's policy was not followed, potentially putting the resident at risk.
A deficiency was identified in a facility where three high-risk residents experienced falls due to inadequate supervision and lack of appropriate interventions. One male resident with heart disease and COPD fell five times within 19 hours, resulting in hospitalization and death from a subarachnoid hemorrhage and lumbar spine fracture. Despite being a high fall risk, he lacked necessary interventions like 1:1 supervision. Another female resident with a history of falls and muscle weakness also did not have adequate fall prevention measures in her care plan. A third female resident with hemiplegia and muscle weakness experienced a fall due to insufficient supervision. The facility's failure to update care plans with fall risk assessments and implement tailored interventions contributed to these incidents.
The facility failed to develop baseline care plans within 48 hours of admission for two residents, leading to a lack of continuity of care. Interviews revealed confusion and miscommunication regarding responsibility for initiating these plans, contrary to the facility's policy.
The facility failed to develop comprehensive care plans for two residents with high fall risks, leading to deficiencies in addressing their needs. Miscommunication among staff regarding care plan responsibilities resulted in the omission of fall risk interventions, despite documented falls and high fall risk scores.
Medication Carts Found Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys for medication carts. During observations, three out of four medication carts were found unlocked and unattended, with residents and staff in close proximity. Specifically, medication carts #1 and #2 were observed unlocked in the early morning with medication drawers facing outward, containing various prescription and over-the-counter medications. The responsible RN admitted to intentionally leaving the carts unlocked in anticipation of the day shift. Later, medication cart #3 was also found unlocked and unattended, with the responsible RN stating she believed she had visual contact with the cart, but her back was turned at the time of observation. She was unaware of the specific medications or the residents for whom they were intended. Interviews with facility leadership, including the administrator and assistant director of nursing, confirmed that all medication carts should have been locked when not in use and that only authorized personnel should have access. Both leaders acknowledged that the failure was due to staff being too busy or inattentive to proper medication storage protocols. Facility policy reviewed indicated that medications must be stored securely and only accessible to licensed or authorized personnel, with medication carts locked when not attended.
Failure to Provide Timely Hygiene Care and Dignity to Residents
Penalty
Summary
The facility failed to treat three residents with dignity and respect by not providing timely assistance with hygiene needs, including brief changes and scheduled showers. One resident, who had severe cognitive impairment and was frequently incontinent, was not assisted with a brief change after directly requesting help from nursing staff at the nurses' station. The resident's family member arrived at the facility to find the call light still on and the resident still soiled, with nurses present at the station but not responding. Documentation showed that this resident did not receive showers on any of his preferred days throughout the month, and the care plan specifically required keeping the resident clean and dry to minimize skin exposure to moisture. Two additional residents, both with moderate cognitive impairment and requiring assistance with hygiene, also did not receive showers on their preferred days for the entire month. Both reported only receiving showers infrequently, with staff citing short staffing as the reason. Observations confirmed foul odors coming from these residents and their rooms, and both residents expressed embarrassment and frustration over their hygiene and the lack of response to their needs. Both had reported their concerns to management, but no changes were made. Interviews with staff confirmed ongoing issues with short staffing, lack of nurse participation in direct care, and failure to answer call lights in a timely manner. The ADON acknowledged that there was no effective system for tracking or documenting showers, and that nurses were not thorough in documenting refusals. Resident council meeting minutes further corroborated these issues, with multiple residents voicing concerns about not receiving showers and call lights not being answered. Observations during the survey also noted multiple call lights ringing with nurses present at the station but not responding.
Insufficient Nursing Staff Resulting in Missed Care and Delayed Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by direct care staff hours falling below the required levels on multiple days. On specific dates, the number of direct care staff hours worked was significantly less than what was needed based on the facility's PPD budget and resident census. This shortfall resulted in inadequate care for residents, particularly in areas such as hygiene and timely response to call lights. Multiple residents with significant care needs, including severe cognitive impairment, incontinence, and mobility limitations, did not receive scheduled showers or timely assistance with hygiene. Documentation showed that several residents missed their preferred shower days repeatedly throughout the month, and interviews with residents and their families confirmed that showers were often skipped due to short staffing. Residents reported having to wait extended periods for assistance with soiled briefs, and some were observed to be in dirty briefs or in rooms with foul odors. Family members and residents consistently stated that staff cited short staffing as the reason for missed care. Staff interviews corroborated these findings, with CNAs reporting that it was nearly impossible to complete all required tasks, including showers and answering call lights, due to insufficient staffing levels. The ADON acknowledged that three CNAs were not enough to meet resident needs, especially during mealtimes. Resident Council meeting minutes further documented ongoing concerns about inadequate staffing, missed showers, and delayed call light responses. The facility's own assessment tool indicated that staffing assignments were based on acuity and needs, but actual staffing did not meet these requirements on the reviewed days.
Failure to Report Drug-Related Incident Involving Residents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately or within the required timeframe to the administrator and appropriate authorities. Specifically, two residents were found in possession of illegal drugs (methamphetamine) and were attempting to smoke them inside the facility. The incident was not reported to the state agency as required by both state policy and the facility's own procedures. One resident, with a history of bipolar disorder, stimulant use, and nicotine dependency, was admitted to the facility and had previously asked other residents if they had connections to obtain methamphetamine. This behavior was reported internally to the DON, ADON, and Administrator. On the day of the incident, the resident left the facility, returned, and was found with another resident in a room with smoke and drug paraphernalia. The DON and Administrator confiscated the drugs and notified the police, but no report was made to the state agency. The second resident, with a history of liver cancer and bipolar disorder, was also involved in the incident and admitted to being offered methamphetamine by the first resident. Interviews with facility staff, including the Administrator and DON, revealed that they did not consider the incident reportable because they believed the drugs were not ingested and no harm occurred. There was no investigation conducted beyond confiscating the drugs and notifying the police. The facility's policy and state guidelines require reporting of such incidents, especially those that pose a threat to resident health and safety, but this was not followed in this case.
Failure to Update Care Plans After Drug Use Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents following incidents involving illegal drug use. Both residents had documented histories of behavioral health issues, including bipolar disorder and stimulant use, and were found in possession of and attempting to smoke methamphetamine within the facility. Despite these incidents, their care plans were not updated to reflect substance abuse or drug-seeking behaviors, nor were new interventions or measurable objectives added to address these new risks. For the first resident, records showed that after admission, the baseline care plan only addressed general behavioral needs and adjustment to the facility, with no mention of substance abuse. Progress notes documented that the resident sought methamphetamine from others and was later found with a suspicious substance and paraphernalia in another resident's room. The incident was reported to facility leadership and law enforcement, but the comprehensive care plan remained incomplete and did not address the substance abuse incident. The second resident, who also had a history of behavioral symptoms and nicotine dependency, was found in a similar situation with the first resident, attempting to smoke methamphetamine. The care plan for this resident focused on previous behavioral issues such as leaving the facility without signing out and not following the smoking policy, but did not include any interventions or objectives related to substance abuse following the incident. Facility policy required care plans to be updated with measurable objectives and timeframes after such events, but this was not done for either resident.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in permanently affixed compartments, as observed during a medication storage inspection. Specifically, medication cart #2 was found unlocked and unattended, with residents and visitors in close proximity. During an interview, the ADMN acknowledged the cart should have been locked at all times when not in use. LVN A, who was responsible for the cart, admitted to leaving it unlocked while assisting a CNA with resident care, forgetting to secure it. This oversight could have allowed unauthorized access to medications. The DON and ADON both emphasized the importance of keeping medication carts locked to prevent unauthorized access, which could lead to medication errors or drug diversion. The facility's policy on the security of medication carts mandates that they be locked during medication passes and when not in use. The policy also specifies that carts should be parked in a way that minimizes unauthorized access. Despite these protocols, the failure to lock the cart was attributed to a lapse in adherence to the policy, possibly due to hurriedness or lack of attention to detail.
Neglect Due to Inadequate Response to Elopement Alarm
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #54, was free from neglect, as evidenced by an incident where the resident left the building unnoticed by staff. Despite the wander guard alarm sounding at the exit door, staff did not take immediate action to prevent the resident's elopement. The resident, who had severe cognitive impairment and required supervision, exited the facility and was later found wandering outside by members of the public. The incident occurred when the resident pushed on the emergency exit door, triggering the alarm. However, staff, including CNA A, did not perform a head count or adequately respond to the alarm. CNA A assumed another resident had set off the alarm and did not verify the whereabouts of all residents. Additionally, two nurses at the nursing station did not respond to the alarm due to a lack of knowledge of the door codes. Interviews revealed that the facility's staff were desensitized to the alarm due to frequent false alarms caused by another resident. The facility's policies and procedures for handling such situations were not effectively communicated to agency staff, and there was a lack of training on door codes and elopement procedures. This oversight led to a delay in realizing the resident was missing, and the resident was exposed to potential harm while outside the facility.
Neglect in Monitoring Leads to Resident Elopement
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent neglect, resulting in a resident with severe cognitive impairment leaving the building unnoticed. The resident, who was wearing a wander guard, exited through a 15-second emergency exit door, triggering an alarm that went unaddressed by staff for several minutes. Despite the alarm sounding, staff did not perform a head count or follow the emergency procedure for a missing resident, allowing the resident to remain outside the facility for over two hours. The resident was eventually found by members of the public, who noticed her wandering in a nearby apartment complex. The resident was cold, shivering, and appeared confused. The public identified the resident's wander guard and contacted the facility, prompting the Assistant Director of Nursing (ADON) to retrieve the resident. Upon return, the resident was assessed and found to have no injuries, but the facility's failure to monitor and supervise residents with known elopement risks was evident. Interviews with staff revealed a lack of knowledge and training regarding door codes and procedures for responding to door alarms. Agency nurses and other staff members were unaware of the necessary actions to take when an alarm sounded, leading to a delay in response and failure to ensure resident safety. The facility's neglect in addressing the alarm and conducting a timely head count contributed to the resident's unsupervised absence and potential risk of harm.
Inadequate Supervision and Response to Elopement and Smoking Risks
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for two residents. One resident, who had a history of exit-seeking behaviors and severe cognitive impairment, managed to elope from the facility. The resident exited through a 15-second emergency exit door, which sounded an alarm. However, the alarm was not promptly addressed by the staff, leading to the resident being found wandering outside in the rain and cold by a member of the public. The resident was eventually returned to the facility without injuries but was exposed to potential harm due to the lack of immediate response from the staff. The staff's inaction was evident as the alarm was ignored for an extended period, and a headcount was not conducted immediately after the alarm was deactivated. The CNA who responded to the alarm did not perform a headcount, assuming another resident had set off the alarm. Additionally, two nurses at the nurse's station did not respond to the alarm because they were unaware of the door codes. This lack of knowledge and response contributed to the resident's prolonged absence from the facility. Another deficiency was noted regarding the improper storage of smoking materials for a resident listed as a smoker. The resident was observed with a lighter and cigarette in his possession, which was not provided by the supervising staff. This oversight posed a risk of accidents related to smoking materials, highlighting the facility's failure to ensure the safe storage and supervision of such items.
Removal Plan
- Resident #54 returned to the nursing home. Resident was assessed with no injuries. Resident behaving per norm. Increased supervision implemented with Resident #54 which included resident in line of sight of an employee at all times until discharge. Elopement assessment updated. RP & MD informed.
- Resident head count performed no additional findings.
- All residents received an elopement assessment. Residents' current elopement assessment will reflect on their face sheet and care plan.
- Elopement binder reviewed to ensure it matches the current residents who were deemed as elopement risks per their elopement assessments.
- Sign on door verified for placement notifying visitors to, Please do not allow residents to follow you out.
- Sign posted by keypads stating: When alarms were sounding, and the door was disengaged perform a resident head count.
- All doors checked for functionality. No concerns noted.
- Check for all residents with roam alerts for functionality. No concerns noted.
- Elopement drill performed each shift.
- Education provided to direct care staff, to include agency staff, regarding missing resident/elopement & over the facility's abuse & neglect policy. Direct care staff will be educated on the elopement binder, its location, and its contents (shows which residents were elopement risks/wander guard residents). Direct care staff, including agency staff, will know when the door was alarming, to respond to the alarming door immediately. If the door was disengaged (open) and alarming the direct care staff will ensure all residents were in house by performing a head count (signs placed for reminders for staff to ensure all residents were in house when alarms were sounding, and the door was disengaged by keypads). Direct care staff, including agency staff, will know the door codes/door code location through this education. Direct care employees will be educated prior to working their next shift. All new and temporary direct care staff will be educated prior to working.
- Residents deemed an elopement risk, that require a roam alert/wander guard will be rounded on every 2 hours to ensure facility was aware of residents' whereabouts.
- All residents with exit seeking behaviors will be reviewed during clinical meeting to ensure safety. Appropriate supervision will occur until residents with exit seeking behaviors, that have a greater need than the roam alert system, were appropriately placed. No concerns noted.
- Elopement drill performed weekly to ensure staff's retention of education to prevent recurrence.
- Ad hoc QAPI performed with medical director to inform them of the incident and the facility's plan to remove the immediacy. No further direction required.
DON Serving as Charge Nurse Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on specific dates. This failure was identified during an interview with the DON, who admitted to working the floor on six occasions due to staffing shortages. The DON stated that she was unaware of the regulation prohibiting her from working as a charge nurse and mentioned that corporate had instructed her to ensure floor coverage, even if it required her to work the floor. The DON also noted that working the floor prevented her from performing her administrative duties effectively. The Administrator (ADMN) confirmed that the DON frequently worked as a charge nurse due to staffing shortages and was also unaware of the regulation. The facility's policy for RN/DON coverage was requested but not provided. This lack of administrative oversight left residents without the necessary nursing administrative oversight that only the DON could provide, as the DON was occupied with charge nurse duties.
Failure to Resolve and Communicate Grievances
Penalty
Summary
The facility failed to promptly resolve grievances for 12 of 12 confidential residents reviewed for grievances. The residents reported that they were aware of how to file a grievance, but the concerns voiced during Resident Council meetings were not addressed, and resolutions were not communicated back to them. This lack of communication led to feelings of frustration among the residents, with one resident expressing that they no longer attended meetings because they felt it was ineffective. Record reviews of Resident Council meeting minutes from August to November 2024 revealed multiple unresolved issues, including delayed response to call lights, insufficient staff at night, and dietary discrepancies. Despite these concerns being documented, there was no evidence in the grievance logs that these issues were formally addressed or resolved. Interviews with staff, including the Social Worker (SW), Director of Nursing (DON), and Activities Director (AD), revealed a lack of clarity and communication in the grievance process, contributing to the unresolved grievances. The facility's grievance policy required grievances to be recorded and resolved within three working days, with findings communicated to the resident or their representative. However, the SW and DON admitted to lapses in following up with residents and completing the grievance process. The Administrator (ADMN) acknowledged the need for a more effective grievance handling process and recognized that unresolved grievances could lead to resident frustration.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which resulted in deficiencies in addressing their specific medical needs. Resident #6, a female with severe cognitive impairment, had a care plan that included continuous oxygen use but lacked any mention of nebulized breathing treatments, despite having a physician's order for such treatments. Observations revealed that her nebulizer was not stored properly, indicating a lack of adherence to care protocols. Resident #30, a male with moderate cognitive impairment, had a care plan that did not include oxygen therapy, even though there was a physician's order for continuous oxygen via nasal cannula. Observations showed that his oxygen equipment was not properly maintained, as the nasal cannula was found on the floor, and the nebulizer was not stored in a bag. This oversight in care planning and equipment management could lead to inadequate respiratory care. Resident #68, a female with a tracheostomy, did not have a comprehensive care plan addressing her trach maintenance and care needs until after the surveyors' entrance. Additionally, Resident #43, a female with no cognitive impairment, had a care plan that failed to document her preference to sleep in a recliner, which was a significant aspect of her care needs. Interviews with staff revealed a lack of communication and understanding of care plans, with some staff unaware of where to find them, leading to confusion about the care required for residents.
Deficiency in Resident Care Due to Wipe Shortage
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and residents' choices, as evidenced by the lack of availability of resident wipes. Observations revealed that cases of resident wipes were stored in the Director of Nursing's (DON) office, with supply closets on multiple halls lacking wipes. Interviews with staff, including CNAs and LVNs, confirmed that wipes were kept in the DON's office, and staff had to request them, often facing shortages during shifts. This practice led to the use of paper towels and toilet paper for resident care, which was not in line with the facility's policy for perineal care. Residents expressed dissatisfaction during a confidential meeting, with all 12 residents reviewed for quality of care reporting issues with the availability of wipes and briefs. Some residents had to personally request wipes from the DON or Assistant Director of Nursing (ADON). The DON acknowledged a shortage of wipes and admitted to not ordering them in time, resulting in insufficient supplies. The ADON noted that the lack of wipes could lead to skin breakdown and infection, emphasizing the importance of using wipes for resident care. The facility's admission agreement and perineal care policy highlighted the necessity of providing adequate supplies for resident care, which was not met in this instance.
Inadequate Staffing Leads to Unmet Resident Needs and Safety Concerns
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of inadequate care and unmet resident preferences. Resident #30, a female with severe cognitive impairment and mobility issues, did not receive her preferred bathing schedule on several occasions, with no documentation of refusals. Similarly, Resident #37, who requires extensive assistance, also missed her preferred bathing days, indicating a lack of adequate staffing to meet these basic care needs. The facility's staffing records revealed consistent shortfalls in direct care staff hours compared to the required hours based on the facility's assessment and census. This staffing inadequacy was corroborated by resident council meeting minutes, which documented numerous complaints about delayed call light responses, insufficient aides, and unmet care needs. Additionally, a confidential group meeting with residents highlighted prolonged wait times for call light responses, leading to incidents of incontinence and potential health issues like urinary tract infections. Further compounding the issue, Resident #54, who has severe cognitive impairment, was able to exit the facility unsupervised, resulting in a police intervention to return her. Interviews with staff and management revealed systemic issues in staffing management, with the Director of Nursing and Administrator acknowledging the challenges in maintaining adequate staffing levels. The facility's reliance on agency staff and the lack of a robust system to address staffing concerns contributed to the ongoing deficiencies in resident care.
Failure to Conduct Monthly Drug Regimen Review for Resident on Anti-Psychotic Medication
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for each resident, specifically for one resident who was on anti-psychotic medication. The deficiency was identified during a review of records and interviews, which revealed that there was no documentation of a medication regimen review for the resident's anti-psychotic medication since the last survey. This oversight could potentially place the resident at risk of not having their medications reviewed for appropriate dosing or pharmacy recommendations implemented. The resident in question was a female with a history of schizoaffective disorder, bipolar type, and dementia, who was prescribed Abilify (aripiprazole) 10mg to be taken at bedtime. Despite a request for a gradual dose reduction in March 2024, there was no evidence of pharmacy recommendations or physician review of these recommendations. Interviews with facility staff, including the ADON and DON, revealed that documentation prior to July 2024 was missing, and there was no proof that the medical director had been notified of the GDR recommendation. The facility's policy required the attending physician and psychiatric provider to lead medication management, including evaluating residents for gradual dose reductions unless clinically contraindicated.
Failure to Follow Posted Menus and Inform Residents
Penalty
Summary
The facility failed to adhere to the posted menus for two consecutive meals, which were observed on 11/18/24 and 11/19/24. On 11/18/24, the lunch menu intended for Monday was not served; instead, the menu planned for Tuesday was provided without informing the residents. Similarly, on 11/19/24, the supper menu was not followed, and residents were not notified of the substitution. These deviations from the planned menu were not communicated to the residents, which could potentially affect their nutritional intake. Interviews revealed that the Dietary Manager (DM) decided to switch the menu due to a few residents' requests to avoid pork, but this change was not communicated to all residents. A group of 12 residents expressed dissatisfaction with the inconsistency of the menu, stating that they often relied on the posted menu to make meal decisions. The Administrator (ADMN) was unaware of these changes and acknowledged that such deviations could disrupt meal planning and food ordering processes. The facility's policy emphasizes the importance of following a standardized menu to ensure nutritional adequacy, which was not adhered to in these instances.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and preparation, as observed during a survey. In the kitchen's freezer, several food items, including pork loins, bread, turkey pot roast, and tater tots, were found without labels or open dates, which is against the facility's policy. The Dietary Manager (DM) acknowledged that all food should be labeled with expiration and receipt dates to prevent serving expired food, which could lead to illness. Additionally, the facility did not ensure proper hand hygiene among dietary staff during meal preparation. An employee was observed exiting and re-entering the kitchen without washing her hands, handling trash, and preparing food without proper handwashing or changing gloves between tasks. The DM confirmed that the staff was expected to wash hands frequently and change gloves between tasks to prevent cross-contamination and infection spread. Despite recent in-service training on hand hygiene, these practices were not followed, posing a risk of foodborne illness to residents.
Inadequate Infection Control Practices During Peri-Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper peri-care and hand hygiene practices observed among three CNAs during care for two residents. CNA-B and CNA-C were observed performing peri-care on a male resident with severe cognitive impairment and a chronic ulcer, using improper techniques such as wiping from back to front and reusing wipes. Additionally, they did not perform hand hygiene between glove changes, increasing the risk of infection. In another instance, CNA-B and CNA-D provided peri-care for a female resident with moderate cognitive impairment and irritant contact dermatitis. They failed to wash their hands or use hand sanitizer throughout the procedure. CNA-D was also observed folding wipes multiple times and using them repeatedly before discarding, and she did not change her gloves before touching the resident's call light and bed control, further compromising infection control. Interviews with the CNAs revealed awareness of the correct procedures, but they cited reasons such as nervousness and insufficient glove supply for their lapses. The Director of Nursing acknowledged the deficiencies, attributing them to a lack of standard training procedures and monitoring, which could lead to cross-contamination and serious health risks for residents.
Failure to Ensure Effective Communication Training for Staff
Penalty
Summary
The facility failed to ensure that four out of sixteen employees received the required effective communication training. Specifically, the Director of Nursing (DON) and Certified Nursing Assistant (CNA B) did not complete this training during their orientation, while Registered Nurse (RN I) and Licensed Vocational Nurse (LVN F) did not complete it annually. This lack of training was identified through interviews and record reviews, which revealed no evidence of completed training in the employee files. CNA B confirmed during an interview that she had not undergone orientation or completed a checkoff list before starting work on the floor, as the DON allowed her to begin working immediately due to her prior experience as a CNA. Interviews with the facility's Compliance and Human Resources Leader (CHRL) and Administrator (ADMN) highlighted systemic issues in ensuring staff training. The CHRL acknowledged that the DON and CNA B had only recently completed their communication training, while RN I and LVN F had not completed their annual training. The CHRL attributed these failures to recent changes in the leadership team, which disrupted the routine monitoring of training. The ADMN expressed an expectation for staff to receive required training but noted that the responsibility for ensuring training completion lay with HR and corporate HR. The ADMN also mentioned that the impact of incomplete training on residents depended on the employees' prior experience, and he had not observed significant negative effects from the training lapses.
Failure to Ensure Annual Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure that two employees, RN I and LVN F, received the required annual training on resident rights. Record reviews of the employees' files showed no evidence that these staff members had completed the necessary training. RN I was hired on 9/27/2022, and LVN F was hired on 2/22/2023, yet neither had completed the mandatory training by the time of the survey. This oversight could potentially place residents at risk of receiving care from staff who are not adequately trained in resident rights. Interviews with facility staff revealed a lack of clarity and accountability regarding the responsibility for ensuring training compliance. The CHRL acknowledged that RN I and LVN F did not complete the training and mentioned that department heads are responsible for their staff's training, with the ADMN ultimately holding supervisors accountable. The ADMN expressed an expectation for staff to receive required training but noted that HR and corporate HR were responsible for monitoring training completion. Changes in the leadership team were cited as a factor contributing to the failure in training compliance.
Failure to Provide Required Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that two employees, RN I and LVN F, received the required annual training on abuse, neglect, exploitation, and misappropriation of resident property, as well as dementia management. This deficiency was identified through interviews and record reviews, which revealed that there was no evidence of these employees completing the necessary training. The CHRL acknowledged that the training was not completed and attributed the oversight to recent changes in the leadership team, which disrupted the routine monitoring of staff training. The responsibility for ensuring that staff received the required training was shared among department heads, HR, and ultimately the ADMN, who should hold supervisors accountable. During interviews, the ADMN expressed that the expectation was for all staff to receive the required annual and orientation training. However, he was unaware of why the training was not completed prior to his tenure at the facility. The ADMN indicated that HR was responsible for ensuring training completion, with corporate HR monitoring the process. Despite the lack of training, the ADMN had not observed significant negative effects on residents, suggesting that the impact might vary depending on the employees' prior experience. The facility's assessment tool and policy documents highlighted the importance of staff training and competencies, yet the failure to adhere to these requirements placed residents at risk.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure that four out of sixteen employees received the required infection prevention and control program training. Specifically, the Director of Nursing (DON) and a Certified Nursing Assistant (CNA B) did not complete the training during their orientation, while a Registered Nurse (RN I) and a Licensed Vocational Nurse (LVN F) did not complete the training annually as required. This lack of training was identified through interviews and record reviews, which revealed no evidence of completed training in the employee files. Interviews with staff highlighted systemic issues in the training process. CNA B reported that she was placed on the floor without completing orientation or a checkoff list, as the DON allowed her to work immediately due to her prior experience as a CNA. The Corporate Human Resources Leader (CHRL) acknowledged that the DON and CNA B eventually received training, but there was no documentation of when it occurred. The CHRL also noted that RN I and LVN F did not complete their annual training. The Administrator (ADMN) expressed that training completion was expected but was not aware of why it was not done before his tenure. The ADMN indicated that HR was responsible for ensuring training completion, with corporate HR monitoring the process. The facility's assessment tool outlined the necessity of staff training and competencies, but recent leadership changes were cited as a factor contributing to the oversight in training compliance.
Failure to Ensure Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that four out of sixteen employees received the required compliance and ethics training. Specifically, the Director of Nursing (DON) and a Certified Nursing Assistant (CNA B) did not complete this training during their orientation, while a Registered Nurse (RN I) and a Licensed Vocational Nurse (LVN F) did not complete their annual training. This lack of training was identified through interviews and record reviews, which revealed no evidence of completed training in the employee files. Interviews with staff highlighted systemic issues in the training process. CNA B reported that she was placed on the floor without completing orientation or a checkoff list, as the DON allowed her to start working immediately due to her prior experience as a CNA. The facility's Compliance and Human Resources Lead (CHRL) confirmed that the DON and CNA B eventually received training, but RN I and LVN F did not complete their annual training. The CHRL noted that department heads are responsible for ensuring their staff receive necessary training, and recent leadership changes may have contributed to the oversight. The Administrator (ADMN) acknowledged the expectation for staff to complete required training but attributed the oversight to HR and corporate HR's monitoring responsibilities.
Failure to Notify Guardian Before Resident Transfer
Penalty
Summary
The facility failed to notify a resident's guardian in writing before transferring the resident to another facility. The resident, a female with severe cognitive impairment and multiple diagnoses including hypertensive heart disease and schizoaffective disorder, was transferred to a facility with a locked unit due to being an elopement risk. The transfer occurred without prior written notice to the resident's guardian or the State Long-Term Care Ombudsman, as required by regulations. The guardian was not informed of the transfer until several days later, which could have caused emotional distress to the resident due to the lack of visitors. Interviews with facility staff revealed a breakdown in communication and responsibility. The social worker acknowledged failing to notify the guardian and admitted to dropping the ball on this responsibility. The Assistant Director of Nursing (ADON) completed the discharge summary and prepared the resident for transfer but did not contact the guardian, believing it was the social worker's responsibility. The facility's policy requires documentation of discussions with the resident or their representative, which was not adhered to in this case.
Failure to Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment was electronically transmitted to the Centers for Medicare & Medicaid Services (CMS) System for a resident whose records were reviewed for closed records. Specifically, the discharge MDS assessment for a resident was not transmitted to CMS within the required 14 days of completion. This oversight could potentially place residents at risk by not providing complete and specific information necessary for payment and quality measure purposes. The resident in question was a male with a history of chronic obstructive pulmonary disease, hypokalemia, malignant neoplasm of the colon, and pain, who was discharged to another facility. The MDS Coordinator and the Regional MDS Coordinator both acknowledged the failure to transmit the discharge MDS within the proper timeframe but did not know the cause of the failure. The Director of Nursing (DON) was also unaware of any discharge MDS not being transmitted in a timely manner. The facility's policy requires all MDS assessments to be completed and transmitted in accordance with current OBRA regulations, and staff responsible for MDS completion are trained accordingly.
Inaccurate Meal Documentation for Resident
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident reviewed for resident records. Specifically, the facility did not ensure that a Certified Nursing Assistant (CNA) accurately documented the dinner meal intake for the resident. This discrepancy was identified during an observation where the Assistant Director of Nursing (ADON) fed the resident, who only consumed 1-2 bites of her meal, yet the meal intake log inaccurately indicated that the resident ate 75-100 percent of her dinner. The resident in question was a female with severe cognitive impairment, requiring extensive assistance for daily activities, and was on hospice care with a Do Not Resuscitate (DNR) order. Her diet was specified as regular fortified food with puree texture and thin fluid consistency. During an observation, it was noted that the resident was unable to swallow her food and required assistance to take drops of water, indicating a significant decline in her ability to eat independently. Interviews with the ADON, Director of Nursing (DON), and the Administrator revealed that the expectation was for accurate and timely documentation of diets by the person providing care. The CNA responsible for the inaccurate documentation admitted to making a mistake due to being in a hurry and acknowledged the importance of accurate documentation, especially for residents with specific dietary needs. The facility's policy on charting and documentation emphasized the need for complete and accurate records to facilitate communication among the interdisciplinary team regarding the resident's condition and response to care.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to inform the representative of a resident about a significant change in the resident's physical status and the need to alter the resident's treatment. Specifically, the facility did not notify the resident's legal guardian of a hospital transfer, which occurred due to the resident's altered mental status. The resident, a female with a history of diabetes, amputation of the left leg, and altered status, was admitted to the hospital for a UTI and metabolic encephalopathy. The resident's electronic progress notes did not show any evidence of notification to the resident's representative about the hospital transfer. Interviews conducted during the investigation revealed that the facility's staff, including the Director of Nursing (DON) and the Administrator, acknowledged the failure to notify the resident's representative. The DON attributed the failure to a lack of communication between nursing staff, exacerbated by the use of agency staff, which led to gaps in communication. The facility's policy required prompt notification of changes in a resident's condition to the resident, their physician, and their representative, but this was not adhered to in this case.
Unsanitary Living Conditions for Two Residents
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents, leading to unsanitary and potentially harmful living conditions. Resident #2's room and bathroom were observed to be in poor condition, with discolored and stained tiles, a wet and stained floor, and a dirty oxygen machine. The resident, who is legally blind and has moderate cognitive impairment, struggled with mobility and incontinence, contributing to the uncleanliness of his environment. Interviews with staff revealed that while housekeeping was performed daily, the resident's blindness and frequent spills were not adequately accommodated, resulting in persistent unsanitary conditions. Resident #6's room and bathroom were also found to be in disrepair, with broken and cracked tiles around the toilet, a loose toilet base, and exposed drywall. The resident, who has severe cognitive impairment, was observed in a room with a pulled-back cover base and a sticky pink liquid stain on the wall. The maintenance supervisor acknowledged the unacceptable state of the bathroom and identified a breakdown in communication regarding work orders, exacerbated by the use of untrained agency staff. Interviews with facility staff, including the administrator and director of nursing, confirmed the unacceptable conditions in both residents' rooms and bathrooms. The maintenance policies and procedures were not effectively implemented, as evidenced by the lack of timely repairs and cleaning. The facility's failure to maintain a dignified and sanitary environment for its residents was acknowledged by multiple staff members, highlighting a need for improved communication and adherence to maintenance protocols.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for a resident who was discharged home. This oversight was identified during a review of the resident's records and interviews with facility staff. The resident, a male with a history of osteomyelitis, shortness of breath, type 2 diabetes mellitus, and hypertension, was discharged against medical advice with his prescriptions and personal items. A family member assisted with the discharge, and the resident was in stable condition at the time of discharge. The facility's policy requires that a copy of the transfer or discharge notice be sent to the Ombudsman at the same time it is provided to the resident and their representative. However, the facility had not sent any 30-day discharge notices or transfer/discharge reports to the Ombudsman since March. Interviews revealed that the social worker, who was new to the role, was unaware of her responsibility to send these notices. The facility's failure to send the required notice could affect residents by limiting their access to advocacy services and appeal processes.
Failure to Develop Comprehensive Care Plan for Resident Outings
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who frequently went out on pass for personal needs. The resident, a male with a diagnosis including respiratory failure, unsteadiness on feet, and lack of coordination, had a BIMS score indicating moderate cognitive impairment. Despite leaving the facility 17 times between specific dates, there was no care plan in place to address his outings. The administrator and DON both acknowledged the oversight, with the administrator assuming the care plan was in place and the DON admitting that the resident was missed during recent audits for care plan updates. The MDS coordinator also believed the resident was going out with a friend, not on his own, and confirmed that such outings should be included in the care plan. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident. This failure could place residents at risk of not receiving the care required to meet their individualized needs.
Failure to Obtain Physician Order for Resident's Daily Pass
Penalty
Summary
The facility failed to ensure that orders were provided for the immediate care and needs of a resident. Specifically, the facility did not obtain a physician's order to allow a resident to go out on pass daily. The resident, a male with a diagnosis including respiratory failure, unsteadiness on feet, and lack of coordination, had a moderate cognitive impairment as indicated by a BIMS score of 8. Despite leaving the facility 17 times between specific dates, there was no physician order in place for these passes. The physician overseeing the resident stated he had not received any request regarding the resident going out on pass and would have concerns due to the resident's cognitive behavior and steadiness on his feet. The Director of Nursing (DON) acknowledged that the facility had been conducting audits on all residents for updates and changes but admitted that this resident was missed. The DON explained that the normal process involves a request by family or the resident, an assessment, and then sending it to the physician for an order, which did not occur in this case. The facility's policy requires verifying or obtaining a physician's order for a resident to leave the facility, which was not followed, potentially putting the resident at risk of missing medications or getting hurt while not under the facility's supervision.
Inadequate Supervision and Assistance Leading to Falls in High-Risk Residents
Penalty
Summary
The report highlights a significant deficiency in a nursing home facility related to inadequate supervision and assistance to prevent accidents, specifically falls. The facility failed to ensure that three residents, identified as Resident #1, Resident #2, and Resident #3, received appropriate supervision and interventions to prevent falls. Resident #1, a male with multiple comorbidities including heart disease and COPD, experienced five falls within a 19-hour period, leading to hospitalization and subsequent death due to a subarachnoid hemorrhage and lumbar spine fracture. Despite being identified as a high fall risk, Resident #1 did not have appropriate interventions in place, such as 1:1 supervision, leading to multiple falls and serious injuries. Similarly, Resident #2, a female with a history of repeated falls and muscle weakness, had a documented high fall risk but did not have appropriate interventions in her care plan to prevent falls. Resident #3, another female resident with hemiplegia and muscle weakness, also experienced a fall due to inadequate supervision. The facility's failure to update care plans with fall risk assessments and implement resident-centered interventions for these high-risk residents contributed to the deficiency in preventing accidents and ensuring adequate supervision.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, placing them at risk of not having continuity of care. Resident #2, a [AGE] year-old female with diagnoses including repeated falls, muscle weakness, anxiety, and depression, was admitted on 03/05/2024. Her clinical record revealed no evidence of a baseline care plan. Similarly, Resident #4, a [AGE] year-old male with diagnoses including kidney disease, heart disease, and amputation, was admitted on 03/22/2024, and his clinical record also lacked a baseline care plan. Both residents' MDS assessments indicated varying levels of cognitive impairment, with Resident #2 showing moderate cognitive impairment and Resident #4 showing no cognitive impairment. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed confusion and miscommunication regarding the responsibility for initiating baseline care plans. The DON believed that floor nurses were responsible for starting these plans, while the MDS Coordinator stated that the DON and Assistant Director of Nursing (ADON) were responsible. The DON admitted to starting Resident #2's baseline care plan but was unaware that it had not been submitted. The facility's policy, revised in December 2016, mandates that a baseline care plan be developed within 48 hours of admission to meet the resident's immediate needs, but this was not adhered to in these cases.
Failure to Develop Comprehensive Care Plans for Fall Risks
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their fall risks. Resident #2, a [AGE] year-old female with diagnoses including repeated falls, muscle weakness, anxiety, and depression, was admitted on 03/05/2024. Despite a high fall risk score of 55% on the Morse Fall Scale and two documented falls, her care plan did not reflect any fall risk or interventions. Similarly, Resident #3, a [AGE] year-old female with hemiplegia, muscle weakness, anxiety, and lack of coordination, had a high fall risk score of 70% and experienced a fall, yet her care plan also lacked any mention of fall risk or interventions. Interviews with facility staff revealed significant miscommunication and confusion regarding responsibilities for updating care plans. The DON believed that floor nurses were responsible for initiating and updating care plans with acute and new issues, while the MDS Coordinator only added care areas triggered by the MDS completion. This miscommunication resulted in the failure to include fall risks and appropriate interventions in the care plans for both residents. The facility's policy on comprehensive person-centered care plans requires measurable objectives, timeframes, and a thorough overview of the resident's care and needs. However, the care plans for Resident #2 and Resident #3 did not meet these requirements, as they failed to address the residents' high fall risks and lacked appropriate interventions. The DON acknowledged the oversight and the need for staff education to ensure accurate and complete care plans in the future.
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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