The Plaza At Lubbock
Inspection history, citations, penalties and survey trends for this long-term care facility in Lubbock, Texas.
- Location
- 4910 Emory, Lubbock, Texas 79416
- CMS Provider Number
- 676105
- Inspections on file
- 42
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Plaza At Lubbock during CMS and state inspections, most recent first.
A resident with a full code status was found unresponsive with no pulse or respirations, but the RN on duty did not initiate CPR, believing the resident showed signs of death. The resident's medical history included malignant neoplasm and other conditions. EMS later noted the absence of rigor mortis, and the RN's documentation was incomplete. Interviews revealed inconsistencies in understanding and executing the facility's CPR policy, leading to a risk for residents with full code status.
A resident was mistakenly given lorazepam, a medication not prescribed to her, due to a mix-up with medication cards. The error was identified by a Med Aid, but the responsible RN did not immediately notify the physician, family, or DON, nor did he initiate increased monitoring. The facility's policies on medication error reporting and change of condition notification were not followed, leading to a delay in communication and monitoring.
A resident received lorazepam without a physician's order due to a misidentification by an RN, who administered the medication to the wrong resident. The error was not immediately reported to the physician or family, delaying necessary monitoring and assessment. The facility's policy for reporting medication errors was not followed, contributing to the deficiency.
A facility failed to protect residents from abuse and neglect, with incidents involving inappropriate sexual comments by an RN towards a resident, verbal abuse and neglect by a CNA towards another resident, and rough handling by the same CNA towards a third resident. These actions led to emotional and physical distress for the residents involved.
A CNA in an LTC facility was observed taking a bag of chips from a resident's room without consent, violating the facility's policy on misappropriation of property. The resident, who had multiple medical conditions and a BIMS score of 00, was unable to communicate effectively. The CNA claimed the resident indicated the chips were a gift, but the facility's policy prohibits accepting gifts or taking residents' belongings without consent.
The facility failed to inform 7 out of 18 residents about their rights to file grievances, including the process, access to forms, and the ability to file anonymously. The grievance procedure was not posted, and residents were unaware of how to submit grievances or receive written decisions.
The facility failed to provide scheduled activities for residents, impacting their physical, mental, and psychosocial well-being. Observations revealed that activities like Washer Toss, Outdoor Lemonade Social, and Bible Study were not conducted as planned, leaving residents waiting without communication from the AD. Interviews indicated a lack of adherence to the activity schedule and insufficient alternative arrangements when activities were canceled or delayed.
The facility failed to properly label and store drugs and biologicals, as observed during a treatment cart inspection. A tube of Medihoney gel and zinc oxide ointment were not dated when opened, and a single-use collagen powder packet was found open without a date. An expired hydrofera blue wound dressing was also found. Staff interviews confirmed these items should have been dated or discarded, highlighting a lapse in adherence to facility policy.
The facility failed to properly label and date food items in the kitchen, as observed during multiple inspections. Unlabeled and undated items included mayonnaise, mustard, sandwiches, milk, egg salad, salsa, juice, and tartar sauce. Interviews with the KMGR and ADM confirmed that the facility's policy required labeling and dating of all food items to prevent foodborne illnesses. The oversight in adhering to these standards could risk food contamination.
The facility failed to maintain an effective infection prevention and control program, with multiple instances of improper hand hygiene and wound care techniques observed among staff. Several CNAs and an LVN did not adhere to proper handwashing protocols before and after providing care to residents, including those with conditions like Parkinsonism and pressure ulcers. Additionally, a CNA failed to sanitize hands between serving meals, risking cross-contamination. Despite receiving training, staff cited nervousness and lack of adherence to protocols as reasons for these deficiencies.
A resident's privacy was compromised during wound care when a CNA and LVN failed to pull the privacy curtain, despite closing the door. The resident, with multiple medical conditions, was exposed during the procedure. Staff interviews revealed a lack of awareness about the necessity of using the privacy curtain, despite training. The facility lacked a specific policy on this matter.
Two residents in an LTC facility received inadequate wound care due to improper techniques used by an LVN. The LVN failed to use a new gauze pad for each cleaning, increasing the risk of infection. Despite training, the LVN admitted to not following correct procedures. The facility's policy lacked specific guidance on cleaning techniques.
A resident in a LTC facility reported feeling violated after a straight catheter procedure was performed without informed consent while she was asleep. The resident, who was cognitively intact and continent, was not informed of the need for a repeat urine sample due to contamination of the previous sample. Facility staff failed to document a physician order for the procedure, and there was a lack of proper communication and consent, leading to the resident's distress and a police report.
A facility failed to protect two residents from abuse, resulting in a deficiency. One resident underwent an invasive catheter procedure without consent, causing her distress, while another resident faced verbal abuse from a CNA. The catheter procedure lacked a physician's order and was performed at an inappropriate time, contributing to the resident's trauma. The verbal abuse occurred at the nurse's station, showing a lack of respect for the resident's dignity.
A resident with a history of acute kidney failure and muscle weakness reported UTI symptoms, but the facility failed to notify the physician immediately. Despite the resident's complaints, there was no documentation of communication with the physician, contrary to the facility's policy. Interviews revealed discrepancies in the notification process, with the RN believing he had informed the FNP, who stated she received no such communication.
A resident with a history of acute kidney failure underwent a straight catheter procedure without a physician's order after a urine sample was deemed contaminated. The procedure was performed while the resident was asleep, without her consent, and contrary to facility policies on urine specimen collection and physician orders. The resident reported feeling violated and traumatized by the experience.
A resident with a history of acute kidney failure and muscle issues did not receive required lab tests upon admission, as per physician orders. The tests were delayed, despite the resident showing symptoms, due to unclear responsibilities and communication among staff. The facility's policy for obtaining and transcribing orders was not followed.
A resident reported symptoms of a UTI, but the facility failed to document communication between staff and the FNP or obtain proper orders for a UA. A straight catheterization was performed without prior consent, leading to the resident feeling violated. Interviews revealed a lack of communication and documentation, contrary to the facility's policy.
The facility failed to provide accurate pharmaceutical services, resulting in undocumented medication administration and medication errors for multiple residents. Medications were not administered within the prescribed 2-hour window, and narcotic sheets were not reconciled properly, with one MA documenting administration while not clocked in. These failures could lead to serious medication errors and adverse effects for the residents.
The facility failed to document medication administration for 41 out of 46 residents reviewed, risking incorrect medication dosages. Multiple residents had scheduled medications that were not recorded in the MAR, and there was no documentation of physician notification for these errors.
The facility failed to immediately inform residents, consult with physicians, and notify representatives of medication errors for two residents. Despite identifying the errors on the same day, notifications were delayed until over a week later. This delay could have resulted in unawareness of changes in the residents' conditions, although no negative outcomes were reported.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, for a resident who was found unresponsive with no pulse or respirations. The resident was documented as having a full code status, meaning all resuscitation procedures should have been provided during a medical emergency. However, the RN on duty did not initiate CPR upon discovering the resident in this state. The RN believed the resident was deceased based on her assessment, which she claimed showed signs of death, although these signs were not fully documented. The resident, a male with a history of malignant neoplasm and other medical conditions, was found unresponsive in his room by a CMA. The CMA reported the situation to the RN, who then assessed the resident and found no pulse or respirations. Despite the resident's full code status, the RN did not perform CPR, citing the presence of signs of death, which included cold skin and cyanosis. However, EMS staff later noted that the resident did not exhibit rigor mortis, and the RN's documentation was incomplete regarding the assessment of death signs. Interviews with facility staff revealed inconsistencies in the understanding and execution of the facility's policy on code status and CPR initiation. The RN believed the resident was a DNR based on computer records, which was incorrect. The facility's policy required CPR to be initiated unless all signs of death were present, which was not adequately assessed or documented by the RN. This failure to initiate CPR placed residents with a full code status at risk, as the facility did not ensure that staff followed proper procedures for resuscitation.
Removal Plan
- DON or designated nurse will in service all licensed nurses on policy and procedure for identifying code status on residents. No nurses will be allowed to work until training has been completed. Any nurses who did not receive training will receive training prior to the start of their next shift.
- DON or designee will educate all staff on emergency policy and procedures when residents are found to be unresponsive. No nurses will be allowed to work until training has been completed. Any nurses who did not receive training will receive training prior to the start of their next shift.
- DON or designee will monitor 10 staff members per week on competency of 7 signs of death/active signs of death, competency of nurses printing code statuses from EMR and on person, and CNA competency on code status on POC.
- Proof of the education will be submitted to QA committee.
- An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal.
- Administrator will forward results of audits monthly to the QAPI Committee for review and/or action.
- The Director of Nursing/designee will be responsible for implementation of New Process. The New Process/system will be started and no employee be able to return to work until they complete the Inservice.
Failure to Notify Physician and Family After Medication Error
Penalty
Summary
The facility failed to notify a resident's physician and family regarding a change in the resident's condition after a medication error occurred. RN C administered lorazepam, a medication not prescribed to Resident #1, due to a mix-up with medication cards. This error was discovered shortly after administration, but RN C did not immediately notify the physician, the family, or the Director of Nursing (DON) as required by facility policy. Resident #1, a cognitively intact female with a history of urinary tract infection, obstructive sleep apnea, and muscle weakness, was mistakenly given lorazepam, which was intended for another resident with a similar last name. The error was identified by Med Aid D, who informed RN C of the mistake. Despite this, RN C did not take immediate action to notify the necessary parties or initiate increased monitoring of Resident #1, who was later found to be difficult to arouse the following morning. Interviews with facility staff revealed that RN C assumed Med Aid D would handle the notification process, which led to a delay in informing the physician and family. The DON was not made aware of the incident until the following day, and the physician was only notified after Resident #1's family expressed concerns. The facility's policies on medication error reporting and change of condition notification were not followed, resulting in a lack of timely communication and monitoring for potential adverse effects.
Medication Error Due to Misidentification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a dose of lorazepam was administered without a physician's order. The error occurred when RN C misread the medication card and administered lorazepam to the wrong resident, who did not have an order for this medication. The resident who received the medication was cognitively intact and had a medical history of urinary tract infection, obstructive sleep apnea, and muscle weakness. The error was discovered shortly after administration, but the physician and family were not notified until the following day. The incident was compounded by a lack of immediate communication and documentation. RN C, who was responsible for the error, did not notify the physician, family, or the Director of Nursing (DON) immediately after the error was discovered. Instead, the error was reported to the DON the following day by Med Aid D, who had been informed of the mistake by RN C. The delay in notification meant that the resident did not receive increased monitoring or assessment immediately following the error. Interviews with staff revealed that RN C was aware of the error shortly after it occurred but did not follow the facility's policy for reporting medication errors. The facility's policy requires immediate evaluation of the patient, notification of the physician and nurse manager, and completion of a Medication Error Report. The DON was not informed of the error until the next day, and the physician was only notified after the DON intervened. This lack of adherence to protocol contributed to the deficiency in ensuring residents were free from significant medication errors.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by inappropriate behavior from staff members towards three residents. Resident #1, a female with multiple medical conditions including spinal stenosis and acute kidney failure, experienced inappropriate sexual comments from RN A. These comments made Resident #1 feel ashamed and embarrassed, leading her to avoid RN A for wound care. The situation was reported by LVN D after Resident #1 confided in her about the discomfort caused by RN A's behavior. Resident #2, a male with conditions such as Parkinsonism and chronic heart failure, faced verbal abuse and neglect from CNA B. Resident #2 reported that CNA B yelled at him for mistakenly addressing her as 'sir' and failed to change his saturated brief, leaving him in discomfort. Despite Resident #2's attempts to communicate his needs, CNA B's response was dismissive, and she did not return to assist him, indicating neglect in care. Resident #3, a male with heart failure and muscle weakness, reported rough handling by a CNA during transfers from his wheelchair to the commode. The description provided by Resident #3 matched CNA B, who was known to be rough and loud with residents. Despite reports of such behavior, the facility's administration was not fully aware of the extent of abuse or neglect by CNA B. The facility's policy on abuse and neglect was reviewed, but the incidents highlight a failure to adhere to these guidelines, resulting in emotional and physical distress for the residents involved.
Misappropriation of Resident's Property by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically a bag of chips, by a Certified Nursing Assistant (CNA). The incident involved a resident with multiple medical conditions, including chronic kidney disease, osteoarthritis, vascular dementia, and cognitive communication deficit, who was unable to communicate effectively due to a BIMS score of 00. The CNA was observed via video evidence taking a bag of chips from the resident's room without consent. The CNA claimed that the resident had pointed to the chips and indicated they were a gift, but the CNA did not take them at that time and later retrieved them, leading to the accusation of misappropriation. The facility's employee handbook and policy on abuse, neglect, and misappropriation clearly prohibit accepting gifts or taking residents' belongings without consent. The CNA admitted to not understanding that taking a snack from a resident was considered misappropriation. Interviews with the Director of Nursing (DON) and the Administrator (ADM) highlighted the potential negative outcomes of such actions, emphasizing the importance of protecting residents' personal belongings. The facility's policy defines misappropriation as the wrongful use of a resident's belongings without consent, which was violated in this instance.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide information to residents and their representatives regarding their rights related to filing grievances or concerns. This deficiency was identified for 7 out of 18 confidential residents. These residents were not informed about the grievance process, did not know where to obtain or submit a grievance form, and were unaware of their right to file grievances anonymously. Additionally, the grievance procedure was not discussed during confidential interviews, and there were no postings of the grievance procedure in prominent locations within the facility. During interviews, the residents expressed that they were unaware of how to file a grievance, where to acquire a grievance form, or who to submit it to. They also did not know that they had the right to receive a written decision once their grievance was resolved. These residents had been in the facility for over six months, indicating a prolonged period without proper information on their rights to file grievances. The facility's grievance policy, last updated in 2020, states that residents should be provided with written information on how to file a grievance upon admission. However, the facility did not adhere to this policy, as observed during the survey. The Administrator, who also served as the Grievance Officer, acknowledged that the grievance procedure was not posted for residents and that there was no means for residents to submit grievances anonymously. The Administrator also noted that grievances were resolved through face-to-face discussions, but there was no written grievance form accessible to residents.
Failure to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group, individual activities, and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 7 of 18 residents reviewed for quality of life. Observations and interviews revealed that scheduled activities such as Washer Toss, Outdoor Lemonade Social, Music Works, Name that Tune, and Bible Study were either not started on time or did not occur at all. Residents expressed their dissatisfaction with the activities not starting on time and the lack of communication from the Activity Director (AD) regarding the status of these activities. On multiple occasions, residents were observed waiting for scheduled activities that did not take place. For instance, during the Washer Toss activity, residents were left waiting without any communication from the AD. Similarly, the Outdoor Lemonade Social and Music Works activities were not conducted as planned, leaving residents waiting without any alternative arrangements. The AD was not present during these scheduled times, and residents reported that activities rarely happened as scheduled, leading them to socialize among themselves instead. Interviews with the AD and the Administrator (ADM) revealed discrepancies in the execution of the activity schedule. The ADM expected the AD to follow the activities on the calendar, inform residents of any changes, and ensure activities began on time. However, the AD admitted to not moving activities to alternative locations when the dining room was unavailable and did not perceive any resident dissatisfaction with the activities not occurring as scheduled. The facility's activity policy emphasized the importance of providing a variety of activities to meet residents' interests and well-being, but the observed practices did not align with these expectations.
Deficiency in Drug and Biological Labeling and Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles, as observed during a treatment cart inspection. Specifically, a tube of Medihoney gel and a tube of zinc oxide ointment were not dated when opened, and a single-use collagen powder packet was found open without a date or resident information. Additionally, a package of hydrofera blue wound dressing was found with an expired date. These observations were confirmed during interviews with LVN A, the DON, and the ADM, who acknowledged that the items should have been dated or discarded as appropriate. The facility's policy requires that medications be labeled with appropriate auxiliary and cautionary instructions, and that non-prescription medications not labeled by the pharmacy be kept in their original containers. The failure to adhere to these policies was attributed to oversight, as staff are responsible for checking treatment carts for expired and undated supplies. The potential negative outcomes of these deficiencies include the use of expired or contaminated supplies, which could affect the effectiveness of treatments and potentially harm residents.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a series of kitchen tours. On the first day, several food items were found unlabeled and undated, including mayonnaise and mustard cups, sandwich halves, milk, egg salad, salsa, juice, and tartar sauce. These items were identified by the kitchen manager (KMGR) after being pointed out. On subsequent days, some items were dated, but new unlabeled and undated items were found, such as juice flutes and pitchers of liquids. Interviews with the KMGR and the administrator (ADM) revealed that the facility's policy required all food items to be labeled and dated when opened or prepared. The KMGR acknowledged the oversight and stated that dates were added based on her recollection of when the items were prepared. Both the KMGR and ADM emphasized the importance of proper labeling and dating to prevent foodborne illnesses. The ADM also noted that items should not be backdated and should be discarded if the preparation date is uncertain. The facility's policies on food storage and hand hygiene were reviewed, highlighting the requirement for proper labeling and dating of food items and the importance of hand hygiene to prevent infection. The FDA Food Code was also referenced, which mandates that ready-to-eat, time/temperature control for safety food must be clearly marked with a date for consumption or disposal if held for more than 24 hours. The failure to comply with these standards could place residents at risk for food contamination and foodborne illness.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and wound care techniques observed among staff members. Specifically, several Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) did not adhere to proper handwashing protocols before and after providing care to residents. For instance, CNA A did not use proper hand hygiene when assisting with incontinent care for a resident, and CNA C failed to wash hands before gathering supplies for incontinent care. Additionally, LVN A did not use proper wound care techniques, and CNA D did not wash hands before or after assisting with wound care for residents. The report highlights specific cases involving residents with various medical conditions, including Parkinsonism, dementia, and pressure ulcers, who were at risk due to these lapses in infection control practices. For example, Resident #7, who was cognitively intact, was assisted by CNA E, who did not use soap after providing incontinent care. Similarly, Resident #15, who had a stage 2 pressure ulcer and was moderately cognitively impaired, was cared for by CNA C, who did not wash hands properly before and after providing care. These actions could potentially lead to the spread of infections among residents. Furthermore, the report details observations of CNA F failing to sanitize hands between serving meals to residents, which could contribute to cross-contamination. Interviews with staff members revealed that although they had received training in infection control practices, nervousness and lack of adherence to protocols were cited as reasons for the observed deficiencies. The facility's policies on infection control and hand hygiene were not consistently followed, as evidenced by the repeated failures in maintaining proper hygiene standards during care and meal service.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during wound care, which was observed by surveyors. A Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) did not pull the privacy curtain while providing wound care to a resident, despite closing the door. This oversight occurred during a procedure that required the resident's pants to be removed, leaving the resident potentially exposed. The resident, a female with multiple medical conditions including spinal stenosis, acute kidney failure, and diabetes, was admitted to the facility with specific wound care orders. Interviews with the involved staff revealed a lack of awareness regarding the necessity of using the privacy curtain in addition to closing the door. Both the CNA and LVN acknowledged their training in privacy and dignity but failed to apply it in this instance. The Director of Nursing (DON) and the Administrator confirmed that staff are expected to use both the door and curtain to ensure privacy, and they recognized the potential for emotional distress and embarrassment for the resident due to this oversight. The facility did not have a specific policy on pulling privacy curtains during care.
Improper Wound Care Techniques Observed
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received the necessary treatment and services consistent with professional standards of practice. This deficiency was observed in the care provided to two residents, who were at risk of complications due to improper wound care techniques. LVN A, responsible for the wound care, did not adhere to the correct wound cleaning techniques, which could potentially lead to the spread of bacteria and infection. Resident #87, a male with multiple medical conditions including a fracture, senile degeneration of the brain, and Guillain-Barre syndrome, was observed receiving wound care that did not follow proper procedures. The LVN used the same gauze pad multiple times to clean the wound, which is against the recommended practice of using a new gauze pad each time to prevent contamination. The resident's care plan and physician orders indicated the need for specific wound care, but these were not followed correctly during the observed procedure. Similarly, Resident #257, a female with conditions such as spinal stenosis, acute kidney failure, and diabetes, also received inadequate wound care. The LVN repeated the same improper technique of using the same gauze pad multiple times on different wounds, increasing the risk of infection. Despite being trained by a wound care education center, the LVN admitted to not following the correct procedures due to nervousness. The facility's policy on wound care did not provide specific guidance on the cleaning technique, contributing to the deficiency.
Failure to Obtain Informed Consent for Medical Procedure
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, dignity, and care, specifically in obtaining informed consent for a medical procedure. The incident involved a female resident with a history of acute kidney failure, muscle weakness, and muscle wasting, who was cognitively intact and required moderate assistance with toileting hygiene. The resident was always continent and did not have any urinary appliances. On a particular night, staff performed a straight catheter procedure to collect a urine sample without obtaining clear informed consent from the resident, who was asleep at the time. The resident reported feeling violated by the procedure, which was performed at approximately 3:30 AM. She stated that she was not informed about the need for a repeat urine sample due to contamination of the previous sample until after the catheterization was completed. The resident expressed that she would have refused the catheterization if she had been awake and informed, preferring to provide a urine sample herself. The procedure was described as painful, and the resident reported the incident to the facility administration and the police, feeling that the procedure was unnecessary and handled inappropriately. Interviews with facility staff revealed a lack of proper documentation and communication regarding the procedure. The Director of Nursing (DON) and Administrator (ADM) acknowledged that there was no physician order for the straight catheter procedure and that consent was typically obtained verbally. The staff involved in the procedure claimed that the resident was awake and communicated during the process, but the resident's account differed, indicating she was not fully aware or consenting. The incident highlighted deficiencies in the facility's processes for obtaining informed consent and documenting medical procedures.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. The first incident involved a resident who was subjected to an invasive straight catheter procedure without her consent while she was asleep. The resident, who was cognitively intact and had no history of using catheters, reported feeling violated and traumatized by the procedure. The facility staff did not have a physician's order for the procedure, and there was no documentation of consent or communication with the resident prior to the procedure. The procedure was performed at an inappropriate time, around 3:30 AM, which contributed to the resident's distress. The second incident involved verbal abuse directed at another resident by a Certified Nursing Assistant (CNA). The CNA repeatedly called the resident names and belittled him, even after being instructed to stop. This behavior occurred at the nurse's station, indicating a lack of respect for the resident's dignity and a failure to maintain a safe and supportive environment. Both incidents highlight significant lapses in the facility's duty to protect residents from abuse and ensure their well-being. The lack of proper documentation, communication, and adherence to procedures contributed to these deficiencies, placing residents at risk of physical harm, mental anguish, and emotional distress.
Failure to Notify Physician of Resident's UTI Symptoms
Penalty
Summary
The facility failed to immediately inform a resident's physician of a significant change in the resident's condition, specifically symptoms of a urinary tract infection (UTI). The resident, a cognitively intact female with a history of acute kidney failure, muscle weakness, and muscle wasting, reported pain and discomfort during urination on a specific date. Despite the resident's complaints, there was no documentation in the nursing notes of communication with the physician regarding this change in condition. The facility's policy requires immediate notification of the physician for acute or sudden changes in a resident's condition, which was not adhered to in this case. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed discrepancies in the notification process. The RN believed he had notified the Family Nurse Practitioner (FNP) and collected a urine sample, but there was no documentation to support this. The FNP stated she did not receive any communication regarding the resident's UTI symptoms. The facility's policy emphasizes the importance of documenting all communication and actions taken in response to changes in a resident's condition, which was not followed, leading to a delay in medical treatment for the resident.
Inappropriate Catheter Procedure Without Physician Order
Penalty
Summary
The facility failed to ensure a resident, who was continent of bowel and bladder, received appropriate treatment for a urinary tract infection. The resident, a cognitively intact female with a history of acute kidney failure, muscle weakness, and muscle wasting, was subjected to a straight catheter procedure without a physician's order. The procedure was performed after a urine sample collected using a urine collection hat was deemed contaminated. The resident was not informed of the need for a new sample or the method of collection prior to the procedure, which was conducted while she was asleep. The facility did not follow its policy on urine specimen collection, as the appropriate measurement method for urine collection was not determined. Additionally, the facility failed to follow its policy on physician orders by not receiving and transcribing physician orders for a urine analysis recollection. The procedure was performed without a specific order for the method of urine collection, leading to the resident experiencing pain and discomfort. The resident reported feeling violated and traumatized by the procedure, which was conducted at an inappropriate time without her consent. Interviews with facility staff revealed a lack of communication and documentation regarding the contaminated urine sample and the subsequent procedure. The Director of Nursing and other staff members acknowledged the absence of proper documentation and orders for the straight catheter procedure. The facility's policies on urine specimen collection and physician orders were not adhered to, resulting in the resident undergoing an unnecessary and invasive procedure without proper consent or notification.
Failure to Conduct Admission Lab Tests
Penalty
Summary
The facility failed to provide or obtain necessary laboratory services for a resident upon admission, as per the physician's standing orders. The resident, a cognitively intact female with a history of acute kidney failure, muscle weakness, and muscle wasting, was admitted to the facility but did not have the required laboratory tests, including BMP, CBC, U/A, and lipid profile, conducted at the time of admission. The lab work was delayed and only completed several days later, despite the resident experiencing symptoms such as burning during urination and discomfort, which were reported to the FNP. Interviews with facility staff, including the DON, ADM, RN, and LVN, revealed a lack of clarity and communication regarding the responsibility for initiating and documenting admission lab orders. The facility's policy required licensed nurses to obtain and transcribe orders according to practice guidelines, but this was not followed. The FNP was unaware that the admission labs had not been completed, indicating a breakdown in communication and adherence to the facility's standard procedures.
Failure to Document and Communicate Resident's UTI Symptoms and Treatment
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who reported symptoms of a urinary tract infection (UTI). On 8/9/2024, the resident informed RN D of feeling as if she had a UTI, but there was no documentation of this communication or any subsequent actions taken. Additionally, there was no record of communication between RN D and the facility's Family Nurse Practitioner (FNP) regarding the resident's condition or obtaining an order for a urinalysis (UA). Further deficiencies were noted when a contaminated UA sample was reported to the facility, and there was no documentation of communication between staff and the FNP or any orders for a UA recollection. The resident underwent a straight catheterization on 8/11/2024 at approximately 3:30 AM without prior notification or consent, leading to feelings of violation and upset. The procedure was performed without documented orders, and the resident's report of discomfort and emotional distress was not recorded in the clinical notes. Interviews with the Director of Nursing (DON), Administrator (ADM), and RN D revealed a lack of communication and documentation regarding the resident's condition and the procedures performed. The DON acknowledged the absence of proper documentation and orders, while the ADM and RN D provided conflicting accounts of the events and communications. The facility's policy on documentation was not adhered to, resulting in incomplete and inaccurate medical records for the resident.
Failure to Provide Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, as evidenced by multiple instances of undocumented medication administration and medication errors. Specifically, the facility did not ensure that medications were administered accurately within the 2-hour window per physician orders for 39 out of 46 residents. Additionally, there was a failure to reconcile narcotic sheets, with one medication aide (MA F) documenting the administration of narcotic medications at times when she was not clocked in or working in the building. These failures could place residents at risk of receiving incorrect amounts of medication or having adverse reactions to medications not prescribed to them. For example, Resident #1, an elderly female with diagnoses including gastroesophageal reflux disease, muscle weakness, and insomnia, had multiple medications scheduled for administration at 7 PM that were not documented as given on 4/12/2024. Similarly, Resident #2, an elderly female with atrial fibrillation and moderate cognitive impairment, had several medications scheduled for 7 PM and 8 PM that were not documented as administered. In both cases, there was no documentation of physician notification of the medication errors in the nurse's notes. Another significant issue involved Resident #6, who received another resident's medication during a medication pass. This resident, a cognitively intact elderly male with diagnoses including hyperlipidemia and cerebral infarction, had multiple medications scheduled for 7 PM that were not documented as administered. Additionally, the facility failed to reconcile narcotic sheets, with MA F documenting the administration of narcotic medications at times when she was not clocked in or working in the building. This lack of proper documentation and reconciliation could lead to serious medication errors and adverse effects for the residents involved.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain resident medical records in accordance with accepted professional standards and practices. Specifically, the facility did not ensure that staff documented medications given to residents in the Medication Administration Record (MAR) for 41 out of 46 residents reviewed. This lack of documentation could place residents at risk of receiving incorrect amounts of medication as prescribed by their physicians. The report details multiple instances where medications were not documented as administered, despite being scheduled and ordered by physicians. For example, Resident #1, a female with diagnoses including gastroesophageal reflux disease, muscle weakness, and hyperlipidemia, had several medications scheduled for administration at 7 PM on 4/12/2024, including a nutritional supplement, bethanechol chloride, lubiprostone, melatonin, and omega-3 fish oil. None of these medications were documented as administered in the MAR. Similarly, Resident #2, a female with atrial fibrillation and moderate cognitive impairment, had multiple medications scheduled for 7 PM and 8 PM on the same date, including Eliquis, a house shake, MiraLAX, a multivitamin, and mirtazapine, which were also not documented as administered. The report also highlights similar deficiencies for other residents, such as Resident #3, who had medications like atorvastatin, ferrous sulfate, and metoprolol succinate scheduled for 7 PM and 8 PM, and Resident #4, who had medications including Colace, lorazepam, and mirtazapine scheduled for 7 PM. In each case, the medications were not documented as administered in the MAR. Additionally, there was no documentation in the nurse's notes for physician notification of these medication errors, further compounding the issue of inadequate record-keeping and potential risk to resident safety.
Failure to Notify Physicians and Families of Medication Errors
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative(s) when there was a change in the resident's health status for two residents reviewed for notification of changes. This failure was identified during an investigation of medication administration errors that occurred on 04/12/2024. The errors involved medications being given at times other than ordered, and in some cases, residents receiving the wrong medications. Despite the errors being identified on the same day, notifications to physicians and family members were not made until 04/23/2024, over a week later. Resident #6, a cognitively intact male with diagnoses including hyperlipidemia, cerebral infarction, protein-calorie malnutrition, and neuropathic bladder, had several medications scheduled for 7 pm that were not documented as administered on 04/12/2024. A nurse's note indicated that a head-to-toe assessment was performed, and the resident's condition was reported to a nurse practitioner, but there was no documentation of immediate notification to the resident's physician or family. Similarly, Resident #25, a cognitively intact male with atherosclerosis and insomnia, had medications scheduled for 8 pm that were not documented as administered. The resident was unable to confirm if he received his medications, and there was no documentation of physician notification of the medication error. Interviews with facility staff revealed a lack of immediate action to notify physicians and family members about the medication errors. The Administrator and Corporate RN were aware of the errors on 04/12/2024 but did not ensure that all necessary notifications were made. The DON and other nursing staff also failed to follow through with proper notification procedures, leading to a significant delay in informing the relevant parties. This delay in notification could have resulted in unawareness of changes in the residents' conditions by their physicians and representatives, although no negative outcomes were reported.
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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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