The Plaza At Richardson
Inspection history, citations, penalties and survey trends for this long-term care facility in Richardson, Texas.
- Location
- 1301 Richardson Dr, Richardson, Texas 75080
- CMS Provider Number
- 676098
- Inspections on file
- 47
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at The Plaza At Richardson during CMS and state inspections, most recent first.
A resident with hypotension, heart disease, and type 2 DM had multiple scheduled oral medications, including Dapagliflozin, Metformin, Midodrine, and Pantoprazole, that were administered late by a med aide, outside the facility’s one-hour medication window. The med aide gave the resident’s morning doses together after the resident had already eaten, then documented them on the MAR as if given on time and did not record them as late or notify the nurse. The DON confirmed expectations that medications be given within the prescribed time frame and that before-meal orders, such as Pantoprazole, be administered as ordered, consistent with facility policy requiring documentation when medications are given at other than the scheduled time.
A medication aide failed to perform hand hygiene and sanitize a wrist blood pressure cuff while checking a resident’s blood pressure and administering medications. The aide did not clean the cuff before use or before placing it back on the med cart and did not wash or sanitize hands before or after direct resident contact. In interviews, the aide acknowledged knowing hand hygiene was required but cited lack of hand sanitizer on the med cart, and the DON confirmed expectations for hand hygiene and equipment disinfection consistent with facility infection control policy.
A dependent female resident with a history of stroke, DM, and HTN, identified as high risk for falls and moderately impaired in decision making, was found lying in bed with side rails up while her call light was on the floor and out of reach, despite a care plan intervention requiring the call light to be kept within reach. The resident reported she used the call light for assistance but could not access it. A CNA acknowledged the call light should have been within reach and repositioned it on the bed rail, and the DON stated she expected call devices to be accessible to residents. The Administrator indicated the facility had no call light policy.
Surveyors found that food items in various storage areas were not properly labeled or dated, some foods showed signs of spoilage, and a dented can was present. The dishwashing process was not followed correctly, with utensils not fully sanitized before use. Additionally, hot and cold foods were not held at safe temperatures, and staff did not consistently check food temperatures before serving, as required by policy and federal regulations.
The facility did not maintain an effective pest control program, resulting in ongoing gnat infestations in two hallways and the kitchen. Staff and residents reported persistent issues with gnats, including sightings in food preparation areas and resident rooms. Residents were disturbed by the gnats, with one nearly ingesting a gnat while eating. Despite staff efforts and pest control visits, the infestation persisted, indicating a breakdown in the facility's pest management procedures.
Surveyors found that drugs and biologicals were not consistently stored in locked compartments, with an unlocked dialysis medication cart and unsecured dialysis fluids left in a resident's room, and an unattended Advair Diskus inhaler left in a common area near the nurse's station. Staff and leadership confirmed that both facility and contract nurses were responsible for medication security, but lapses occurred despite existing policies and training.
A resident with multiple medical conditions, including Parkinson's Disease and dysphagia, experienced regurgitation in his room, and the resulting food debris remained on the floor for nearly three hours. Staff interviews revealed confusion about responsibilities for cleaning, and the facility's policy requiring a clean and comfortable environment was not followed, resulting in the resident feeling uncomfortable and the room remaining unclean.
Expired gentle female intermittent catheters were found stored in the medication room, despite the facility's procedures requiring regular audits by the ADON and Central Supply Personnel. Staff interviews revealed inconsistent auditing practices and a lack of a specific policy for expired medical supplies, resulting in the failure to promptly remove and dispose of expired items.
Expired IV and PICC supplies, including catheters and connectors, were found stored in the facility's only medication room despite staff statements that regular audits should have removed them. Interviews with an LVN, DON, ADONs, and Central Supply Personnel revealed inconsistent auditing practices and a lack of a specific policy for expired medical supplies.
A CNA failed to perform hand hygiene after using a cellphone while feeding a resident with multiple complex medical conditions, in violation of facility policy requiring hand cleaning before and after meal assistance. The DON confirmed staff expectations for hand hygiene and no phone use during feeding.
A resident with severe cognitive impairment and total care needs experienced a femur fracture that was initially assessed as chronic and attributed to age and osteopenia. Despite the injury being diagnosed as an acute fracture requiring surgery, the incident was not reported to the State Agency within required timeframes, as facility leadership did not consider it suspicious or related to neglect, contrary to policy and regulatory requirements.
The facility failed to ensure safe and orderly discharges for three residents, leading to inadequate preparation and communication. A resident with moderate cognitive impairment was discharged to a different address than provided, while another with severe cognitive impairment was transferred to a facility far from family without proper notice. A third resident was moved due to dissatisfaction with care, but the discharge process lacked communication, causing medication issues at the new facility.
The facility failed to effectively involve three residents and their responsible parties in the discharge planning process, leading to confusion and inadequate preparation for their transitions. A resident with moderate cognitive impairment was discharged without her preferences being considered, and the discharge address was not verified. Another resident with severe cognitive impairment was moved to a facility without the RP's full agreement, feeling rushed due to financial pressures. A third resident was transferred to a new facility chosen by the RP, but the process lacked proper communication, resulting in medication issues.
A resident with severe cognitive impairment experienced an incident where another resident sat on her lap, which was reported as a grievance. The facility failed to identify a Grievance Official, leading to the grievance not being properly investigated or addressed. The SW informed the DON and Administrator, but no thorough investigation or additional interventions were implemented.
The facility failed to properly store, label, and date food items in their kitchen, including an opened jar of barbeque sauce in dry storage, exposed brown sugar, and unlabeled peaches. Rotten tomatoes, expired jalapenos, and buttermilk were also found, posing a risk for foodborne illnesses. The Dietary Director acknowledged these oversights, which violated the facility's food storage policy.
A resident in a LTC facility missed seven doses of scheduled Oxycodone due to the facility's failure to obtain the medication from the hospice company. The resident, with a history of cancer-related pain, experienced unnecessary pain as a result. Despite receiving morphine for pain management, the resident preferred Oxycodone for scheduled doses. The acting DON and staff were unaware of the issue until a surveyor inquiry, highlighting a lack of communication and coordination with the hospice provider.
The facility failed to treat a resident with dignity during discharge, resulting in her being found unresponsive at home. The LVN did not complete a full assessment or document vital signs before discharge. Additionally, another resident was not provided a dignified dining experience as the ADON stood while assisting with meals, contrary to facility policy.
A resident with cognitive impairment and a history of stroke, schizophrenia, and anxiety disorder was found shaving with a disposable razor, which was against facility policy. Staff interviews confirmed that residents should not have access to such items due to safety risks. The facility's policy on hazardous areas emphasized the need to prevent such hazards.
A CNA failed to perform proper hand hygiene while providing incontinence care to a resident with severe cognitive impairment and multiple health conditions. The CNA did not wash or sanitize hands after removing gloves and before entering another resident's room, despite the availability of hand sanitizer. Interviews with the CNA, DON, and Administrator highlighted the importance of hand hygiene in preventing infection spread, as outlined in the facility's perineal care policy.
A facility failed to report an allegation of sexual abuse involving a resident to the State Survey Agency within the required timeframe. The resident, with multiple diagnoses including Parkinson's and dementia, initially reported inappropriate behavior by a CNA to a therapist. However, the resident later denied the allegations when questioned by the administrator, who conducted an internal investigation and did not report the incident to the state, contrary to facility policy and regulations.
A facility failed to update a resident's care plan to include a diagnosis of prostate cancer, despite the resident's history of the condition. The MDS Coordinator, new to the role, had not yet updated the care plan, risking neglect as staff might be unaware of the diagnosis. Facility policy mandates reporting changes in condition to the MDS Coordinator for care plan updates, which was not followed.
Late and Undocumented Medication Administration by Med Aide
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate and timely administration and documentation of medications for a resident. The resident had diagnoses including hypotension, hypertensive heart disease with heart failure, atherosclerotic heart disease, and type 2 diabetes, and was prescribed Dapagliflozin, Metformin, Midodrine, and Pantoprazole, among other medications. On the survey date at 10:18 AM, Med Aide B checked the resident’s blood pressure with a wrist cuff, obtaining a reading of 104/46, and then prepared the resident’s 8 AM and 9 AM medications together in a small cup. At 10:24 AM, Med Aide B administered six pills, including Dapagliflozin 5 mg, Pantoprazole 40 mg, Metformin 1000 mg, and Midodrine 10 mg, well outside the facility’s policy window for 8 AM medications. Review of the Medication Administration Record (MAR) for that month showed the 8 AM medications documented as given by Med Aide B without any notation that they were administered late. The electronic record contained no note indicating late administration. In an interview, Med Aide B acknowledged that the 8 AM and 9 AM medications were given late and stated he understood medications were to be given within one hour before or after the scheduled time, but he did not notify the nurse or document the late administration and reported he was unaware of how to document late medications in the electronic system. The DON stated she expected medications to be administered within the one-hour window on the MAR, noted that Pantoprazole should have been given prior to breakfast and that the resident had already eaten by the time it was administered, and indicated that the charge nurse should be notified when medications are not given on time. Facility policy required medications to be administered within one hour of the scheduled time and required circled initials and explanatory notes on the MAR when medications are given at other than the scheduled time, which was not followed in this case.
Failure to Perform Hand Hygiene and Sanitize Blood Pressure Cuff During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during medication administration and vital sign monitoring. On 01/07/26 at 10:18 AM, surveyors observed Med Aide B check a resident’s blood pressure using a wrist blood pressure cuff without sanitizing the cuff and without performing hand hygiene before the procedure. After use, Med Aide B placed the wrist blood pressure cuff on top of the medication cart without sanitizing it and did not wash or sanitize hands before administering the resident’s medications. The facility’s policy, Fundamentals of Infection Control Precautions, states that hand hygiene is the primary means of preventing transmission of infection and is required before and after direct resident contact and upon and after contact with a resident’s intact skin, including when taking blood pressure. During an interview at 10:30 AM on the same day, Med Aide B acknowledged that he should have washed or sanitized his hands prior to taking the resident’s blood pressure and before and after administering medications, and stated there was no hand sanitizer on or in the medication cart, which he cited as the reason for not sanitizing his hands. He further stated he should have performed hand hygiene to prevent cross contamination and infection. At 10:40 AM, the DON confirmed that Med Aide B was expected to wash or sanitize his hands prior to checking blood pressure, prior to administering medications, and after medication administration, and that the blood pressure cuff should be sanitized before resident use and before being returned to the medication cart. Review of Med Aide B’s Medication/Administration Competency, dated 06/08/25, showed that his training included proper hand hygiene and correct timing of medication administration.
Inaccessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident’s call system was accessible at the bedside as required by the resident’s care plan. A female resident with a history of stroke, diabetes, and hypertension was dependent on staff for ADLs including dressing, hygiene, toileting, bathing, positioning, and transfers, and was assessed as moderately impaired in daily decision making. Her comprehensive care plan, last reviewed on 12/23/25, identified her as at high risk for falls related to gait and balance problems and included an intervention to keep the call light within reach and encourage her to use it for assistance as needed. On observation, the resident was lying in bed with positioning rails on both sides, and her call button was found on the floor below the bed, out of her reach. The resident reported that she used the call button to obtain staff assistance but could not reach it and was dependent on staff. A CNA stated that the call button must have fallen off the bed and acknowledged it should be within the resident’s reach, then wrapped the call button cord around the right positioning rail so it was accessible. The DON stated she expected residents’ call devices to be within reach while in bed and confirmed that this resident used her call light for assistance. The Administrator reported that the facility did not have a policy for call lights.
Deficient Food Storage, Labeling, Sanitation, and Temperature Control in Kitchen
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food storage, preparation, and sanitation practices. Observations revealed that opened food items in the stand-by refrigerator, walk-in refrigerator, walk-in freezer, and dry storage were not consistently labeled or dated. Specific examples included a carton of soy milk with a broken seal and no date, bags of produce and bread without labels or use-by dates, and saran-wrapped packages of cheese and cake mix lacking proper dating. Additionally, a dented can of yams was found in dry storage, and some food items showed signs of spoilage, such as a molding carrot. Further deficiencies were observed in the dishwashing process. The three-compartment sink was not used according to established protocols, as evidenced by the assistant dietary manager attempting to use a serving spoon that had not been properly sanitized. Food particles were present in the rinse compartment, and the sanitizing solution was not initially prepared or tested correctly. The posted instructions required dishes to be immersed in sanitizer for at least one minute at the correct concentration, but this was not followed during the surveyor's observation. Temperature control for prepared foods was also inadequate. Hot foods on the steam tray line, such as pureed pinto beans, were held at temperatures below the required threshold, and cold foods like banana pudding cups were not maintained at safe temperatures. Staff interviews confirmed that temperature checks were not consistently performed prior to serving, and there was a lack of knowledge regarding proper holding temperatures and procedures. These failures were documented through direct observation, staff interviews, and review of facility policies and federal food safety regulations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnat flies in two of the three hallways reviewed and in the facility's only kitchen. Multiple observations documented gnats flying around the hand washing sink, in resident rooms, common areas, and near food preparation areas such as the deep fryer and steam tray table. Staff interviews confirmed ongoing issues with gnats, with reports of staff attempting to manage the problem by pouring bleach down drains and setting traps, while awaiting pest control services. The pest control log indicated heavy gnat activity in specific hallways and common areas, and the facility's policy required regular pest control measures and maintenance of structural barriers to prevent pest entry. Residents reported being bothered by the gnats, with one resident stating that a gnat flew into her mouth while eating, causing distress. Another resident expressed agitation due to the persistent presence of gnats in his room and noted that complaints to staff had not resolved the issue. Staff interviews revealed that maintenance was responsible for pest control and that the problem was attributed to food left in resident rooms. Despite monthly pest control visits and additional treatments, gnats continued to be observed throughout the facility, indicating a failure to effectively implement the pest control program as outlined in facility policy.
Failure to Secure Medications and Biologicals
Penalty
Summary
Surveyors observed that the facility failed to store all drugs and biologicals in locked compartments and did not restrict access to authorized personnel only. Specifically, an unlocked dialysis medication cart containing intravenous medications, including Heparin and Zemplar, was found in a resident's room. Additionally, dialysis fluids were left unsecured on the resident's bedroom floor. The resident, who had end-stage renal disease and severe cognitive impairment, reported that an outside agency used the cart and fluids for in-room dialysis, and was unaware that the medications and fluids were left unlocked. Facility staff, including the RN and DON, confirmed that both the contract dialysis nurse and facility nursing staff were responsible for ensuring these items were secured, but acknowledged the oversight. Another incident involved an unsecured and unattended Advair Diskus inhaler found in a common area near the nurse's station. The inhaler, which was not labeled with a resident's name and had 57 doses remaining, was left in the basket of a vital sign machine with no staff or residents present. When shown the medication, an LVN acknowledged that it should have been locked on a cart and immediately removed it to secure storage. Facility leadership, including the ADM and DON, stated that nurses and medication aides were responsible for maintaining medication security and that environmental rounds were conducted to monitor for unsecured medications. A review of facility policy confirmed that medications and biologicals are to be stored safely and securely, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. Despite this policy and staff training, the survey identified lapses in medication security, with medications left unlocked and unattended in both resident rooms and common areas.
Failure to Timely Clean Resident Room After Regurgitation Incident
Penalty
Summary
A deficiency occurred when a resident's bedroom floor was not cleaned of regurgitated food for nearly three hours, from 11:50 AM to 2:40 PM. The resident, a male with diagnoses including Parkinson's Disease, encephalopathy, prostate cancer, unspecified dementia, and a psychotic disorder with hallucinations, was observed to have dried regurgitated food on both sides of his bed. The resident, who was cognitively intact and had dysphagia, reported feeling 'nasty' due to the presence of the regurgitated food, which had been there for an extended period. Staff interviews revealed that the CNA assigned to the hallway was unaware of the mess and stated that CNAs were responsible for ensuring resident rooms were kept clean and free from food or liquids on the floor. The LVN confirmed that both CNAs and housekeeping were responsible for maintaining cleanliness, with housekeeping making morning rounds and being available on a PRN basis. The DON and Administrator both stated that staff were expected to report and address spills or debris promptly, with the Administrator specifying that debris should not remain on the floor for over an hour. A review of facility records showed a recent complaint regarding room conditions, and the facility's policy emphasized the right of residents to a safe, clean, and comfortable environment. Despite these policies and expectations, the regurgitated food remained on the resident's floor for several hours, indicating a failure to maintain a sanitary and homelike environment as required.
Expired Catheters Not Removed from Medication Room
Penalty
Summary
The facility failed to ensure that expired gentle female intermittent catheters were removed from the medication room, as required by their internal auditing procedures. During an observation, unopened catheters with a manufacturer expiration date of 06-01-24 were found stored in the medication room. Interviews with staff revealed that the medication room was supposed to be audited for expired supplies daily by the ADON and twice weekly by Central Supply Personnel, with oversight by the DON. However, the presence of expired supplies indicated that these audits were not consistently or effectively performed. Staff members acknowledged that expired supplies should have been disposed of immediately and recognized the risk of infection associated with their use. Further interviews revealed inconsistencies in the auditing process and a lack of a specific policy addressing expired medical supplies. Central Supply Personnel stated that a monthly clean sweep was performed, in addition to twice-weekly checks, but was unaware of the expired supplies found. The DON and other staff members admitted to being unaware of the expired supplies and cited possible oversight. Additionally, an RN confirmed that there was no policy specifically covering expired medical supplies. These findings demonstrate a breakdown in the facility's processes for monitoring and removing expired medical supplies from resident care areas.
Expired IV and PICC Supplies Not Removed from Medication Room
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids by not removing expired IV and PICC supplies from the only medication room. During an observation and interview, multiple expired supplies were found, including Insyte Autoguard IV Catheters of various gauges and expiration dates, Invision Plus Needleless IV Connectors, and Stat Lock PICC Plus Stabilization Devices. These expired items were discovered despite the facility's stated procedures for regular auditing of the medication room by the ADON, Central Supply Personnel, and oversight by the DON. Interviews with staff revealed inconsistencies and lapses in the auditing process. The LVN present acknowledged that expired supplies should have been disposed of daily, and the DON, ADONs, and Central Supply Personnel each described different frequencies and responsibilities for auditing the medication room. Central Supply Personnel stated that a monthly clean sweep was performed, with additional twice-weekly checks, but was unaware of the expired supplies present. Additionally, it was reported that the facility did not have a specific policy addressing expired medical supplies.
Failure to Perform Hand Hygiene During Resident Feeding
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene while feeding a resident. During an observation, the CNA was seen texting on her cellphone while feeding the resident and did not use hand sanitizer before resuming assistance. The CNA later confirmed in an interview that she did not typically use her phone during feeding and acknowledged she did not sanitize her hands after using her phone before assisting the resident. The resident involved was a male with multiple diagnoses, including dementia, muscle wasting and atrophy, protein-calorie malnutrition, dysphagia, hypertensive heart disease, cerebral atherosclerosis, constipation, pain, muscle weakness, and benign prostatic hyperplasia. Facility policy required staff to use alcohol-based hand cleaner or soap and water before and after assisting a resident with meals, and staff were not permitted to use phones while feeding residents. The Director of Nursing confirmed that staff were expected to follow these protocols.
Failure to Timely Report Alleged Neglect and Injury of Unknown Source
Penalty
Summary
The facility failed to report an allegation of neglect involving a female resident with severe cognitive impairment, multiple comorbidities, and total dependence for activities of daily living. The resident complained of left knee pain, which was assessed by an LVN, and an x-ray was ordered after notifying the physician. The x-ray revealed a chronic fracture of the distal femur, and the resident was subsequently transferred to the hospital, where an acute oblique distal left femoral diaphyseal fracture was diagnosed, requiring surgical intervention. Despite these findings, the incident was not reported to the State Agency within the required timeframes. Interviews with the DON and Administrator revealed that the incident was not reported because the fracture was believed to be chronic and attributed to the resident's age and osteopenia, and thus not considered suspicious or related to abuse or neglect. The facility's abuse policy and relevant provider letters require immediate reporting of incidents involving neglect, exploitation, or mistreatment, including injuries of unknown source, but the facility did not follow these protocols in this case.
Inadequate Discharge Planning for Residents
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for the safe and orderly transfer or discharge of three residents. Resident #1, a female with moderate cognitive impairment and multiple health conditions, was discharged to a private residence with home health services arranged. However, there was a lack of documentation regarding her preferences for discharge planning, and the social worker did not have direct contact with the resident or her representative due to a previous poor relationship. The discharge process was rushed due to financial liability concerns, and the resident ended up at a different address than the one provided. Resident #2, a female with severe cognitive impairment and multiple health issues, was discharged to another nursing facility. The facility did not document the resident's preferences for discharge planning, and the social worker's communication with the resident's representative was inadequate. The representative felt pressured to accept a facility chosen by the facility, which was far from the family, and was not informed of the discharge date until the day of the transfer. The facility's failure to properly involve the resident's representative in the discharge planning process led to a lack of coordination and communication. Resident #3, a female with moderate cognitive impairment and various medical conditions, was discharged to a different skilled nursing facility due to dissatisfaction with care. The resident's representative chose the new facility, but the discharge process was poorly managed, with inadequate communication and no discharge meeting to discuss the transition, medications, or clinical information. This resulted in issues with medication orders at the new facility. The facility's discharge planning process did not adequately consider the residents' and their representatives' preferences and needs, leading to disorganized and potentially unsafe discharges.
Ineffective Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for three residents, which did not focus on the residents' discharge goals and did not allow them to be active partners in their transition. Resident #1, a female with moderate cognitive impairment and multiple health conditions, was discharged without her preferences for discharge planning being reflected in her care plan. The social worker (SW) did not have direct contact with Resident #1 or her responsible party (RP) due to a previous poor relationship, and the discharge address provided was not verified, leading to confusion about the resident's actual discharge location. Resident #2, who had severe cognitive impairment and required maximal assistance with activities of daily living, was discharged to a facility chosen by the SW without the RP's full cooperation or agreement. The RP was not informed of all available nursing facilities and felt rushed into a decision due to financial pressures on the facility. The RP was surprised by the discharge date and felt that the facility's choice of a new nursing facility was not suitable due to its distance from the family. Resident #3, with moderate cognitive impairment and dissatisfaction with the care received, was moved to a different skilled nursing facility chosen by the RP. However, the discharge process lacked proper communication and a formal discharge meeting, resulting in issues with medication orders at the new facility. The SW claimed to have followed the facility's discharge procedures, but the RP reported inadequate communication and planning, which could negatively affect the resident's health and psychosocial status.
Failure to Address Grievance Due to Lack of Grievance Official
Penalty
Summary
The facility failed to identify a Grievance Official responsible for overseeing the grievance process, which led to a grievance for a resident not being properly investigated or addressed. The resident, who had severe cognitive impairment due to Non-Alzheimer's Dementia, experienced an incident where another resident sat on her lap during a visit by her representative. The grievance was reported to the Social Worker (SW), who noted the incident in the Grievance Tracking Log and informed the Director of Nursing (DON) and the Administrator. However, the SW did not conduct a thorough investigation or implement additional interventions beyond the existing requirement for 24-hour staff presence in the Memory Care Unit. Interviews revealed that the DON was unaware of the grievance and did not know who the Grievance Official was, while the Administrator, who was supposed to be the Grievance Official, was not informed of the grievance. The facility's policy stated that the Administrator or their designee should oversee the grievance process, receive and track grievances, and lead necessary investigations. The lack of communication and oversight resulted in the grievance not being properly addressed, potentially leaving the resident's concerns unresolved.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen. During an inspection, several issues were identified, including improperly stored, labeled, and dated food items. Specifically, an opened jar of barbeque sauce was found in dry storage despite instructions to refrigerate it after opening. Additionally, a 25-pound bag of brown sugar was left exposed, and a plastic cup filled with peaches in the refrigerator was not labeled or dated. Rotten tomatoes with visible bruising and open holes were found in the walk-in refrigerator, along with an opened jar of jalapenos with a black substance around the lid and an expired date. An opened container of buttermilk was also found with an expired date, and a container of sliced vegetables in the freezer was covered but not labeled or dated. The Dietary Director acknowledged responsibility for ensuring expired and rotten foods were discarded and admitted that the expired and rotten items found were an oversight. She explained that staff members prepping food were responsible for labeling leftovers or prepared foods with the contents and preparation date. The director also noted that the barbeque sauce should have been refrigerated, and the brown sugar was awaiting a storage bin. The facility's Food Receiving and Storage policy mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated, aligning with the Food and Drug Administration Food Code requirements. These failures could potentially place residents at risk for foodborne illnesses.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in the resident missing seven doses of scheduled pain medication. The resident, who was under hospice care, was supposed to receive Oxycodone every four hours for pain management. However, the facility did not obtain the medication from the hospice company in a timely manner, leading to the resident experiencing unnecessary pain. The issue was identified after a surveyor inquiry prompted the delivery of the medication. The resident involved was an elderly female with a history of cancer, cancer-related pain, hypertension, depression, and anxiety. She had severe cognitive impairment and required scheduled and PRN pain medication. Despite the facility's care plan emphasizing the need for immediate response to pain complaints and evaluation of pain interventions, the resident's scheduled Oxycodone doses were not administered from the afternoon of one day through the afternoon of the next day. During this period, the resident received morphine for pain management, but she expressed a preference for Oxycodone and used morphine for breakthrough pain. Interviews with facility staff revealed a lack of communication and coordination with the hospice company responsible for delivering the medication. The acting DON, who had been in the position for only five days, was unaware of the medication delivery issue until informed by the surveyor and the resident. The facility's usual DON was on leave, and the acting DON, along with other staff members, failed to ensure the timely reordering and delivery of the resident's pain medication. The hospice company acknowledged the delay in medication delivery and implemented a new policy requiring nurses to personally check medication stocks.
Failure to Uphold Resident Dignity During Discharge and Dining
Penalty
Summary
The facility failed to ensure that Resident #218 was treated with dignity and respect during the discharge process. Resident #218, a female with Alzheimer's disease, anemia, type 2 diabetes mellitus with diabetic neuropathy, dementia, and legal blindness, was discharged from the facility to her home. The discharge process was mishandled as the resident was not picked up at the scheduled time, leading to a late-night transport. The Licensed Vocational Nurse (LVN) responsible for Resident #218 did not complete a full assessment or document vital signs before discharge, as she was unaware of the need to do so. The resident was found unresponsive upon arrival at her home, and the hospice nurse confirmed her death. Additionally, the facility failed to provide Resident #25 with a dignified dining experience. Resident #25, a male with Alzheimer's disease, non-Alzheimer's dementia, and depression, required assistance with meals. During a lunch meal service, the Assistant Director of Nursing (ADON) assisted Resident #25 while standing, which is against the facility's policy that emphasizes feeding residents with attention to safety, comfort, and dignity. The ADON acknowledged that standing while feeding a resident could compromise their dignity. These deficiencies highlight the facility's failure to uphold resident rights and dignity, as outlined in their policies. The lack of proper documentation and assessment during Resident #218's discharge and the inappropriate feeding method for Resident #25 demonstrate a disregard for the residents' dignity and quality of life.
Resident Access to Hazardous Item
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically by allowing a resident access to a disposable razor. The resident, a female with a history of stroke, schizophrenia, and anxiety disorder, was identified as moderately cognitively impaired and required assistance with personal hygiene tasks. Despite this, she was observed shaving her chin with a disposable razor, which she stated was provided by an unknown staff member. This incident occurred while the resident was lying in bed, and she mentioned that staff usually assisted her with shaving but were busy at the time. Interviews with facility staff, including an RN and the Administrator, confirmed that residents were not supposed to have access to disposable razors due to the risk of injury. The facility's policy on hazardous areas, devices, and equipment, dated July 2017, emphasized the importance of identifying and addressing hazards to ensure resident safety. The presence of the razor in the resident's room was a clear violation of this policy, as it posed a potential risk for injury or harm to the resident.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of a CNA during the care of a resident. The CNA did not perform hand hygiene while providing incontinence care to a resident with severe cognitive impairment and multiple health conditions, including hypertension, peripheral vascular disease, end-stage renal disease, non-Alzheimer's dementia, and aphasia following a stroke. The CNA was observed changing the resident's brief and cleaning him without washing or sanitizing his hands after removing gloves. He then proceeded to another resident's room without performing hand hygiene, despite the availability of hand sanitizer in the hallway. Interviews with the CNA revealed a lack of adherence to proper hand hygiene protocols, as he admitted to not using hand sanitizer due to its absence in the room and forgetting to wash his hands between resident rooms. The Director of Nursing and the Administrator both emphasized the importance of hand hygiene in preventing the spread of infections, stating that CNAs are expected to wash their hands between residents. The facility's policy on perineal care, which the CNA had been trained on, also outlined the necessity of washing hands thoroughly before and after care.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the State Survey Agency within the required two-hour timeframe. The incident involved a resident who reported to a therapist that a CNA had licked and nibbled his ear and inappropriately touched him during a shower. The therapist informed the facility's administrator, who conducted an internal investigation but did not report the allegation to the state, as required by regulations. The resident involved was a male with multiple diagnoses, including Parkinson's Disease, dementia, and a cognitive communication deficit, and had a BIMS score indicating moderate impairment. Despite the resident's initial report to the therapist, he later denied the allegations when questioned by the administrator. The administrator also conducted safe surveys with other residents, who did not report any abuse, and allowed the CNA to return to work with restrictions. The facility's policy requires immediate reporting of abuse allegations to state authorities, but the administrator chose not to report the incident, believing there was no risk after his investigation. The social worker expressed concern that not reporting the incident infringed on the resident's rights, but the administrator decided to handle the situation internally, contrary to the facility's policy and state regulations.
Failure to Update Resident Care Plan with Prostate Cancer Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident was not updated to reflect the diagnosis of prostate cancer, despite the resident having a history of this condition. This oversight was identified during a review of the resident's care plan, which had an initial date and a revision date, neither of which addressed the prostate cancer diagnosis. The MDS Coordinator, who had been in the position since October 2023, acknowledged that the care plan was not updated due to her still acclimating to her duties. She recognized the risk of neglecting the resident's needs because staff might not be aware of the prostate cancer diagnosis. The facility's policy requires changes in a resident's condition to be reported to the MDS Assessment Coordinator for review and updating of the care plan, which was not adhered to in this case.
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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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