Trinity Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Trinity, Texas.
- Location
- 314 E Caroline St, Trinity, Texas 75862
- CMS Provider Number
- 676439
- Inspections on file
- 38
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 22 (3 serious)
Citation history
Health deficiencies cited at Trinity Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with diabetes, hemiplegia, a colostomy, and an indwelling Foley catheter, who was care planned as dependent for toileting and at risk for skin breakdown, was found in bed with a strong urine odor, a urine-soaked pillowcase between the thighs, wet groin and inner thighs with redness, a saturated underpad with brown rings up to the upper back, and white, flaky skin around the penis, along with a small open area on a previously healed sacral wound and long, dirty fingernails. Two CNAs reported that residents were supposed to be checked every 2 hours, but one had only emptied the catheter bag earlier in the shift without providing incontinence care, and both indicated the resident appeared not to have been changed overnight. The resident stated staff had come in a couple of times overnight when the catheter began leaking, that this was the first visit that morning, that he could tell when he was wet, and that he disliked having dirty nails. The DON and Administrator confirmed expectations for 2-hour checks, walking rounds at shift change, and cleaning nails when visibly soiled, and acknowledged that being left wet was unacceptable and could result in skin breakdown, infections, or mental anguish.
A resident with incontinence, diabetes, and impaired mobility did not receive timely and appropriate skin assessment and care as outlined in the care plan and facility protocols. The resident reported long waits for incontinence care and ongoing genital discomfort. On observation, CNAs provided proper perineal care technique during the survey visit, but the resident’s scrotum was reddened and open wounds were present on the inner thigh. Nursing staff, including the charge nurse and treatment nurse, were unaware of any active skin issues because a CNA had noticed genital redness for about a week but failed to report it, instead applying barrier cream independently. Subsequent assessment identified new in-house moisture-associated skin damage/incontinence-associated dermatitis with documented wound measurements, despite existing policies and in-services requiring immediate reporting of redness and other skin changes.
A resident with Alzheimer’s disease, expressive language disorder, osteoporosis, and total dependence for ADLs was transferred with a mechanical lift by two CNAs who failed to lock the lift’s wheels as required by the care plan and facility policy. One CNA operated the lift without engaging the wheel lock, causing a wheel to lift off the floor during lowering, and then stood on the lift to force the wheel down while the other CNA guided the resident into a wheelchair. The CNA operating the lift reported she believed the lock was broken, stated she had previously informed the DON and had refused to use the lift in the past, and said this lift was used because other battery-operated lifts were not fully charged. The DON and Administrator stated that two staff are required for lift use, wheels should be locked when in position, staff should not use malfunctioning equipment, and issues should be reported, consistent with the facility’s safe lifting policy.
A resident with Alzheimer’s disease, expressive language disorder, osteoporosis, and total dependence for ADLs was care planned to require a Hoyer lift with two staff for transfers. During an observed transfer, two CNAs used a mechanical lift but one CNA failed to lock the wheels before lifting and moving the resident, resulting in a wheel lifting off the floor and the CNA standing on the lift to force the wheel down while the other CNA guided the resident into a wheelchair. One CNA stated she believed the wheel lock was broken, that this was the only usable lift because others were not charged, and that she had reported the issue and previously refused to use the lift. The DON reported that mechanical lift use required two staff, locked wheels, and competency check-offs on hire and annually, but documentation showed one CNA lacked a mechanical lift competency on hire and no such record was found for the other CNA, despite facility policy requiring competency evaluations.
A resident with severe cognitive impairment and a stage 4 pressure ulcer had active orders and a care plan requiring Enhanced Barrier Precautions (EBP), including gown and gloves, during high-contact care such as dressing. Despite an EBP sign posted on the door, a CNA provided incontinent care, dressed, and repositioned the resident while wearing only gloves and no gown, then left the room after discarding the gloves and sanitizing hands. In interviews, the CNA reported not realizing the resident was on EBP and noted the absence of PPE in the hallway, while the DON and Administrator confirmed that residents with chronic wounds require gown and glove use for high-contact care under facility policy and existing EBP orders.
A resident with metabolic encephalopathy, dementia, psychiatric illness, muscle weakness, and a history of falls experienced numerous witnessed and unwitnessed falls over several months, including falls with injury and visible bruising in various stages of healing. The resident, who required assistance with transfers and was identified as high risk for falls, was described by staff as impulsive, often refusing to use the call light and "throwing" himself between bed and wheelchair, especially to go smoke. Although some fall-prevention measures such as a low bed, fall mats, call light access, room rearrangement, frequent checks, therapy, pharmacy review, and occasional 1:1 supervision were in place, the DON acknowledged that no new interventions were implemented as falls recurred. Staff also reported limited facility-based behavioral training despite the resident’s challenging behaviors and worsening agitation after family-installed cameras were used to prompt him to get up, leading to the cited deficiency for failure to provide adequate supervision and to develop and implement effective fall-prevention interventions.
A resident with moderate cognitive impairment, multiple medical conditions, and significant behavioral issues (yelling, striking staff, throwing objects) sustained a skin tear on the forearm after a CNA, who reported being hit multiple times during ADL care, grabbed the resident’s arm/hand to block further blows. Nursing notes documented the behavior episode and resulting skin tear, and the family reported being told that the CNA grabbed the resident’s arm and also claimed to have video of the CNA grabbing the resident while assisting him back to bed. The Admin, who was out of the country at the time, acknowledged she did not report the allegation to the state, did not investigate it, and did not suspend the CNA, despite the facility policy requiring immediate (within 2 hours) reporting and thorough investigation of alleged abuse or injuries of unknown source. CNA and LVN staff stated they had not received facility-based behavioral training, even though they regularly cared for this behaviorally challenging resident.
A resident with moderate cognitive impairment, multiple comorbidities, and a history of falls required extensive assistance with ADLs and was known to exhibit agitation and striking behaviors. During ADL care, the resident screamed, struck a CNA multiple times, and attempted to hit her in the face; the CNA grabbed the resident’s arm/hand to block further hits, and the resident sustained a skin tear on the forearm that was later assessed and treated by nursing staff. The CNA and an LVN who witnessed the event reported the incident to the DON and the administrator, and the family was informed that the CNA had grabbed the resident’s arm and caused a laceration. The administrator, who was out of the country, acknowledged she did not personally report or investigate the allegation and assumed the DON had notified the state, resulting in the facility’s failure to report an alleged abuse incident to the administrator and State Survey Agency within the required 2-hour timeframe, contrary to its abuse investigation and reporting policy.
A resident with metabolic encephalopathy, bipolar disorder with psychotic features, impaired mobility, and moderate cognitive impairment experienced repeated falls and behavioral escalation over an extended period. Although the care plan identified high fall risk and psychotropic use, it contained only general fall precautions and basic behavior monitoring, without individualized interventions for impulsivity, aggression during care, or de-escalation strategies. Staff interviews confirmed the resident frequently became agitated, attempted to strike staff, and threw himself during transfers, and that they had no structured guidance in the care plan. The MAR included a PRN order for Naloxone (Narcan) and shift monitoring for opioid overdose, but the care plan did not address suspected overdose or emergency response actions. The DON acknowledged that no new interventions were added to the care plan despite ongoing falls and behavioral concerns.
A resident with multiple comorbidities, moderate cognitive impairment, and a history of substance abuse had a standing PRN order for intranasal naloxone (Narcan) for suspected opioid overdose and an order for shift-by-shift monitoring for overdose indicators, which staff consistently documented as absent. On one occasion, the resident was found unresponsive but breathing, and staff, who suspected possible drug use and opioid toxicity, called EMS but did not administer Narcan prior to EMS arrival, despite facility policy directing naloxone use when overdose is suspected and Narcan being available on-site. EMS administered two doses of intranasal naloxone, after which the resident became alert, while a CNA and an LVN later confirmed prior suspicions of family-provided drugs and uncertainty among staff about giving Narcan.
A resident with a PICC line for IV access did not have this device or its required care interventions included in their care plan, despite physician orders for dressing changes and ongoing IV therapy. Staff interviews confirmed the omission, and facility policy requires care plans to be updated to reflect all current needs.
A resident with a PICC line did not have their dressing changed within the required 7-day interval as ordered by the physician and facility policy. Staff interviews confirmed that only RNs could perform the dressing change, but the overdue change was not identified until the survey. The lapse was acknowledged by clinical leadership, who recognized the importance of timely dressing changes to prevent infection.
A resident with multiple chronic conditions and dependent on staff for ADLs did not receive scheduled showers or adequate hair care, resulting in a large hair mat that required cutting. Documentation of hygiene care was incomplete or missing, and staff did not consistently document or communicate refusals or care provided, contrary to facility policy.
A resident with multiple chronic conditions who required assistance with ADLs did not have complete or accurate documentation in their clinical records for baths, showers, hair care, or refusals of care. Staff interviews and record reviews confirmed that scheduled care and refusals were often not documented, and required notifications were not consistently made, contrary to facility policy.
The facility failed to promptly notify physicians and obtain wound care orders when residents experienced changes in condition, such as the development or worsening of pressure injuries. For example, a resident with a new unstageable pressure injury did not have the wound care physician notified for two days, and another resident admitted with severe pressure injuries did not have wound care orders implemented until several days after admission. Staff interviews revealed ongoing issues with accountability, documentation, and timely communication regarding wound care and physician notification.
Multiple residents with or at risk for pressure injuries did not receive timely or consistent wound care, weekly skin assessments, or implementation of dietary and support surface interventions as ordered. Nursing staff failed to document or perform required treatments, and there was a lack of accountability and communication regarding wound care orders and changes in condition, resulting in the development and worsening of pressure ulcers.
Two residents experienced significant medication errors when critical medications for hypertension, heart failure, and anticoagulation were either not administered or not ordered as required. One resident did not receive Metoprolol and Entresto as prescribed, while another did not have Entresto ordered upon admission and missed multiple doses of Eliquis, with documentation gaps in the MAR. Staff interviews revealed inconsistent practices in medication reconciliation, order entry, and documentation of refusals, contributing to these errors.
The facility failed to ensure that a resident who fell and hit her head received prompt assessment, neuro checks, and timely notification of the physician and family by the assigned RN, with required documentation and incident reporting not completed. Additionally, nurses did not perform or document head-to-toe skin assessments after a CNA identified possible ant bites on three residents, and weekly skin assessments were not documented as required.
A resident with multiple chronic conditions did not receive several ordered medications on multiple occasions, as shown by unexplained blanks in the MAR. Staff interviews indicated a lack of documentation and accountability for missed doses, and the resident reported increased pain when medications were not administered. Facility policy requires documentation for any missed or withheld medications, but this was not followed.
Staff failed to follow infection control protocols during care of three residents, including not performing hand hygiene before donning gloves, not changing gloves between dirty and clean tasks, and not wearing required PPE such as gowns during wound care under enhanced barrier precautions. These lapses occurred despite staff having received relevant training and facility policies outlining proper procedures.
A resident with multiple chronic conditions did not have a comprehensive care plan meeting held or rescheduled after a hospitalization, resulting in the resident and her representative not being invited or included in the required quarterly care plan review. Facility staff confirmed the oversight, and records showed no care plan conferences occurred after the missed meeting, contrary to facility policy requiring regular interdisciplinary care plan development with resident and representative participation.
The facility's kitchen failed to maintain sanitary conditions, with the dish machine not reaching the required temperature and expired, moldy food items found in the refrigerator. Staff were unaware of these issues, and the kitchen was short-staffed, complicating daily checks. The Administrator was not informed of the problems, and facility policies on dishwashing and food storage were not followed.
The facility failed to maintain an effective pest control program, resulting in a roach infestation in the kitchen. Observations revealed roaches on walls, floors, and near food preparation areas. Despite monthly pest control treatments, the issue persisted, with staff acknowledging the ongoing problem. The Administrator expressed concerns about foodborne illness risks due to the infestation.
The facility failed to complete baseline care plans within 48 hours for three residents, including a resident with cellulitis, another with a hip fracture, and a third with sepsis due to MRSA. This deficiency was identified through record reviews and staff interviews, revealing that the DON was responsible for ensuring these plans were completed, with the weekend RN handling weekend admissions. The facility's policy requires baseline care plans to be developed within 48 hours to meet residents' immediate care needs.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to hand hygiene and PPE protocols. A CNA did not sanitize hands between handling meal trays, and staff did not wear required PPE for residents on enhanced barrier precautions or contact isolation. These lapses in infection control practices could lead to cross-contamination and increased infection risk.
The facility failed to provide required effective communication training to six new staff members, including LVNs, a SW, and CNAs, during their orientation. This oversight was identified through employee file reviews and acknowledged by the Administrator, who was unaware of the training requirements. The DON recognized the potential risks of inadequate training, such as staff being unable to deescalate situations or communicate effectively with residents, especially those with dementia.
The facility failed to provide mandatory infection control training to five staff members upon hire, as required by their infection prevention and control program. This oversight was identified through interviews and record reviews, with the Administrator acknowledging the lapse and the DON assuming responsibility for future training.
The facility failed to ensure CNAs completed mandatory training in Abuse, Neglect, and Exploitation (ANE) and dementia management during orientation. Three CNAs were identified as not having completed these trainings, and interviews revealed a lack of awareness and responsibility for training requirements. The Administrator and DON acknowledged the potential risk to residents from untrained staff.
The facility failed to provide mandatory behavioral health training for six employees, including LVNs, a SW, and CNAs, upon hire. Personnel files showed no evidence of completed training, and interviews revealed a lack of awareness and oversight by the Administrator and DON, potentially placing residents at risk.
A resident's Hydrocodone-Acetaminophen tablets were misappropriated due to the facility's failure to follow proper medication receipt and storage procedures. Staff interviews revealed that the required verification process involving two nurses and the pharmacy delivery person was not adhered to, leading to the medication's disappearance. The incident was reported to the police for investigation.
A resident's room in an LTC facility was found to have a privacy curtain with a suspected feces stain and a wheelchair with a strong urine odor. Staff interviews revealed inconsistencies in cleaning responsibilities and schedules, with the Maintenance Supervisor and housekeeping staff unaware of the issues until reported. The facility's policy on cleaning was not followed, leading to unsanitary conditions.
A facility failed to conduct a Level II PASARR review for a resident who returned from a behavioral hospital with a new diagnosis of major depressive disorder. The MDS Coordinator did not complete the necessary documentation, and the DON and Administrator were unaware of the PASARR process, leading to a lack of required evaluations and potential service provision.
The facility failed to provide necessary ADL assistance for two residents, leading to deficiencies in personal hygiene and grooming. A resident with COPD did not receive the required assistance with bathing, as her care plan indicated, and expressed not having a shower or bed bath in over a year. Another resident with a stroke was observed with long, dirty nails and reported not receiving proper nail care or a recent shower. Both residents expressed a desire to be clean, highlighting the facility's failure to follow care plans and ensure proper hygiene.
A resident with dementia and bipolar disorder was found with smoking materials in his possession, contrary to the facility's policy requiring supervision and secure storage of such items. The resident was observed with a lighter and cigarettes in his room and on his person, despite the facility's policy that smoking materials be locked away. The DON and Administrator confirmed the policy breach, acknowledging the risk of fire or injury.
The facility failed to document the required witness signatures for drug destruction in January and February 2025, with records lacking the necessary signatures from the DON, ADON, and Pharmacist. The DON was unaware that other staff could serve as witnesses, and the Administrator was not involved in the process, leading to a risk of drug diversion.
A resident with cognitive decline was found with Nystatin powder improperly stored at her bedside, despite not having an order or assessment to self-administer medications. Facility staff confirmed that the medication should have been secured in the medication cart, as per policy, to prevent unauthorized access and misuse.
The facility failed to maintain a gas stove in safe operating condition, with a malfunctioning pilot light causing gas leakage. The Maintenance Supervisor was unaware of the issue due to a lack of a maintenance logbook, and the Administrator was not informed of the problem by the Dietary Manager, who is no longer employed. The facility did not provide a policy for essential equipment maintenance.
The facility failed to ensure proper hairnet use by kitchen staff, as observed when the Dietary Manager and another staff member had exposed hair while preparing food. This oversight could lead to unsanitary conditions and food contamination, violating both facility policy and FDA Food Code standards.
A CNA failed to follow proper hand hygiene protocols during incontinent care for a resident with severe cognitive impairment and a history of UTIs. The CNA did not sanitize her hands between glove changes and exited the room with a glove on, breaching infection control practices. The DON was unaware of the incident, highlighting a lapse in infection prevention measures.
Failure to Provide Timely Incontinence and ADL Care Resulting in Poor Hygiene and Skin Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance and timely incontinence care to a dependent resident, resulting in poor personal hygiene and skin issues. The resident was an older adult with type 2 diabetes, colostomy, hemiplegia of the right dominant side, an indwelling Foley catheter, and an ostomy, and was care planned as dependent on staff for toileting hygiene and at risk for skin integrity problems. His care plans directed staff to keep his skin clean and dry, provide incontinence care as quickly as possible after voiding or bowel movements, ensure he was clean, dry, and free from odor, and maintain his dignity and privacy. On the survey date, two CNAs entered the resident’s room to provide incontinence care and noted a strong urine odor. The resident was in bed on an air mattress, with contractures in both hands and long, dirty fingernails with a dark brown substance underneath. When linens were pulled back, a urine-soaked pillowcase with a strong odor was found between his thighs, and his groin and inner thighs were wet with redness noted to the mid-thigh. The underpad was wet with urine and had a brown ring extending to his upper back, and his back was entirely wet from urine. White, dried, flaky skin was observed around the base of his penis, and an old healed sacral wound with a small open area was noted. The CNAs cleaned his genital area and catheter tubing and placed a clean underpad, and both stated he would receive a shower. One CNA stated that the resident’s condition appeared as if he had not been changed during the previous night, noting the bad urine odor and that his entire bed was wet. She reported that residents were to be checked every two hours and that she had last showered him two days earlier, at which time he had no redness or open areas on his buttocks. The other CNA, on her fourth day at the facility, stated that the resident looked very raw with a bad rash down his legs and that the brown rings on the wet underpad indicated he had been in that condition for a long time; she confirmed that rounds were supposed to be done every two hours and that earlier in her shift she had only emptied his catheter drainage bag without providing incontinence care. The resident reported that staff had come into his room a couple of times the previous night when his catheter began leaking and had placed something between his legs, that this was the first time anyone had come in that morning, that he could tell when he was wet, and that he did not like having dirty nails. The DON and Administrator both stated that residents should be checked at least every two hours, that walking rounds should be done at shift change to ensure residents are clean and dry, and that nails should be cleaned when visibly soiled, and acknowledged that being left wet would be unacceptable and could lead to skin breakdown, infections, or mental anguish.
Failure to Assess and Report Incontinence-Related Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, specifically related to skin assessment and incontinence care. The resident was an adult male with pneumonia, type 2 diabetes, and a right above-knee amputation, who was always incontinent of bowel and bladder and required extensive assistance with ADLs. His MDS and care plans documented bladder incontinence and potential for altered skin integrity, with interventions including incontinent care after each episode, weekly skin inspections, keeping skin clean and dry, and notifying appropriate staff of any new skin breakdown. At the time of survey, there were no documented active ulcers, wounds, or skin problems for this resident. During interview, the resident reported frequently waiting 30 minutes to an hour for incontinent care, stated he was currently wet and had not been changed that day, and described pain and itching around his genitals. He reported that staff often answered his call light and said they would return but did not come back. Observation of incontinent care by CNAs showed appropriate technique during that episode, but the resident’s scrotum was reddened and open wounds were visible on his right thigh/groin area. The charge nurse initially stated the resident had no active skin integrity issues and that no new concerns had been reported, and the treatment nurse also reported being unaware of any open wounds or active wound care orders for this resident. Further interviews revealed that a CNA had observed redness to the resident’s genitals and surrounding skin for about a week but did not report it to nursing staff, instead applying barrier cream on her own because the redness “comes and goes.” This was contrary to facility expectations and prior in-service education that CNAs immediately report any skin integrity concerns, including redness and rashes, to nursing staff. When the treatment nurse subsequently assessed the resident, she identified open wounds on the right inner thigh and redness to the scrotum, and a skin assessment documented new in-house moisture-associated skin damage/incontinence-associated dermatitis measuring 10 cm by 10 cm. Facility policies and in-service materials required perineal care to prevent infection and skin irritation and to observe skin condition, and directed staff to notify the wound care nurse immediately for new wounds, rashes, redness, or any abnormal skin finding, which did not occur in this case.
Improper Use of Mechanical Lift During Dependent Resident Transfer
Penalty
Summary
The facility failed to ensure a resident’s environment remained as free of accident hazards as possible when staff did not properly and safely use a mechanical lift during transfers. The resident was an elderly woman with Alzheimer’s disease, expressive language disorder, osteoporosis, and documented ADL self-care performance deficits and limitations in physical mobility. Her care plan and MDS indicated she was dependent on staff for all ADLs, including transfers, and required a Hoyer lift with two staff for transfers. During an observed transfer, two CNAs applied the sling and used the mechanical lift to move the resident from bed to wheelchair. CNA B widened the base and placed the lift under the bed, but did not lock the wheels before lifting the resident. After elevating the resident, CNA B closed the legs of the lift, moved it to the wheelchair, then widened the base again and began lowering the resident. As the resident was being lowered, one of the lift’s wheels lifted off the floor, and CNA B stood on the lift to force the wheel back into contact with the floor while CNA A guided the resident into the wheelchair. In interviews, CNA B stated she knew she should have locked the wheels but claimed the wheel lock was broken and that this lift was usually the only one available because the other two battery-operated lifts were never fully charged. She reported she had informed the DON that the lift’s wheels could not be locked and that the lift had been in this condition since she started working there about three months earlier. She also stated she had previously refused to use the lift but felt she was treated as lazy when she did so. CNA A reported she did not notice that the wheels were not locked and was not aware of any problem with the locks. The DON stated that two staff were required for mechanical lift use, that residents should be secured with one staff operating the lift and one guiding it, and that the wheels should be locked once in position. The Administrator stated staff should not use mechanical lifts if the locks did not work and should report issues to nursing, Maintenance, or the DON. The facility’s “Safe Lifting and Movement of Residents” policy required staff to be trained in the use of mechanical lifting devices and to be observed for competency and adherence to policies and procedures regarding safe equipment use.
Failure to Ensure Competent and Safe Use of Mechanical Lift During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff, specifically a CNA, had appropriate competencies and skill sets to safely use a mechanical lift for resident transfers. A resident with Alzheimer’s disease, expressive language disorder, osteoporosis, and significant ADL self-care and mobility deficits was care planned and assessed as dependent for all ADLs and requiring a Hoyer lift with two staff for transfers. On the observed date, two CNAs entered the resident’s room to transfer her using a mechanical lift, applied gloves, positioned the lift under the bed, and attached the sling that was already under the resident to the lift. During the transfer, CNA B did not lock the wheels of the mechanical lift before raising the resident from the bed. After lifting the resident, CNA B closed the legs of the lift, moved it to the wheelchair, then widened the base again and began lowering the resident. As the resident was being lowered, one of the lift’s wheels came off the floor, and CNA B stood on the lift to force the wheel back into contact with the floor while CNA A guided the resident into the wheelchair and detached the sling. CNA B later stated she knew she should have locked the wheels but claimed the wheel lock was broken and that this lift was typically the only one available because the other battery-operated lifts were never fully charged. CNA B reported she had been trained in mechanical lift use in the past, had informed the DON that the lift’s wheels would not lock, and that the lift had been in this condition since she started working at the facility about three months earlier. She also stated she had previously refused to use the lift but felt she was treated as lazy when she did so. The DON stated that two staff were required for mechanical lift use, that wheels should be locked when positioning, and that staff had competency check-offs on hire, as needed, and annually; however, she could not locate a mechanical lift competency checklist for CNA A and record review showed CNA B had no skills check-off on hire and none was provided before survey exit. Facility policy required facility- and resident-specific competency evaluations upon hire, annually, and as deemed necessary based on the facility assessment.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure staff followed its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident with a chronic wound. The resident was an older adult with dysphagia, hypertension, and a history of cerebral infarction, and had severe cognitive impairment with a BIMS score of 3. The resident’s care plan, revised in November 2025, documented a stage 4 pressure ulcer on the right lateral ankle and required EBP, including gown and gloves, during high-contact care. Physician orders and the facility’s order listing confirmed an active order for EBP beginning in November 2025, and an EBP sign was posted on the resident’s door. On the observed date, CNA A entered the resident’s room, where the EBP sign was posted, and provided incontinent care and dressing without wearing a gown, using only gloves. She dressed the resident and repositioned her in bed, then removed her gloves, discarded them, exited the room, and sanitized her hands. In a subsequent interview, CNA A stated she was unaware the resident was on EBP, did not notice the sign, and expected PPE to be available in the hallway, which it was not. She acknowledged that gown and gloves should be worn for residents on EBP during care such as dressing. The DON and Administrator both confirmed that the resident was on EBP, that gowns and gloves were required for high-contact care including dressing, and that the DON, as the Infection Preventionist, was responsible for ensuring staff were trained on infection control. The facility’s written policy on Personal Protective Equipment–Enhanced Barrier Precautions specified that gown and glove use is required during high-contact resident care activities, including dressing, for residents with chronic wounds.
Failure to Revise Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and develop and implement effective fall-prevention interventions for a cognitively impaired resident with a significant history of falls. The resident was an older male with metabolic encephalopathy, lack of coordination, bipolar disorder with psychotic features, muscle weakness, muscle wasting and atrophy, a lumbar compression fracture, and a documented history of falls. His quarterly MDS showed a BIMS score of 6, indicating moderate cognitive impairment, and he required partial to moderate assistance with sit-to-stand and bed-to-chair transfers. The care plan identified him as high risk for falls due to confusion, impaired balance, incontinence, unawareness of safety needs, narcotic and psychotropic medication use, poor balance, and unsteady gait, and noted that he would attempt to transfer from bed to chair without assistance. Despite this high fall risk, record review showed the resident experienced repeated falls over several months, including multiple falls on the same day and both witnessed and unwitnessed events in his room and other facility areas. Facility documentation listed numerous falls across June, July, August, and September, including six separate falls on one date and at least two falls with injury, one of which resulted in a laceration and another that led to EMS transport and hospital evaluation for altered mental status. EMS and hospital records noted a known history of multiple falls and visible bruising in various stages of healing, including to the face and a bandaged wound to the forearm. Interviews with staff and family confirmed that the resident had frequent falls and multiple bruises over his body from these events. Interviews revealed that the resident was described as impulsive, defiant at times, and often refused to use his call light, instead attempting to transfer himself, particularly to go smoke. The Administrator, DON, ADON, LVN, and CNAs reported that the resident would “throw himself” during transfers from bed to chair or chair to bed and that most falls occurred when he attempted to transfer without assistance, often from wheelchair to bed. Staff stated that interventions in place included lowering the bed, placing fall mats, ensuring call lights were in reach, rearranging the room, frequent checks, therapy involvement, pharmacy reviews, and, at times, one-on-one supervision when behaviors were “really bad.” However, the DON acknowledged that, despite a fall timeline showing multiple recurrent falls, there were no new interventions implemented with each fall. The facility’s own fall policy required assessment after each fall, identification of causes and patterns within 24 hours, and modification of interventions when falls recurred, but the record review and interviews showed that interventions were not consistently revised in response to the resident’s ongoing falls and behaviors. Additional interviews indicated gaps in staff training related to behavioral management for residents with challenging behaviors. CNA A, who frequently cared for the resident, reported that she had not been trained on the facility’s policy related to residents with behaviors, although she had EMT training from outside the facility. LVN A also stated she had not received behavioral training at the facility, relying instead on prior nursing experience. Staff and administration reported that the resident’s behaviors and falls worsened after the family installed cameras in his room and the family member began waking him for smoke breaks and speaking to him through the camera, which prompted him to attempt transfers despite his weak legs and dementia. The combination of the resident’s high fall risk, repeated falls with injuries, lack of consistent modification of interventions after each fall, and incomplete behavioral-specific training for staff led to the identified deficiency in providing adequate supervision and assistive devices to prevent accidents. The facility’s written policy, “Assessing Falls and Their Causes,” required that after each fall, staff assess the resident, identify potential causes and patterns within 24 hours, and modify interventions when falls continued despite existing precautions. However, the DON’s review of the fall timeline and her statement that there were no new interventions with each fall demonstrated that this policy was not followed for this resident. Staff interviews consistently described the resident as frequently falling, having multiple bruises, and being known to throw himself during transfers, yet the interventions remained largely unchanged over time. This failure to adjust the care plan and interventions in response to the resident’s ongoing falls and behaviors, in the context of his complex medical and cognitive conditions, formed the basis of the deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.
Failure to Protect Resident From Physical Abuse and to Report and Investigate Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired male resident from physical abuse and to ensure staff were trained and knowledgeable in responding appropriately to resident behaviors. The resident, with metabolic encephalopathy, bipolar disorder with psychotic features, lack of coordination, muscle weakness, muscle wasting and atrophy, a lumbar vertebral compression fracture, a history of falls, and a BIMS score of 6 indicating moderate cognitive impairment, required supervision or assistance with personal hygiene, transfers, bed mobility, toileting, dressing, and bathing. Nursing documentation shows that on one morning the resident was yelling loudly and continuously in the hallway, and when a CNA entered his room, he was irritated and agitated, struck the CNA four times, and attempted to strike her in the face. The CNA reported grabbing the resident’s arm to prevent being struck, after which the resident pulled his arm away, resulting in a skin tear. Later that day, nursing documentation identified a 5 cm x 2.5 cm skin tear on the resident’s left forearm, which was treated, and the NP and Administrator were notified. The resident’s family member reported being notified that a CNA had grabbed the resident’s arm and caused a laceration during ADL care in his room and stated that video she viewed showed the CNA grabbing the resident’s arm while assisting him back to bed, although she did not provide the videos. CNA A stated that the resident had severe behavioral issues, including screaming, yelling, throwing objects, hitting staff, and attempting to break things, and that he often required one-on-one attention. She described an incident in which the resident struck her multiple times in the chest during ADL care, and she reacted by grabbing his hand and blocking him from hitting her again, which caused a small skin tear on his arm. She indicated she was unsure if an investigation had been done and that she had not been suspended after the incident. The Administrator stated she was on vacation when notified that CNA A had grabbed the resident’s arm, causing a skin tear, and that the DON was the assigned abuse coordinator and should have reported the incident to the state. She acknowledged she did not personally report the incident, investigate the allegation, or suspend the alleged perpetrator, and said she assumed the DON had reported it. She also stated that a state surveyor later told her she did not need to report it. LVN A reported that the resident had moderate dementia with behavioral disturbances that escalated with family involvement and camera installation, and confirmed witnessing the resident attempt to hit CNA A, who then grabbed his hand, causing a skin tear, and that she reported the incident to the DON and Administrator. Both CNA A and LVN A stated they had not received behavioral training at the facility, despite the facility’s Abuse Investigation and Reporting policy requiring all alleged violations involving abuse, neglect, or injuries of unknown source to be reported immediately, but no later than two hours if abuse or serious injury is suspected, to the administrator and appropriate agencies, and requiring a thorough internal investigation and timely notification of outcomes.
Failure to Timely Report Alleged Abuse Involving Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively impaired male resident with multiple medical conditions, including metabolic encephalopathy, bipolar disorder with psychotic features, muscle weakness, and a history of falls. The resident required extensive assistance with transfers, bed mobility, toileting, dressing, and bathing, and had a BIMS score of 6, indicating moderate cognitive impairment. On the date of the incident, nursing documentation noted the resident was heard screaming loudly and continuously; a CNA entered the room and reported that the resident appeared irritated and agitated, screamed at her, struck her four times, and attempted to strike her in the face. The CNA stated she grabbed the resident’s arm to prevent injury to herself, and the resident pulled his arm away, resulting in a 5 cm x 2.5 cm skin tear to the left forearm. Subsequent nursing documentation recorded discovery and treatment of the skin tear, including cleansing with normal saline, application of steri-strips, and notification of the NP and the administrator later that day. The resident’s family member reported being notified by the facility that a CNA had grabbed the resident’s arm and caused a laceration during ADL care, and stated she had video showing the CNA grabbing the resident’s arm while assisting him back to bed, although she did not provide the videos. Interviews with staff confirmed the physical interaction: the CNA reported that during ADL care the resident struck her multiple times in the chest, and she reacted by grabbing his hand to block further hits, which caused a small skin tear. An LVN who was present stated she saw the resident attempt to hit the CNA, who then grabbed the resident’s hand, causing the skin tear, and reported the incident to the DON and administrator. The administrator stated she was on vacation and out of the country when she was notified of the incident involving the CNA grabbing the resident’s arm and causing a skin tear. She identified the DON as the assigned abuse coordinator and said the DON should have reported the incident to the state, but acknowledged she did not personally report the incident, investigate the allegation, or suspend the alleged perpetrator, and assumed the DON had called the incident into the state. The CNA and LVN both indicated they reported the incident to the DON and administrator, and the CNA identified the administrator as the facility’s abuse coordinator. Review of the facility’s Abuse Investigation and Reporting policy, revised July 2017, showed that all alleged violations involving abuse, neglect, or injuries of unknown source must be reported immediately, but no later than two hours if abuse or serious injury is suspected, to the administrator and appropriate agencies, including the State Survey Agency. The facility failed to ensure this allegation of abuse was reported within the required two-hour timeframe as required by federal and state regulations and facility policy.
Failure to Revise Care Plan for Falls, Behaviors, and Naloxone Use
Penalty
Summary
Surveyors identified a failure to revise and implement a comprehensive, person-centered care plan for a male resident with metabolic encephalopathy, bipolar disorder with psychotic features, impaired mobility, muscle weakness, and a history of repeated falls. The resident had a BIMS score of 6, indicating moderate cognitive impairment and impaired safety awareness, and required extensive assistance with ADLs and transfers. Facility fall tracking showed numerous falls over several months, including multiple falls on the same day, reflecting ongoing unsafe transfer attempts, impulsive behavior, and poor safety awareness. Although the care plan identified the resident as high risk for falls and listed general fall-prevention measures, it was not updated with new or individualized interventions despite the continued pattern of falls and documented injuries such as skin tears, abrasions, periorbital bruising, and a laceration. The resident also had a care plan for Risperdal use related to bipolar disorder with severe psychotic features, but this plan only directed staff to monitor and record target behaviors and did not include individualized interventions for behavioral escalation, impulsivity, or aggression during care. The care plan lacked guidance on de-escalation techniques or safe response strategies during combative episodes, even though interviews with a CNA and an LVN confirmed the resident frequently became agitated, attempted to strike staff, and threw himself during transfers. Additionally, the MAR showed an active order for PRN Naloxone (Narcan) nasal spray and a requirement to monitor each shift for signs and symptoms of opioid overdose, yet the care plan did not address suspected overdose or changes in condition requiring emergency response, nor did it provide instructions on when or how to respond to suspected overdose. The DON acknowledged that no new interventions were added to the care plan despite recurrent falls and behavioral concerns, and no care plan policy was provided upon exit.
Failure to Administer Ordered Naloxone for Suspected Opioid Overdose
Penalty
Summary
Facility nursing staff failed to administer ordered naloxone (Narcan) to a cognitively impaired male resident when he was found unresponsive but breathing, despite having a standing PRN order for intranasal naloxone for suspected opioid overdose. The resident’s medical record showed multiple diagnoses including metabolic encephalopathy, bipolar disorder with psychotic features, muscle weakness, and a history of falls, with a BIMS score indicating moderate cognitive impairment and a need for assistance with transfers. The MAR for the month documented a standing order for naloxone nasal spray to be given every 2 minutes as needed for suspected opioid overdose, as well as an order to monitor each shift for signs and symptoms of opioid use or overdose, with staff consistently documenting that no such signs were present. On the date of the incident, EMS was called for the resident being unresponsive; upon EMS arrival, facility staff reported that Narcan had not been administered. EMS documentation showed that the resident was unresponsive on EMS arrival and that two doses of intranasal naloxone were administered, after which the resident became alert and verbally responsive, with stable vital signs. EMS notes also recorded that an unknown nurse reported no narcotic medications had been given by the facility and that staff suspected the family might be providing drugs during visits, with a known history of substance abuse prior to admission. A CNA reported having prior suspicions that the family was bringing in street drugs, noting that the resident’s condition would change and he would become unresponsive after family visits, and that she had previously observed EMS administer Narcan with immediate improvement. An LVN confirmed that staff suspected possible drug use or opioid toxicity based on the resident’s history and symptoms of unresponsiveness and lethargy, but stated they waited for EMS because they were unsure if it was safe to give Narcan. The DON confirmed Narcan was available in the Omnicell, staff had been trained, and facility policy directed staff to call 911 and administer naloxone when opioid overdose was suspected, but it was not administered by facility staff before EMS arrival in this event.
Failure to Include PICC Line Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a PICC line for intravenous access. Despite physician orders for regular PICC/Midline dressing changes and the presence of the PICC line, the resident's care plan did not include any interventions or maintenance instructions related to the PICC line. The care plan only addressed antibiotic therapy for infections but omitted the specific needs and care associated with the resident's IV access. Interviews with facility staff, including the MDS Coordinator, Director of Clinical Operations, and Administrator, confirmed that the care plan was incomplete and did not reflect the resident's current needs regarding the PICC line. The staff acknowledged that the omission could result in the resident not receiving necessary care. Facility policy requires that care plans be comprehensive, person-centered, and updated as resident conditions change, but this was not followed in this instance.
Failure to Change PICC Line Dressing per Physician Order
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of parenteral fluids by not managing a resident's PICC line dressing according to professional standards and physician orders. The resident, who had multiple diagnoses including UTI, type 2 diabetes, vascular dementia, hypertension, and hemiplegia, was admitted with an order for PICC/Midline dressing changes using sterile technique every 7 days or as needed if the dressing became wet or soiled. Observations revealed that the PICC line dressing was dated 10 days prior, exceeding the 7-day interval specified in the physician's order and facility policy. Interviews with staff, including an LVN, ADON, Director of Clinical Operations, and the Administrator, confirmed that only RNs were permitted to change PICC line dressings and that the dressing had not been changed as required. The staff were not aware that the dressing change was overdue until it was pointed out during the survey. The facility's policy and the physician's order both required dressing changes at least every 7 days, but this was not followed for the resident in question. The failure to change the dressing as ordered was acknowledged by multiple staff members, who also recognized that not adhering to the schedule could place residents at risk for infection.
Failure to Provide Required Hair Care and Scheduled Hygiene Services
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs), including personal hygiene and grooming, did not receive necessary hair care and scheduled showers or baths. The resident, who had multiple diagnoses such as cognitive communication deficit, muscle wasting, Parkinson's disease, diabetes, dementia, and major depressive disorder, was assessed as requiring assistance with personal care and was dependent for showers and partial/moderate assistance with hair care. Despite these needs, documentation showed missed or incomplete records for scheduled showers and personal hygiene, with several days lacking any documentation or indication of care provided. There was also no documentation specific to hair care, and no refusals were noted in the records for the relevant period. The resident developed a large mat of hair at the back of her head, which had to be cut out. Family concerns were raised when a family member discovered the hair mat during a visit and noted that she had not been notified of any refusals for showers. Staff interviews revealed that the resident often refused showers and hair care, preferring bed baths, but when bed baths were provided, hair care was not performed. Staff also admitted to sometimes missing documentation of refusals and not always informing the charge nurse as required. The care plan did not include specific interventions for hair care refusals, and there was a lack of consistent documentation and communication regarding the resident's refusals and the care provided. Interviews with nursing and administrative staff confirmed that the expectation was for residents to receive scheduled showers and hair care, and that refusals should be documented and reported. However, staff were not consistently aware of the resident's refusals or the lack of hair care, and notifications to family members were not made until after the issue was identified. The facility's own policy required documentation of care provided, refusals, and notification of supervisors, but these procedures were not followed, resulting in the resident not receiving necessary grooming and hygiene services.
Failure to Document ADL Care and Refusals in Resident Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for a resident who required assistance with activities of daily living (ADLs), specifically regarding documentation of baths, showers, hair care, and refusals of care. The resident, who had multiple diagnoses including cognitive communication deficit, muscle wasting, Parkinson's disease, diabetes, dementia, and major depressive disorder, was dependent on staff for personal hygiene and bathing. The care plan indicated the need for extensive assistance with bathing or showering at least three times weekly, and interventions were in place to notify a family member in case of refusals. However, there was no intervention specific to hair care refusals or documentation. Record reviews revealed multiple dates with missing documentation for both personal hygiene and bath/shower care, as well as a lack of documentation regarding hair care and refusals. Comprehensive CNA Shower Review sheets also lacked entries for hair washing on several dates. Nurse progress notes did not include any documentation of refusals for baths, showers, or hair care. Interviews with staff confirmed that the resident often refused showers and hair care, but these refusals were not consistently documented, and staff sometimes failed to notify the charge nurse as required by facility policy. The facility's policy required all services provided, progress toward care plan goals, and any changes in the resident's condition to be documented in the medical record, including refusals and notifications to family or physicians. Despite this, staff interviews and record reviews confirmed that documentation was incomplete or missing for several scheduled care events, and refusals were not properly recorded or communicated, resulting in a failure to maintain clinical records in accordance with accepted professional standards.
Failure to Notify Physicians and Obtain Timely Wound Care Orders Following Changes in Resident Condition
Penalty
Summary
The facility failed to promptly notify physicians and obtain appropriate wound care orders when residents experienced changes in condition, specifically related to pressure injuries. For three residents reviewed, there were significant lapses in communication and documentation. One resident developed an unstageable pressure injury to the right heel, but the wound care physician was not notified until two days after the injury was identified, and there was no documentation of physician notification or wound care orders on the day the wound was discovered. Additionally, after a surgical debridement, the facility did not contact the surgeon or wound care physician to obtain updated wound care orders. Another resident was admitted with bilateral stage 4 pressure injuries to the heels, but the facility did not obtain or implement wound care orders until several days after admission. Documentation showed that while the resident's physician was notified of the admission, there was no evidence that the wounds were reported or that wound care orders were requested at that time. For a third resident, the facility failed to monitor and report the status of a stage 4 pressure ulcer to the wound care physician, and there were gaps in the completion of required skin assessments. Interviews with staff revealed ongoing issues with accountability and follow-through regarding skin assessments and wound care. The facility did not have a dedicated treatment nurse, and regular nursing staff were responsible for these tasks, leading to inconsistent completion of assessments and treatments. Staff also reported confusion about when and how to notify physicians and document changes, and there was a lack of clear processes for ensuring timely physician notification and order implementation when residents' conditions changed.
Removal Plan
- Contact the facility wound care consulting provider to ensure no information had been relayed regarding the residents currently under care.
- Discuss Residents #11, #12, and #13 with the MDS Coordinator and the Assistant Director of Clinical Operations; ensure no new orders are needed.
- Contact the consulting wound care physician and inform of the resident being seen by the surgeon, debridement, and wound deterioration.
- Contact the resident representative and inform of the debridement, deterioration of the wound, and ask which consulting wound physician is preferred.
- Contact the wound care consulting physician to inform of the most recent measurements and wound condition for Resident #12.
- Compare wound measurements and condition for Resident #13 to previous observations and notify the wound care consulting physician.
- Notify the resident representative for Resident #13.
- Compare all measurements and wound condition observations to previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician.
- Re-educate all nurses present regarding when to report skin issues to the provider vs. the wound care consulting physician, how to document physician communication regarding wound care, and how to contact the wound care consulting physician.
- Continue in-service until all nurses have been in-serviced and provide re-education prior to beginning their next scheduled shift.
- Review the 24-hour report to ensure a progress note is written when the wound care physician visits each resident and when the wound care physician is contacted to update with changes in wound condition.
- Provide education to all nurses regarding the completion of the Skin Issues evaluation when a new wound is discovered or when a resident is admitted with a wound, to notify the Director of Nurses and Facility Administrator, to notify the attending physician and/or the consulting wound care physician to obtain treatment orders and begin treatment orders immediately upon receipt, to make a notation on the 24-hour report of the new wound and to inform the Certified Nurse Aides of the residents wound and any changes needed for the residents plan of care.
- In-service nurses regarding admitting a resident with wounds, informing the physician of wound(s) discovered during the initial assessment, obtaining orders for treatment, ensuring orders for treatment are initiated immediately (not when electronic health record defaults to the next day), and inquiring about existing wound when receiving report from the discharging facility.
- Re-educate nurses regarding notification of the physician when there is a change in condition of a wound and remind to document all physician interaction in the electronic health record.
- Replace the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management to ensure treatment and services are provided to prevent and heal pressure ulcers.
- Hold a daily stand-down meeting by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately.
- Conduct an impromptu QAPI meeting with the Facility Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations and Assistant Director of Clinical Operations.
- Ensure all residents have a current skin assessment completed and documented in the electronic health record and all residents with wounds are evaluated to ensure all appropriate interventions are in place and the attending physician and consulting wound care physician have been notified.
Failure to Provide Timely and Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure injuries for four residents. For one resident, weekly skin assessments were not completed after a certain date, and there was a delay in obtaining and implementing wound care orders after an unstageable pressure injury was identified. Additionally, dietary recommendations from the dietician were not implemented, and wound care treatments were missed on multiple days, with no documentation of resident refusal. Another resident was admitted with bilateral stage 4 pressure injuries to the heels, but wound care orders were not obtained or implemented until several days after admission, and head-to-toe skin assessments were not completed as required. Wound care was also missed on several days for this resident. A third resident experienced deterioration of an existing pressure wound, which progressed from stage 3 to stage 4 and increased in size. Wound care was not performed as ordered for ten days, and weekly skin assessments were not completed after a certain date. An intervention for a low air loss mattress, as specified in the care plan, was not implemented. For a fourth resident, wound care was not performed as ordered for ten days, and weekly skin assessments were not completed after a specific date. There was no documentation that this resident refused treatment for her wound. Observations and interviews revealed that staff were not consistently performing or documenting required skin assessments and wound care. The facility did not have a designated treatment nurse, and floor nurses were responsible for wound care and assessments, but these tasks were often not completed as scheduled. Staff interviews indicated a lack of accountability and follow-through, with missed documentation and communication lapses regarding wound care orders and changes in resident condition. Facility policies required notification of the attending physician for new skin alterations and evaluation and documentation of skin changes, but these procedures were not consistently followed.
Removal Plan
- Dietary recommendations for Resident #11 were approved with orders written.
- Consulting wound care physician was contacted by the Corporate Director of Clinical Operations regarding Resident #11's wound and treatment orders.
- Resident representative for Resident #11 was contacted to determine preferred wound care physician.
- Resident #11 scheduled to be seen by the wound care physician.
- Wound care consulting physician was contacted by the Corporate Director of Clinical Operations regarding Resident #12 to inform of most recent measurements and wound condition.
- Resident representative for Resident #12 was notified of current wound condition by the MDS Coordinator.
- Admitting nurse for Resident #12 was provided with individual education regarding ensuring residents admitted with a wound have orders for treatment, notifying the physician, and immediately rendering treatment upon admission.
- Wound care consulting physician was notified by the MDS coordinator regarding Resident #13's wound condition.
- Resident representative for Resident #13 was notified by the MDS Coordinator.
- All nursing staff present at the time of notation were provided with an in-service on how to document when a resident is not available for a visit by a consulting provider.
- Facility MDS coordinator evaluated all current wounds, measured wounds, and documented the condition of all wounds in the Skin Issue evaluation of the electronic health record.
- Nursing administration team compared all measurements and wound condition observations to previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician.
- All nurses present at the time of notification were re-educated in the form of an in-service regarding completion of weekly skin assessments, including how to complete the assessment, what to look for, when to complete the assessment, what to document, and when to report skin issues.
- Nurses will be provided with notification of consequences for failure to complete scheduled skin assessments during their shift.
- Completion of skin assessments will be monitored by the Director of Nursing and by the designated Weekend Nursing Supervisor.
- A complete head to toe skin inspection was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Assistant Corporate Director of Clinical Operations on all residents.
- Nurses present at the time of notification were in-serviced by the administrative nursing team regarding admitting a resident with wounds, informing the physician, obtaining orders for treatment, ensuring orders for treatment are initiated immediately, and inquiring about existing wounds when receiving report from the discharging facility.
- Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Facility Administrator were re-educated on reviewing the missing documentation report for the Treatment Administration Record from the electronic health record.
- The missing documentation report for Treatment Administration Records will be reviewed by the Director of Nursing during the morning clinical meeting.
- Facility Administrator will ensure review of missed documentation report, admission record review, admission order reconciliation, and review of the 24/72-hour report.
- Facility has begun the process of replacing the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management.
- Another provider has been contacted and is willing to provide wound care consultant nurse practitioner service.
- Facility Administrator and Administrative Nursing Team will review the nursing schedule to ensure one designated nurse is scheduled to review wounds, complete measurements, evaluate wound condition and prepare the weekly skin report at least once per week.
- Weekly skin report will be reviewed by the Administrative Nursing Team and the Facility Administrator to ensure all interventions are present including supplements/vitamins as recommended by the registered dietician, support surfaces are appropriate, and treatments are evaluated for effectiveness.
- Weekly skin report review meeting will occur on Tuesday of each week.
- The Assistant Director of Nursing will divide daily treatments/wound care between the day shift and night shift to allow floor nurses more time to complete the treatment/skin assessment processes.
- A daily stand-down meeting will be held by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately.
Significant Medication Errors Due to Omission and Documentation Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission and improper administration of critical medications for two residents. For one resident, Metoprolol and Entresto, both prescribed for hypertension and heart failure, were not administered as ordered on a specific evening. Additionally, upon admission from the hospital, Entresto was not ordered for another resident, despite it being listed on the hospital discharge medication list. This omission was not identified or corrected by the admitting nurse or subsequent staff responsible for medication reconciliation and order entry. The same resident also failed to receive Eliquis, an anticoagulant prescribed for atrial flutter, on eight occasions in a single month. The medication administration record (MAR) showed multiple blanks with no documentation to indicate whether the medication was given or refused. Interviews with nursing staff revealed inconsistent documentation practices, with some staff admitting to forgetting to chart medication administration or not following up on missed doses. There was also a lack of clarity and communication regarding the process for documenting refusals and ensuring that all medications were administered as ordered. The resident who missed multiple doses of Eliquis was later hospitalized and diagnosed with atrial fibrillation with rapid ventricular response, acute on chronic systolic and diastolic heart failure, and a small pulmonary embolus. Staff interviews indicated that the resident was sometimes noncompliant or refused medications, but there was no consistent documentation of refusals or evidence that appropriate notifications were made to the physician or family. The facility's policies required that all medication refusals or omissions be documented in the MAR, but this was not consistently followed, leading to significant medication errors.
Removal Plan
- The administrative nursing team (Director of Nursing, Assistant Director of Nursing and MDS Coordinator) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will complete medication order reviews for all residents admitted and re-admitted to ensure no residents are in jeopardy or threat of harm.
- Chart reviews of the remaining residents admitted and re-admitted will be completed by the administrative nursing team with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations to ensure accurate reconciliation of hospital discharge orders/admitting orders to those that were verified with the attending physician and transcribed into the electronic health record.
- Chart reviews will ensure all diagnosis/health conditions of residents is being/has been addressed/noted in the electronic health record.
- The Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator were counseled and provided with an in-service by the Director of Clinical Operations and the Assistant Director of Clinical Operations regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and reviewing the missing medication report each morning during the morning meeting process.
- The Facility Administrator will be responsible for ensuring the daily review of the missed medication report, admission record review, admission order reconciliation, and review of the 24/72-hour report. In the absence of the Facility Administrator the Director of Nursing will be responsible.
- All nurses and certified medication aides present at the time of the notification will be provided with in-service training regarding the admission/re-admission process, the admission/readmission medication reconciliation process, transcribing and carrying out physician orders, how to document different scenarios of medications not given (refused, spit out, held for vital signs outside of parameters, etc.), checking the dashboard throughout and at the end of their shift to ensure no medication documentation is missing.
- The staff in-service will be conducted by the Administrative Nursing Team and will continue until all nurses and certified medication aides have been provided with the beforementioned education; the remaining nurses and certified medication aides will be educated prior to beginning their next shift.
- All newly hired nurses and certified medication aides will be educated regarding how to document missed doses, refused doses, and accessing the dashboard to ensure all doses are accounted for before the end of their shift before beginning their first assigned shift.
- A QAPI meeting was conducted with the Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations, and Assistant Corporate Director of Clinical Operations. The root cause analysis of the alleged deficient practice was reviewed and interventions to correct and prevent future occurrence were discussed.
- The Consultant Pharmacist was contacted by the Corporate Director of Clinical Operations and discussed the alleged deficient practice; it was decided that all new and re-admissions to the facility will be reviewed by a pharmacist with the consultant pharmacy group every Monday, Wednesday and Friday.
- The Consultant Pharmacist will review all residents admitted /re-admitted to the facility. In addition to the regular medication regimen review the consulting pharmacist will reconcile current physician orders to those given from the discharging entity. Upon completion of his/her review, the consulting pharmacist will provide a summary of findings/recommendations to the Director of Nursing, Assistant Director of Nursing and Facility Administrator. Immediately upon receipt of the recommendations the Director of Nursing will ensure any physician recommendations are addressed and carried out.
- The recommendations from the consultant pharmacist will be reviewed during the morning meeting Monday through Friday and the Facility Administrator and Director of Nursing will verify they are complete with a physician acceptance or declination, orders corrected or changed as recommended/agreed to by physician, plan of care updated, and resident/resident representative informed of changes.
- The Corporate Director of Clinical Operations will provide an in-service to the Facility Administrator and administrative nursing staff regarding the review of the pharmacy consultant admission/re-admission drug regimen review/medication reconciliation process that is to be reviewed during the morning meeting every Monday through Friday.
- The facility nursing administration staff (Director of Nursing, Assistant Director of Nursing, and MDS Nurse) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will begin a full audit of all resident medication orders.
Failure to Provide Timely Assessment and Documentation After Falls and Skin Issues
Penalty
Summary
The facility failed to ensure that residents received care and services in accordance with professional standards of practice for four residents reviewed for quality of care. In one instance, a resident with dementia, osteoporosis, hypertension, and atrial fibrillation experienced a fall and hit her head. The care plan required immediate assessment, vital signs, and neuro checks, as well as notification of the physician and family. However, the assigned RN did not promptly assess the resident, did not conduct or document a neuro assessment, and failed to notify the physician and family in a timely manner. The incident was not documented in the 24-hour report, and the required incident report was not completed. The RN admitted to not documenting her actions and leaving work without completing the necessary paperwork, and the resident was not sent to the ER until the following day after further assessment by another nurse. Additionally, the facility failed to ensure that head-to-toe skin assessments were completed by a nurse after a CNA identified possible ant bites on three residents. Although the CNA reported the findings to the nurse and ADON, there was no documentation of a nursing assessment or progress note for the affected residents on the dates the bites were identified. Weekly skin assessments were also not documented for these residents during the relevant periods. Interviews with staff confirmed that nurses were responsible for completing these assessments and that there was a lack of accountability and follow-through in ensuring that assessments were performed and documented. Observations and interviews with residents confirmed the presence of ant bites and issues with ants in their rooms. Staff interviews revealed that the facility did not have a dedicated treatment nurse, and that nurses were responsible for weekly and as-needed skin assessments. The ADON and Administrator acknowledged ongoing problems with staff not completing required assessments and documentation, and that there was no system in place to hold staff accountable for these lapses. Facility policy required immediate assessment and documentation after falls and new skin issues, but these protocols were not followed in the cited cases.
Failure to Administer and Document Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident. Multiple instances were identified where ordered medications were not administered as scheduled, as evidenced by blank entries on the Medication Administration Record (MAR) for various dates. The missed medications included Levothyroxine, Calcium Carbonate, Cyclosporine drops, Tizanidine, Lyrica, Ativan, Atorvastatin, Toprol, Ramelteon, Ropinirole, Duloxetine, Entresto, and Topiramate. The MARs did not contain documentation or reasons for the missed doses, contrary to facility policy, which requires documentation if a medication is withheld, refused, or not given at the scheduled time. The resident involved was a female with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes, and hypothyroidism. She required maximal assistance with most activities of daily living and had an intact cognitive status. Her care plan included interventions to administer medications as ordered for conditions such as hypothyroidism, restless leg syndrome, chronic pain, neuropathy, anxiety disorder, and other chronic conditions. During interviews, the resident reported increased pain levels when medications were missed, although she was unsure which specific medications were not received. Staff interviews revealed a lack of awareness or recall regarding the missed medications. Nursing and medication aide staff stated that any held or refused medications should be documented in the MAR and a progress note made, but the MARs reviewed showed unexplained blanks. The Assistant Director of Nursing acknowledged ongoing issues with staff accountability and documentation, and administrative staff were unaware of the specific missed medications but confirmed that the expectation was for medications to be administered as ordered. The facility's policy requires safe, timely administration of medications and proper documentation when medications are not given.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff during care of three residents. One certified nursing assistant (CNA) did not perform hand hygiene before donning gloves and failed to change gloves or sanitize hands when moving from dirty to clean tasks during incontinent care. The CNA also placed clean linens and a gown on the resident while still wearing contaminated gloves, contrary to facility policy and infection control standards. The CNA acknowledged during interview that these actions were incorrect and could lead to cross-contamination. A licensed vocational nurse (LVN) was observed performing wound care for a resident with a stage 4 pressure ulcer. The LVN did not change gloves or perform hand hygiene between cleaning the wound and applying a clean dressing, despite recognizing during interview that this was required to prevent infection. Facility records confirmed that the LVN had received training on proper wound care technique, including enhanced barrier precautions, prior to the incident. Additionally, the MDS Coordinator failed to wear a gown as required under enhanced barrier precautions while providing wound care to a resident with a chronic wound. The resident's care plan and physician orders specified the need for enhanced barrier precautions, including gown and gloves, during high-contact care. The MDS Coordinator admitted during interview that a gown should have been worn and that failure to do so could expose residents to infection. Facility policy and staff interviews confirmed that residents with chronic wounds require enhanced barrier precautions and that appropriate signage should be posted to indicate this requirement.
Failure to Hold Timely Interdisciplinary Care Plan Meeting with Resident and Representative
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was prepared and reviewed by an interdisciplinary team with the participation of the resident and her representative for one resident. The resident, who had diagnoses including major depressive disorder, type 2 diabetes, and hypertensive heart disease with heart failure, was admitted to the facility and was cognitively intact, as indicated by a BIMS score of 15. She required assistance with eating, oral hygiene, and was dependent on staff for toileting. The resident was actively involved in her assessment and goal setting. A review of records showed that the last care plan conference for the resident occurred in March, with both the resident and her representative in attendance. Although another care plan meeting was scheduled for June, it was not held because the resident was hospitalized at that time, and the meeting was not rescheduled. There were no further care plan conferences documented for the resident after March, and the resident and her representative were not invited to any subsequent meetings. Interviews with facility staff, including the MDS Coordinator, AD, DOR, and DM, confirmed that the resident missed her quarterly care plan meeting and that the oversight was not corrected. Staff interviews revealed that care plan meetings were typically held weekly, with each resident expected to have a meeting quarterly and as needed. The MDS Coordinator was responsible for scheduling and conducting these meetings, which involved the IDT and addressed all aspects of the resident's care. Staff acknowledged that missing care plan meetings could result in residents and their representatives not being informed or able to address concerns. The facility's policy required the IDT, in conjunction with the resident and their representative, to develop and implement a comprehensive, person-centered care plan, which was not followed in this instance.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially expose residents to foodborne illnesses. During an observation, it was noted that the dish machine was not reaching the required temperature of 120 degrees as per the manufacturer's guidelines. The temperature gauge on the dish machine did not exceed 108 degrees, and the Dietary Aide (DA) was unaware of how to check the temperature or where to find it. The Dietary Manager (DM) acknowledged the issue and mentioned that the dish machine had been reaching the required temperature according to the dish machine log, but agreed to contact the company for repairs. Additionally, the facility failed to remove expired and spoiled food items from the refrigerator. Observations revealed nine containers of yogurt with past expiration dates, and boxes of cabbages, onions, cucumbers, and tomatoes that were either moldy or had a strong, unpleasant odor. The DM was unaware of these items and stated that the cooks and tray aides were responsible for checking the refrigerators daily. The Registered Dietitian (RD) confirmed that all foods should be labeled, dated, and expired or old foods should be removed to prevent residents from consuming them. Interviews with staff revealed that the kitchen was short-staffed, making it difficult to check refrigerators and freezers daily. The Maintenance Supervisor was not aware of the dish machine issue until it was reported by the Administrator, and there was no maintenance logbook to track issues. The Administrator acknowledged the oversight responsibility and stated that the dietary manager had not informed her of the kitchen issues. The facility's policies required food service staff to be trained in dishwashing machine use and to report inadequate temperatures immediately, but these procedures were not followed, leading to the deficiencies observed.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the kitchen. Observations on February 24, 2025, revealed roaches crawling on the walls, floor, and even on a recipe binder near food preparation areas. The Dietary Manager (DM) acknowledged the presence of roaches and mentioned that pest control services were conducted monthly. However, the issue persisted, as evidenced by further observations on February 25, 2025, where roaches were found on the steam table and walls. The Administrator, upon witnessing the infestation, instructed the staff to clean the kitchen and serve lunch on paper plates that day. Interviews with staff and the pest control representative indicated that the facility had been experiencing issues with roaches for some time. The Pest Control Representative noted that the kitchen was a problem area due to loose food and catch basins that attracted roaches. Despite monthly treatments with various chemicals, the infestation continued. The Maintenance Supervisor, who had been in her role for three months, confirmed the ongoing issue and mentioned that the kitchen was cleaned and sprayed with a residual bug spray. The Administrator expressed concerns about the risk of foodborne illnesses due to the pest problem and emphasized the need for a clean and pest-free kitchen.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for three residents, which is a requirement to ensure effective and person-centered care. Resident #167, a female with cellulitis, was admitted without a baseline care plan being completed. Her medical records indicated she was cognitively intact and required assistance with daily activities, had a diabetic foot ulcer, and was receiving treatment for an infection. Resident #174, admitted with a hip fracture, also did not have a baseline care plan implemented within the required timeframe. Resident #175, who was admitted with sepsis due to MRSA and had a surgical wound, did not have a baseline care plan initiated until several days after admission. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for ensuring baseline care plans were completed, with the weekend RN tasked with handling admissions during weekends. The MDS nurse acknowledged the importance of these care plans in communicating residents' needs and affecting discharge planning. The facility's policy, revised in December 2016, mandates that baseline care plans be developed within 48 hours of admission to meet residents' immediate care needs. The failure to adhere to this policy could result in staff not being adequately informed about how to care for the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with infection control practices. During meal service, a CNA did not wash or sanitize her hands between handling meal trays for different residents, which could lead to cross-contamination. Despite being aware of the need for hand hygiene, the CNA admitted to not receiving specific training on infection control during meal service. In another instance, a CNA did not wear the required personal protective equipment (PPE) while providing care to a resident on enhanced barrier precautions (EBP) due to a feeding tube. The CNA acknowledged the oversight and the potential risk of spreading germs to other residents. Similarly, another resident on contact isolation due to MRSA did not have appropriate signage, and staff entered the room without donning PPE, indicating a lack of awareness and adherence to isolation protocols. Additionally, staff failed to follow EBP protocols for a resident with a colostomy and urinary catheter, as observed when a nurse and a CNA provided care without wearing gowns. Despite training on infection control and PPE requirements, staff admitted to forgetting to use PPE, which could increase the risk of infections. The facility's policies on hand hygiene, PPE, and isolation precautions were not consistently followed, contributing to the deficiencies observed.
Failure to Provide Effective Communication Training to New Staff
Penalty
Summary
The facility failed to ensure that six new employees received the required training on effective communication during their orientation. The employees affected included two Licensed Vocational Nurses (LVNs), a Social Worker (SW), and three Certified Nursing Assistants (CNAs). The lack of training was identified through a review of employee files, which showed that these staff members had not completed the necessary training upon hire. This oversight was acknowledged by the Administrator, who admitted to being unaware of the training requirements. Interviews conducted during the investigation revealed that the Director of Nursing (DON) was not initially responsible for staff training, as this task was previously managed by the Assistant Director of Nursing (ADON). However, the DON recognized the potential risks associated with the lack of training, such as staff being unable to deescalate situations or effectively communicate with residents, particularly those with dementia. The facility's assessment tool highlighted the importance of training on effective communication, infection control, and dementia management, but these requirements were not met for the new employees in question.
Failure to Provide Mandatory Infection Control Training
Penalty
Summary
The facility failed to provide mandatory training on infection prevention and control standards, policies, and procedures to five staff members, including an LVN, a social worker, and three CNAs, upon their hire. The staff members in question were hired between October 2024 and February 2025, but their personnel files indicated they had not completed the required training during orientation. This oversight was identified through interviews and record reviews conducted by surveyors. During interviews, the Administrator acknowledged a lack of awareness regarding the training requirements and accepted responsibility for ensuring all staff receive proper training on hire and annually. The Director of Nursing (DON) indicated that the Assistant Director of Nursing (ADON) had previously been responsible for staff training, but the DON would now assume this responsibility. The absence of training could potentially place residents at risk of infection due to staff not being adequately trained in infection control practices.
Failure to Complete Mandatory CNA Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed mandatory training in Abuse, Neglect, and Exploitation (ANE) and dementia management during their orientation. This deficiency was identified for three CNAs, referred to as CNA O, CNA P, and CNA Q, who were reviewed for training compliance. The record review of employee files revealed that these CNAs, hired on different dates, had not completed the required trainings during their orientation period. Interviews conducted during the investigation highlighted a lack of awareness and responsibility regarding training requirements. The Administrator admitted to not knowing that these trainings were mandatory, while the Director of Nursing (DON) acknowledged that the Assistant Director of Nursing (ADON) had previously been responsible for staff training. The DON expressed concern that residents could be at risk of being cared for by untrained staff. The Administrator also recognized her ultimate responsibility for ensuring proper training and acknowledged the potential increased risk of harm to residents if staff were not adequately trained.
Failure to Provide Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to provide mandatory and effective behavioral health training for six employees, including two Licensed Vocational Nurses (LVNs), a Social Worker (SW), and three Certified Nursing Assistants (CNAs). These employees were not given the required behavioral health training upon hire, as stipulated by the facility's policy and regulations. The personnel files of these employees, hired between October 2024 and February 2025, showed no evidence of completed behavioral health training, which is essential for ensuring that staff can adequately care for residents with behavioral health needs. Interviews with the facility's Administrator and Director of Nursing (DON) revealed a lack of awareness and oversight regarding the training requirements. The Administrator admitted to not knowing that these trainings were mandatory and acknowledged her ultimate responsibility for ensuring staff received proper training. The DON indicated that the Assistant Director of Nursing (ADON) had previously been responsible for staff training, but she would now assume this responsibility. Both acknowledged that the absence of proper training could place residents at risk of being cared for by untrained staff.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically the diversion of Hydrocodone-Acetaminophen tablets. The incident involved Resident #17, a male with a history of cognitive impairment and other medical conditions, who was prescribed this narcotic pain reliever. The medication was reported missing on December 31, 2024, when it was discovered that a whole card of the medication was unaccounted for. Interviews with multiple staff members, including medical assistants, licensed vocational nurses, and registered nurses, revealed that the established procedure for receiving and verifying narcotic medications was not properly followed. The process required two nurses and the pharmacy delivery person to verify the medication count and sign off on the receipt, ensuring the medications were stored securely. However, discrepancies in the medication count were not identified at the time of delivery, and the medication was not appropriately secured, leading to its misappropriation. The Director of Nursing and the Administrator were informed of the missing medication and subsequently involved the police to investigate the incident. The facility's policies on medication delivery and abuse prevention were reviewed, highlighting the requirement for strict adherence to procedures to prevent such occurrences. Despite these policies, the failure to follow protocol resulted in the misappropriation of Resident #17's medication, compromising the resident's right to be free from such exploitation.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, specifically in relation to the cleanliness of a privacy curtain and a wheelchair. The resident, who was diagnosed with Alzheimer's disease, PBA, osteoporosis, and an expressive language disorder, was observed in a room where the privacy curtain had a large brown splatter stain, suspected to be feces, and the wheelchair had a strong urine odor. Staff members present during the observation acknowledged the issues and indicated that the night shift staff were responsible for cleaning the wheelchairs and cushions, but they were unsure about the cleaning schedule for the privacy curtains. Interviews with various staff members, including the Maintenance Supervisor, DON, and housekeeping staff, revealed a lack of clarity and consistency in the cleaning responsibilities and schedules for both the privacy curtains and wheelchairs. The Maintenance Supervisor admitted that there was no set schedule for cleaning the privacy curtains and that she was only made aware of the issue after it was reported. The Transport Driver, responsible for cleaning the wheelchairs, stated that he cleaned them monthly but did not have documentation to support this claim. Housekeeping staff were not consistently informed or trained about their responsibilities regarding the privacy curtains. The Administrator was unaware of the specific issues with the resident's environment but acknowledged that the Maintenance Supervisor and housekeeping staff were responsible for ensuring cleanliness. The facility's policy on cleaning and disinfection indicated that environmental surfaces should be cleaned according to CDC recommendations, but the lack of adherence to this policy contributed to the unsanitary conditions observed in the resident's room.
Failure to Conduct PASARR Level II Review for Resident with New Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed major depressive disorder for a Level II PASARR review following a significant change in condition. The resident, who was admitted with diagnoses including adjustment disorder with depressed mood, major depressive disorder, dementia, and osteoporosis, was discharged to a behavioral hospital and returned with a new diagnosis of major depressive disorder. Despite this, the facility did not complete a new Level 1 PASARR with the updated diagnosis, which is necessary to ensure the resident receives appropriate services. Interviews revealed that the MDS Coordinator, who was responsible for PASARR coordination, was unaware of the need to complete a form 1012 for further evaluation and did not complete the necessary documentation. The Director of Nursing and the Administrator were also not familiar with the PASARR process or the new diagnosis, leading to a lack of necessary evaluations and potential service provision for the resident. The facility's policy requires screening for mental disorders upon admission and readmission, but this was not adhered to in this case.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in personal hygiene and grooming. Resident #1, a cognitively intact female with chronic obstructive pulmonary disease, required assistance with bathing due to physical mobility limitations. Despite her care plan indicating the need for extensive assistance with bathing at least three times weekly, records showed she was documented as having bathed herself on multiple occasions without proper staff assistance. During an interview, Resident #1 expressed that she had not received a shower or bed bath in over a year, and staff had not offered alternative bathing methods, such as a bed bath, which she desired. Resident #173, a female with a diagnosis of cerebral infarction, was observed with long, dirty nails and reported not having received proper nail care or a recent shower. Her baseline care plan emphasized the need for anticipating and meeting all her needs to ensure well-being and dignity. However, documentation lacked evidence of nail care, and during an interview, she expressed a desire to be clean. The Director of Nursing acknowledged the risk of infection from inadequate nail care and showers, and the Administrator noted the importance of following care plans to prevent residents from feeling dirty and to reduce infection risks.
Failure to Supervise Resident Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to smoking policies for a resident, leading to a deficiency in preventing accidents and hazards. Resident #27, who has diagnoses of dementia, pneumonia, and bipolar disorder, was observed with smoking materials in his possession, contrary to the facility's policy. The resident was supposed to return his lighter and cigarettes to the staff after smoking, but he was found with these items in his room and on his person. The facility's policy requires that smoking materials be stored securely and only accessed under supervision, which was not adhered to in this case. Observations and interviews revealed that Resident #27 had been keeping his smoking materials in a metal container and had access to tobacco stored in the activity room. The Director of Nursing (DON) and the Administrator confirmed that no residents were allowed to keep smoking materials in their rooms, and the materials should be locked away. The failure to enforce these policies and ensure the resident returned his smoking materials after use posed a risk of fire or injury, as acknowledged by the facility staff.
Failure to Document Drug Destruction Witness Signatures
Penalty
Summary
The facility failed to establish a comprehensive system for documenting the receipt and disposition of controlled drugs, which is essential for accurate reconciliation and compliance with pharmacy service policies. Specifically, during the months of January and February 2025, the facility did not document the required number of witness signatures for drug destruction. On January 28, 2025, the drug destruction records were signed only by the Director of Nursing (DON) and the Pharmacist, lacking the necessary additional witness signatures. Similarly, on February 20, 2025, the records were signed solely by the Pharmacist without any witness signatures. Interviews revealed that the DON was unaware that staff other than herself and the Assistant Director of Nursing (ADON) could serve as witnesses for drug destruction. The absence of an ADON in January and the oversight in February contributed to the failure to obtain the required signatures. The Administrator was not involved in the drug destruction process and was unaware of the missing signatures, acknowledging the risk of drug diversion due to the lack of proper documentation. The facility's policy, revised in April 2019, mandates at least two witness signatures for the destruction of controlled substances, which was not adhered to in these instances.
Improper Storage of Medication at Resident's Bedside
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as evidenced by the improper storage of Nystatin powder at the bedside of a resident. The resident, an elderly female with diagnoses including congestive heart failure, hypertension, cognitive communication deficit, and cognitive decline, was found with the medication on her nightstand without an order to self-administer or a care plan reflecting such capability. Observations confirmed the presence of the medication in the resident's room, and the resident was unaware of the contents of the bottle. Interviews with facility staff, including an LVN and the DON, revealed that the medication should not have been in the resident's room, as the resident did not have the necessary assessment or order to self-administer medications. The facility's policy requires medications found at the bedside without authorization to be removed and secured. The DON and Administrator both acknowledged that the resident was not authorized to self-administer medications and emphasized that medications should be kept secured in the medication cart to prevent misuse or access by other residents.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically a gas stove with a malfunctioning pilot light that allowed gas to leak. On February 24, 2025, during an observation and interview, it was noted that one of the six burners on the stove did not light using the pilot light and could not be lit with a lighter. The Dietary Manager (DM) indicated she would report this issue to the Maintenance Supervisor. However, the Maintenance Supervisor, who had been in her role for three months, was unaware of the stove issue until the following day. She mentioned that the facility had no maintenance logbook due to it frequently going missing, and maintenance issues were communicated verbally. The Maintenance Supervisor stated that she had a list of maintenance issues provided by the Administrator, but the last update was in January 2025, and the kitchen issues were not included. She was only made aware of the oven problem on February 25, 2025, and had no knowledge of the burner issue. The Administrator, who started in September 2024, was also unaware of the stove problems and mentioned that the Dietary Manager had not informed her of any kitchen issues, leading to the Dietary Manager's departure from the facility. The facility failed to provide a policy for essential equipment maintenance upon request before the survey exit.
Improper Hairnet Use in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed on 8/27/2024. During a kitchen inspection, it was noted that the Dietary Manager (DM) and another staff member were not wearing hairnets effectively, leaving parts of their hair exposed. The DM had a long ponytail that was not fully covered by her hairnet, while the other staff member had hair exposed on the sides and back of her head. Both individuals acknowledged the oversight and the potential for hair to fall into food, which could lead to unsanitary conditions and food contamination. The facility's policy on preventing foodborne illness, revised in October 2017, mandates that food and nutrition services employees must wear hairnets or caps to prevent hair from contacting exposed food and clean equipment. This policy aligns with the FDA Food Code 2022, which requires food employees to wear hair restraints to effectively keep hair from contacting exposed food. The facility's failure to ensure proper hairnet use by kitchen staff was acknowledged by the Administrator, who confirmed awareness of the incident and the importance of proper hairnet use to prevent contamination.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) who did not follow proper hand hygiene protocols during incontinent care for a resident. The CNA did not sanitize or wash her hands between glove changes while providing care to a resident who was totally dependent on staff for toileting hygiene and was always incontinent of urine and bowel. This lapse in protocol was observed during an incident where the CNA removed gloves, failed to sanitize her hands, and then donned new gloves before continuing care. Additionally, the CNA exited the resident's room into the hallway with a glove still on her hand, which she used to dispose of trash, further breaching infection control practices. The resident involved had severe cognitive impairment and a history of urinary tract infections, necessitating careful infection control measures. The Director of Nursing (DON), who was new to her role, was unaware of the incident and acknowledged that staff should sanitize their hands between glove changes and not leave the room with gloves on. The facility's policy on hand hygiene emphasized its importance in preventing the spread of infections, yet the CNA's actions contradicted these guidelines, potentially exposing residents to infectious diseases.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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