Twin Pines Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Victoria, Texas.
- Location
- 3301 E Mockingbird Ln, Victoria, Texas 77904
- CMS Provider Number
- 675638
- Inspections on file
- 45
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 22 (2 serious)
Citation history
Health deficiencies cited at Twin Pines Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents with significant cognitive and physical impairments had active diet orders and observed use of mechanical soft textures and divided plates that were not reflected in their comprehensive person-centered care plans. One resident with cerebral palsy, hemiplegia, and moderate intellectual disability had a long-standing order for an RCS/LCS/NSOT diet with a divided plate and only pink sugar, and staff, including an ST, confirmed the divided plate was needed and used, but it was omitted from the care plan. Another resident with Alzheimer’s disease, dementia, and anxiety had orders for a regular diet with mechanical soft texture, a divided plate, drinks in coffee cups, and double liquids, and was observed receiving mechanical soft food, yet the care plan only listed a regular diet and supervision for eating without noting the mechanical soft texture or divided plate. The MDS nurse, DON, and interim ADM acknowledged that the care plans should accurately reflect these required interventions.
A resident with severe cognitive impairment, multiple fractures, vascular dementia, Down syndrome, and bradycardia had a quarterly MDS showing a need for moderate assistance with eating and a mechanically altered diet, including mechanical soft texture, pureed meat with gravy, and a magic cup at lunch. Although active orders and meal observations confirmed these interventions and assistance were being provided, the comprehensive person-centered care plan continued to list only an ADL self-care deficit and a regular diet with an optional divided plate, omitting the required eating assistance and specific diet orders. The MDS RN, DON, and interim ADM acknowledged that the care plan had not been reviewed and revised by the interdisciplinary team after the MDS assessments as required by facility policy.
Staff entered a resident's room without knocking on multiple occasions, despite being trained on resident rights and facility policy requiring them to do so. The resident, who has multiple medical and mental health conditions, reported feeling upset and that her privacy was invaded. Leadership confirmed the expectation to knock and monitor compliance, but the deficiency occurred when staff failed to follow this protocol.
Two residents with significant medical and cognitive needs did not have their call lights within reach while in bed, despite care plans requiring this for safety and fall prevention. Observations confirmed the call lights were either on the floor or on a bedside table out of reach. Staff interviews revealed inconsistent practices and lack of a formal policy regarding call light placement.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's care.
Two residents with severe cognitive impairment experienced preventable accidents due to the facility's failure to identify and address known hazards, such as unbuckling seatbelts during van transport and manipulating bed controls. Staff did not consistently report or document unsafe behaviors, and care plans were not updated to include necessary interventions after incidents, resulting in injuries including a laceration and a knee fracture.
A resident with hemiplegia and reduced mobility experienced an unwitnessed fall resulting in a leg fracture, but the subsequent MDS assessment failed to document the major injury due to reliance on EMR incident closure and lack of manual tracking. Staff interviews revealed gaps in oversight and assessment accuracy during a period without a DON, leading to the deficiency.
A resident with cancer diagnoses missed a scheduled oncology appointment due to the facility's failure to arrange transportation. The resident and his representative reported previous cancellations of appointments for similar reasons. Interviews with staff revealed confusion and lack of communication regarding appointment scheduling and transportation, contributing to the deficiency.
A facility failed to maintain privacy for two residents. One resident's medical information was potentially exposed when a medication aide left a computer screen unlocked. Another resident's privacy was compromised during wound care due to a jammed curtain that could not be fully closed, leaving the resident exposed. The first resident had intact cognition, while the second had severe cognitive impairment and required assistance with hygiene.
The facility's kitchen failed to meet food safety standards, with issues such as uncovered tea glasses, improper hairnet use by a dietary aide, and unsanitary conditions in the pantry, including spilled salt, sweetener, and flour on the floor, as well as an oily substance and dusty debris on surfaces.
The facility failed to maintain a safe and sanitary environment in Hallways A and E, with issues such as cracked doors, dislodged phone jacks, scrape marks, water-damaged ceiling tiles, and dislodged floor molding. These deficiencies were observed and confirmed by the Assistant Maintenance Director and the Administrator.
A resident with Alzheimer's and a fall risk had their call light placed out of reach, contrary to their care plan. The nursing assistant admitted to the oversight, and the facility lacked a formal policy on call light accessibility, though it was monitored by charge nurses.
A resident's right to a safe, clean, and comfortable environment was compromised due to a foul odor emanating from their restroom. Despite the restroom appearing clean, the odor persisted for several days, causing discomfort to the resident. Staff interviews indicated that the odor might have been caused by issues with the drains, which had been a problem in the past.
A facility failed to include a resident's medication allergies and physician-prescribed diet in the baseline care plan within 48 hours of admission, as required by policy. The resident, with conditions such as COPD and Chronic Kidney Disease, was admitted without this critical information documented, which was confirmed by RN/MDS B. The responsibility for baseline care plans was with the recently resigned DON, and the oversight was not caught by the admitting nurse or ADONs.
A resident with severe cognitive impairment and multiple health issues experienced several falls, including two with injuries, but the facility failed to update her care plan with new interventions. Despite discussions in management meetings, the care plan was not revised after significant falls, leaving staff without current information to prevent future incidents. The facility's policy required care plan updates after significant changes, but this was not followed, highlighting a process failure in maintaining current care plans.
The facility failed to ensure a hazard-free environment in the Hallway A shower room, where two unsecured bottles of K-Quat cleaning disinfectant were found. The AIT and LVN acknowledged the risk of residents accessing and potentially consuming the product. The Housekeeping Supervisor confirmed that the disinfectant should have been secured in a locked cabinet.
A resident with dementia and COPD had their oxygen tubing and mask improperly stored, with the tubing coiled on the concentrator and the mask on the floor. Staff interviews confirmed the equipment should be bagged to prevent contamination, but the facility's policy lacked guidance on proper storage.
A facility failed to store Latanoprost eye drops in a refrigerator as required, leaving it at room temperature in the Annex Medication Room. An LVN confirmed the medication was not stored correctly, which could affect its effectiveness. The DON, responsible for medication room maintenance, had recently resigned, creating uncertainty about oversight.
A resident with dementia and a moderate risk of wandering eloped from the facility unnoticed, despite having a care plan in place. The resident was found at a convenience store after crossing a street, and the incident was unwitnessed. Facility staff confirmed that door alarms were working, but the elopement still occurred, highlighting a failure in supervision and accident prevention.
A resident with a known egg allergy was served meatloaf containing egg, leading to an allergic reaction. The resident self-administered an epi-pen and was transferred to the hospital. The cook admitted to not following the recipe, resulting in the oversight. This incident highlights a failure in communication and adherence to dietary protocols.
The facility failed to maintain adequate staffing levels, particularly during night shifts, resulting in delayed responses to call lights, cold meals, and insufficient care for residents. Staff and residents reported significant delays in assistance and meal services, with some residents waiting over an hour for help. The facility's assessment did not adequately address staffing needs, contributing to these ongoing issues.
A LTC facility reported a 16% medication error rate involving two residents. An LVN administered medications late and failed to give one medication due to dosage form issues. The errors were attributed to a busy shift and the absence of a medication cart, violating the facility's policy of administering medications within one hour of the scheduled time.
The facility failed to ensure medication carts were locked and attended, as required by regulations. Observations revealed that medication carts were left unlocked and unattended, with medications accessible to unauthorized individuals. LVN F admitted to leaving a cart unlocked while attending to a resident, and similar issues were noted with other carts. The facility's policy mandates that carts be locked and medications not be pre-prepared, which was not adhered to.
Three residents in the facility did not receive their prescribed dietary support. A resident with dementia and weight loss did not receive a health shake or red glass as prescribed. Another resident with severe cognitive impairment and dysphagia was served an inadequate portion of pureed spaghetti and meatballs due to incorrect scoop usage. A third resident with severe cognitive impairment and a pressure ulcer did not receive a prescribed house shake with dinner. The facility's red glass program, intended to alert staff to residents needing additional monitoring, was not followed.
The facility failed to document wound care treatments for two residents with severe cognitive impairment and Stage 4 pressure ulcers. Interviews with the DON and an LVN revealed lapses in the auditing process, with both unaware of missed treatments. The facility's policies on infection control and hand hygiene were reviewed, but no corrective actions were mentioned.
A resident with severe cognitive impairment was left exposed during wound care when an LVN walked away to retrieve a trash can, violating the facility's policy on resident dignity and privacy. Interviews with staff confirmed that the resident should have been covered to maintain privacy.
Two residents in an LTC facility were unable to press the call light due to physical and cognitive limitations, despite care plans indicating the need for reachable call lights. Observations and staff interviews confirmed the residents' inability to use the call lights, and no alternative solutions were provided, violating their right to reasonable accommodation of needs.
A resident with severe cognitive impairment and multiple health issues did not have their care plan updated to reflect edema in the left hand and the need for elevation, despite these conditions being documented. Facility staff interviews revealed a lack of communication and clarity regarding the responsibility for updating care plans, leading to the oversight.
A resident with multiple diagnoses, including dementia and malnutrition, experienced significant weight loss, but the facility failed to update the care plan to reflect prescribed dietary interventions. Despite being on a mechanically altered diet and receiving nutritional supplements, the care plan was not revised to include these changes. Interviews with staff revealed inconsistencies in updating care plans, contrary to facility policy.
A resident with severe cognitive impairment and a Stage 4 pressure ulcer did not receive adequate pain management during wound care procedures. Despite verbal expressions of pain, nursing staff failed to assess or administer pain relief, contrary to the facility's policies. The resident's previous opioid medication was discontinued, and only a PRN order for Tylenol was in place, which was not consistently used before wound care.
A resident with dysphagia and no teeth was not provided with a mechanically ground meat diet as prescribed, leading to difficulty in eating. Despite a dietary order change, the resident was served whole meat, indicating a communication lapse within the facility's dietary department.
A resident with a documented onion allergy was served a meal containing onions, as the staff was not informed of the allergy. The resident could not eat the meal and was not provided an alternative, contrary to the facility's food preparation policy.
Two residents with severe cognitive impairments and Stage 4 pressure ulcers received wound care that did not adhere to infection control protocols. An LVN and an RN failed to perform proper hand hygiene before and during the procedures, increasing the risk of infection. The facility's policies on infection control were not followed, as observed during the survey.
The facility did not post the required nurse staffing information at designated entrances on two consecutive days. Observations confirmed the absence of postings, and interviews revealed that the ADON responsible for this task was off duty and unaware of who would cover her responsibilities. The DON admitted there was no staffing policy in place.
Failure to Include Ordered Diet Textures and Divided Plates in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that included all ordered dietary interventions and adaptive equipment for two residents. For one resident with type II diabetes mellitus, major depressive disorder, hemiplegia and hemiparesis, moderate intellectual disability, and cerebral palsy, the comprehensive care plan dated 07/16/2025 identified a focus on potential risk for malnutrition with an RCS/LCS/NSOT diet, but did not include the ordered use of a divided plate. The resident’s active diet order, in place since 10/04/2024, specified an RCS/LCS/NSOT diet with regular texture and consistency, a divided plate, and only pink sugar, yet the divided plate was omitted from the care plan despite being part of his ongoing care. Surveyor observations on 02/06/2026 showed this resident consistently received meals on a plastic divided plate in both the assisted feeding dining room and his room. The resident exhibited involuntary muscle contractions and hand deformities related to cerebral palsy, and the speech therapist reported having evaluated him months earlier and recommending a divided plate due to his hand deformities and need for assistance. During an interview, the resident stated it was easier to eat with a divided plate. Despite these clinical needs and the standing physician order, the divided plate intervention was not reflected in the resident’s comprehensive care plan. For a second resident with Alzheimer’s disease, major depressive disorder, dementia, and anxiety, the quarterly MDS indicated he could usually understand and be understood, required setup and supervision for eating, and was on a therapeutic diet. His comprehensive care plan dated 07/11/2025 included a focus on ADL self-care performance deficit with supervision for eating as needed and noted that he was on a regular diet, but did not document his ordered mechanical soft texture diet or the need for a divided plate. Active orders dated 10/15/2025 specified a regular diet with mechanical soft texture, regular consistency, a divided plate, drinks in coffee cups, and double liquids. Observations confirmed he was receiving mechanical soft texture food, and his meal ticket reflected mechanical soft texture, yet these requirements were not incorporated into the care plan. The MDS nurse, DON, and interim administrator each acknowledged in interviews that the comprehensive person-centered care plan should accurately reflect the care and services the residents require.
Failure to Update Comprehensive Care Plan After MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to develop, review, and revise a comprehensive, person-centered care plan within seven days of the comprehensive assessment and after subsequent MDS assessments, as required. For one resident, the comprehensive care plan dated 03/20/25 listed an ADL self-care performance deficit and a regular diet with the option of a divided plate, but did not include that the resident required moderate assistance with eating or that she was on a mechanically altered diet with specific nutritional interventions. The facility’s own policy stated that the resident’s care plan would be reviewed after each admission, quarterly, annual, and/or significant change MDS assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. The resident involved was an older female with multiple diagnoses, including fractures of the left femur and right radius, vascular dementia, Down syndrome, and bradycardia. Her quarterly MDS assessment showed she was sometimes understood, usually understood others, had a BIMS score of 0/15 indicating severely impaired cognition, required moderate assistance with eating, and was on a mechanically altered diet. Active orders reflected a regular diet with mechanical soft texture, magic cup with lunch, pureed meat with gravy, and the option for a divided plate. Observations confirmed she was receiving a mechanical soft diet and assistance with eating at meals, and had a magic cup at lunch, but these needs and interventions were not reflected in the comprehensive care plan. During interviews, the MDS RN acknowledged not knowing why these needs and orders were missing from the care plan and stated it should have been reviewed and revised after the last comprehensive assessment, while the DON and interim administrator affirmed that the care plan needed to accurately reflect the care required and be reviewed and revised by the team after MDS assessments.
Failure to Knock Before Entering Resident Room Violates Dignity and Privacy
Penalty
Summary
Staff failed to treat a resident with respect and dignity by not knocking before entering her room on multiple occasions. Observations showed that both the MDS nurse and a speech therapist entered the resident's room without knocking, despite the resident being present and her call light being on. Interviews with the staff involved confirmed that they were trained on resident rights and facility policy, which requires staff to knock and announce themselves before entering any resident's room. Both staff members acknowledged that not knocking was disrespectful and intrusive, and that all residents should receive the same respect. The resident, who has a history of muscle weakness, difficulty walking, cognitive communication deficit, insomnia, major depressive disorder, and hypertensive emergency, reported that staff frequently entered her room without knocking, which upset her and made her feel her privacy was invaded. Facility leadership, including the DON and administrator, confirmed that the policy requires staff to knock and that monitoring is done through observations and rounds. The facility's resident rights policy emphasizes respect for personal privacy and dignity, but the failure of staff to follow this policy led to the deficiency.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for residents in their rooms, specifically for two residents with significant medical and cognitive needs. Observations revealed that one resident's call light was found on the floor under the bed while the resident was lying in bed, and another resident's call light was on a bedside table, out of reach, while the resident was also in bed. Both residents had care plans that required the call light to be within easy reach and for staff to remind or encourage them to use it for assistance as needed. Record reviews indicated that both residents had multiple diagnoses, including dementia, heart failure, and a history of falls, and required partial to moderate assistance with transfers and daily activities. Their care plans specifically included interventions for fall prevention and safety, such as ensuring the call light was within reach and checking on the residents at routine intervals. Despite these documented needs and interventions, staff failed to maintain the call lights within reach, as observed during the survey. Interviews with staff, including CNAs, LVNs, the DON, and the ADM, revealed inconsistent understanding and implementation of call light placement policies. While staff stated that the expectation was for call lights to always be within reach and that all staff were responsible for ensuring this, there was no formal written policy in place. Staff also acknowledged that failure to keep call lights within reach could result in residents being unable to call for help, but could not explain why the deficiency occurred for the two residents in question.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Prevent Accidents and Update Care Plans Following Resident Incidents
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with severe cognitive impairment. In the first case, a resident with end-stage renal disease, syncope, vascular dementia, and bradycardia, who was dependent for transfers and had a history of falls, was transported to dialysis in the facility van. Despite prior incidents where the resident had unbuckled her seatbelt or attempted to stand during transport, these behaviors were not documented in her care plan, and no interventions were implemented to address them. Staff, including the van driver and activity director, were aware of these behaviors but did not consistently report them to nursing or administration, and no team meeting was held to discuss or address the risk. As a result, the resident unbuckled her seatbelt during transport, fell from her wheelchair, and sustained a laceration to her forehead, requiring emergency medical attention. In the second case, another resident with severe vascular dementia and schizoaffective disorder, who required substantial assistance for transfers, experienced an unwitnessed fall from her low bed, resulting in a right knee patella fracture and a skin tear. Although interventions such as a floor mat and low bed were in place, the resident was able to manipulate the bed controller, raising the bed and increasing her risk of falling. Staff interviews revealed that the resident had a history of moving the bed out of the lowest position by pressing buttons on the controller, but this risk was not addressed in her care plan. After the fall, the care plan was not updated to include new interventions or to reflect the changes in the resident's condition, despite facility policy requiring immediate care plan revision after such incidents. In both cases, the facility did not identify or address known hazards and risks in the residents' environments, failed to update care plans with necessary interventions, and did not ensure that staff communicated and documented unsafe behaviors or incidents. These failures resulted in preventable accidents and injuries, and the lack of care plan updates meant that staff may not have been aware of the residents' specific risks or the interventions needed to prevent further incidents.
Failure to Accurately Code Major Injury on Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their clinical status, specifically regarding a fall with major injury. A male resident with a history of hemiplegia, hemiparesis, epilepsy, and reduced mobility experienced an unwitnessed fall in his room, resulting in a left leg fracture. Nursing notes documented the fall and subsequent injury, including swelling and the application of a brace. However, the resident's subsequent Quarterly MDS assessment did not indicate that a major injury had occurred, instead documenting that there had been no major injury since admission or the prior assessment, despite the definition of major injury including bone fractures. Interviews with facility staff revealed that the process for tracking and documenting falls relied heavily on the electronic medical record (EMR) system, which only flagged incidents that were marked as closed. The MDS Coordinator stated that if a fall incident was not closed in the EMR, it would not be included in the information used to complete the MDS assessment. In this case, the fall incident remained open for nearly two months, and as a result, the MDS assessment did not reflect the major injury. The absence of a Director of Nursing (DON) during this period contributed to lapses in oversight, as responsibilities were distributed among Assistant DONs and other staff. Further, the facility's administrative and clinical leadership described a process in which daily meetings were held to discuss incidents and update care plans, but there was no manual tracking system for falls, and the MDS Coordinators depended on the EMR's automated prompts. The compliance nurse and MDS Consultant were involved in reviewing documentation, but it was unclear if every assessment was checked for accuracy. Facility policy required that each assessment be conducted with appropriate participation from health professionals and that each individual certify the accuracy of their portion, but this process was not followed in this instance, resulting in an inaccurate assessment.
Failure to Transport Resident to Oncology Appointment
Penalty
Summary
The facility failed 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, the facility did not transport a resident to a scheduled appointment with an oncologist. This failure was identified for a resident who had a diagnosis of secondary malignant neoplasm, squamous cell carcinoma, unilateral paralysis of vocal cords, and localized enlarged lymph nodes. The resident was cognitively intact and required substantial assistance with mobility. The deficiency occurred when the resident missed an oncology appointment due to the facility not scheduling transportation. The resident's care plan included the need to anticipate and meet his needs, which was not adhered to in this instance. The resident's representative and the resident himself reported that the facility had previously canceled appointments due to transportation issues, indicating a pattern of neglect in ensuring the resident attended necessary medical appointments. Interviews with facility staff revealed a lack of clarity and communication regarding the scheduling of appointments and transportation. The transportation nurse and LPN involved were unaware of the missed appointment, and there was confusion about the appointment's presence on the transportation calendar. The facility's administration acknowledged the absence of a formal procedure to ensure appointments were correctly documented and communicated, leading to the resident missing a critical oncology appointment.
Privacy Breach Due to Unlocked Computer Screen and Incomplete Curtain Closure
Penalty
Summary
The facility failed to ensure personal privacy for two residents, leading to a deficiency in maintaining confidentiality and dignity. For the first resident, a medication aide did not lock the computer screen after stepping away, potentially exposing the resident's personal medical information. This incident occurred in the dining room, where the aide admitted to not locking the screen, acknowledging that the resident's information might have been exposed. The resident had an intact cognition with a BIMS score of 15, indicating awareness of their surroundings. For the second resident, two LVNs were unable to fully close the privacy curtains while providing wound care, leaving a two-foot gap that exposed the resident's buttocks. The resident had severe cognitive impairment with a BIMS score of 3 and required assistance with toileting hygiene. The LVNs confirmed the curtain could not be closed due to a jam, and the housekeeping supervisor acknowledged issues with curtain maintenance, such as missing hooks and worn-out wheel bearings, which had not been addressed due to a lack of communication with the maintenance department.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Key deficiencies included the absence of foot-operated waste baskets near the hand-washing station, which is essential for maintaining hygiene standards. Additionally, a tray of glasses filled with tea was left uncovered, exposing the beverages to potential contamination. Dietary Aide H was observed wearing a hairnet that did not fully cover her hair, which could lead to hair contaminating food or food preparation areas. Further observations revealed unsanitary conditions in the pantry, including individual packets of salt and artificial sweetener scattered on the floor, an oily liquid substance under a container of fry oil, and spilled flour under a container of flour. Dusty debris was also noted on the lower shelf of the food preparation counter. These conditions violate the Food Code standards, which require food to be stored in a clean, dry location and protected from contamination, and nonfood-contact surfaces to be cleaned regularly to prevent soil residue accumulation.
Environmental Deficiencies in Hallways A and E
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two of the seven hallways reviewed. On Hallway A, several issues were observed, including wood cracks on the interior bathroom door in one room, a dislodged phone jack and a black scrape mark on the wall in another room, and wall penetrations in a third room. Additionally, water marks were found on ceiling tiles, and some tiles were missing at the end of Hallway A. On Hallway E, similar deficiencies were noted, such as paint scraped off the bathroom door in one room, a dislodged ceiling tile, and a continuously running toilet in another room. Furthermore, a section of floor molding was dislodged from the wall across from the TV viewing area. These observations were confirmed during an interview with the Assistant Maintenance Director and the Administrator, who acknowledged awareness of some of the needed repairs.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents to maintain their independence and safety. The deficiency was identified during an observation in the resident's room, where the call light was found on the nightstand, out of the resident's reach. This oversight was confirmed by the nursing assistant assigned to the resident, who admitted to placing the call light on the nightstand earlier in the morning and forgetting to return it to an accessible position. The resident involved in this deficiency is an elderly female with Alzheimer's disease, insomnia, and a history of seizures, conditions that increase her risk of falls and necessitate the availability of a call light for assistance. The resident's care plan specifically included an intervention to ensure the call light was within reach due to her fall risk. Despite this, the facility did not have a formal policy addressing call light accessibility, although the RCN acknowledged its importance and stated that charge nurses monitor this task during their rounds.
Foul Odor in Resident's Room Due to Drain Issues
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as evidenced by a foul odor emanating from the restroom of the resident's room. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, Hyperlipidemia, and Anemia, had a BIMS score indicating moderate cognitive impairment. The resident reported that the odor had been present for a few days and was bothersome. Observations confirmed the presence of the odor, although the restroom appeared clean with no apparent source of the odor. Interviews with facility staff, including a nursing assistant and the administrator, confirmed the presence of the odor and suggested that issues with the drains might be the cause. The Housekeeping Supervisor acknowledged that similar issues had occurred in the past and were resolved by treating the drains. The facility's policy on resident rights emphasizes the provision of housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment, which was not upheld in this instance.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The baseline care plan for the resident did not include critical information such as allergies to specific medications (Atorvastatin, Flomax, and Tramadol) and the physician-prescribed diet. This omission was confirmed during an interview with RN/MDS B, who acknowledged that the baseline care plan should have included these details. The responsibility for developing baseline care plans was attributed to the Director of Nursing (DON), who had recently resigned, and the oversight was not caught by the admitting nurse or the Assistant Directors of Nursing (ADONs). The resident in question was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Hyperlipidemia, and Chronic Kidney Disease. The resident's clinical record indicated a regular diet with regular texture and consistency was ordered by the physician. The facility's policy on baseline care plans emphasizes the importance of completing and implementing these plans within 48 hours to ensure continuity of care, communication among staff, and resident safety. However, the failure to include essential healthcare information in the baseline care plan could result in improper care for the resident.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident after each assessment, specifically following falls that resulted in injuries. The resident, an elderly woman with severe cognitive impairment and multiple health issues including encephalopathy and orthostatic hypotension, experienced several falls since her admission. Despite these incidents, the care plan was not updated to reflect new interventions after falls on specific dates, including one that resulted in a head injury requiring medical attention. The resident's care plan, last reviewed in late November, did not include any updates or new interventions following her falls in September and December. The care plan had a focus area for fall risk, but the interventions listed were not revised after the resident's significant falls. Interviews with facility staff revealed that while falls were discussed in management meetings, the responsibility for updating the care plan was not clearly executed, particularly after the resignation of the Director of Nursing. The facility's policy required care plans to be reviewed and revised after significant changes, but this was not adhered to in the case of the resident. The lack of updates to the care plan meant that staff did not have access to the most current information needed to prevent future falls, as confirmed by interviews with the facility's nursing staff. The deficiency highlights a failure in the facility's process for ensuring care plans are kept current and reflective of residents' needs following significant events like falls.
Unsecured Cleaning Disinfectant in Shower Room
Penalty
Summary
The facility failed to maintain a hazard-free environment in the Hallway A shower room, as observed during a survey. On December 3rd, two unsecured 32-ounce bottles of K-Quat cleaning disinfectant were found in the unlocked shower room, one placed on a standing tile ledge and another inside an unlocked standing shower cabinet. During interviews, both the AIT and LVN acknowledged that the unsecured disinfectant bottles posed a risk hazard to residents who might enter the shower room and potentially consume the cleaning product. The Housekeeping Supervisor confirmed that the disinfectant should have been secured in a locked cabinet after use and acknowledged the risk of resident access to the product. The facility's admission packet, revised in April 2022, states that residents have the right to live in a safe, decent, and clean environment.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for a resident who required oxygen therapy, as observed during a survey. The resident, a male with dementia and chronic obstructive pulmonary disease, had an order for oxygen at 2-3 liters via nasal cannula at night and as needed for shortness of breath. Observations revealed that the resident's oxygen tubing and nasal cannula were not stored properly; they were coiled loosely on top of the oxygen concentrator, and the oxygen/nebulizer mask was found lying on the floor behind the concentrator. Interviews with the resident and staff confirmed the improper storage of the oxygen equipment. The resident mentioned that he used oxygen at night and sometimes received nebulizer treatments, with tubing changes occurring weekly. A Licensed Vocational Nurse (LVN) and the Resident Care Nurse (RCN) both acknowledged that the oxygen tubing and mask should be stored in a plastic bag to prevent contamination and damage. However, the facility's policy on oxygen administration did not address the proper storage of oxygen equipment, contributing to the deficiency.
Improper Storage of Latanoprost in Medication Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls in the Annex Medication Room. During an observation, a bottle of Latanoprost 0.0005% solution for a resident was found stored at room temperature on the medication room counter, despite the label indicating it should be refrigerated until opened. The Licensed Vocational Nurse (LVN) present confirmed that the medication was not stored in the refrigerator as required, which could affect its therapeutic effectiveness. Interviews with the LVN and the Registered Charge Nurse (RCN) confirmed that the Latanoprost should have been refrigerated until opened and that maintaining recommended storage temperatures is crucial to ensure medication effectiveness. The facility's policy on medication storage, revised in 2012, also specifies that Latanoprost should be refrigerated until initial use. The Director of Nursing (DON), who was responsible for the maintenance of the medication room, had recently resigned, leaving uncertainty about who would now oversee medication storage.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in an elopement incident involving a resident. The resident, a male with unspecified dementia, peripheral vascular disease, and bipolar disorder, was cognitively impaired with a BIMS score of 8 and had a moderate risk of wandering behavior. Despite these known risks, the resident managed to leave the facility unnoticed on the morning of June 21, 2024. The resident's care plan, which had been initiated in August 2022, identified a risk of wandering behavior, but the interventions in place were insufficient to prevent the elopement. On the day of the incident, the facility's van driver began searching for the resident at 8:15 a.m., and a Code Orange for elopement was called at 8:30 a.m. The resident was found at a convenience store several blocks away at 8:50 a.m. by facility staff and local law enforcement. The elopement was unwitnessed, and the resident had crossed a street to reach the location. The facility's incident report noted that the resident exited through one of the facility's entrance doors, but the door alarms were found to be in working order during subsequent observations. Interviews with the facility's staff, including the Administrator and Assistant Maintenance Director, confirmed that regular inspections of exit doors were conducted, but the elopement still occurred. The facility's policy on elopement prevention and response was in place, but it failed to prevent this incident, placing the resident in immediate jeopardy.
Failure to Accommodate Resident's Food Allergies
Penalty
Summary
The facility failed to ensure that food provided to a resident accommodated their known allergies, leading to a serious allergic reaction. On September 4, 2024, a resident with a documented allergy to eggs was served meatloaf containing egg, which resulted in the resident experiencing an allergic reaction. The resident, who had a history of anaphylaxis, self-administered an epi-pen and was subsequently transferred to the hospital for further evaluation. The resident's medical records clearly indicated an allergy to eggs, and the care plan had documented this allergy. Despite this, the dietary staff did not adhere to the resident's dietary restrictions. The cook admitted to not following the recipe and using egg in the meatloaf, which was confirmed during interviews with staff. This oversight placed the resident in immediate jeopardy, as they had to use emergency medication and seek hospital care. The incident highlights a breakdown in communication and adherence to dietary protocols within the facility. The dietary staff failed to verify the ingredients used in the meal, despite being questioned about the presence of egg. This lapse in procedure and communication led to the resident consuming a meal that triggered a severe allergic reaction, necessitating emergency intervention and hospitalization.
Inadequate Staffing Leads to Delayed Care and Resident Complaints
Penalty
Summary
The facility failed to maintain sufficient nursing staff with the appropriate competencies and skills to ensure resident safety and well-being. This deficiency was observed on multiple occasions, specifically during the night shifts from 6:00 PM to 6:00 AM on several dates. The number of Certified Nursing Assistants (CNAs) scheduled was inadequate compared to the resident census, leading to insufficient care for the residents. For instance, on certain nights, there were only one or two CNAs available for over 100 residents, which is far below the required staffing levels to meet the needs of the residents. The lack of adequate staffing resulted in numerous grievances from residents and their families. Complaints included delayed response times to call lights, with some residents waiting up to an hour or more for assistance. Additionally, meal services were delayed, with food often being served cold due to the lack of staff to deliver trays promptly. These issues were consistently reported in resident grievances, resident council meetings, and direct observations by surveyors. Interviews with staff and residents further highlighted the impact of staffing shortages. Staff members reported being overworked, with some working extended hours to cover shifts. This led to delays in medication administration and incomplete documentation. Residents expressed concerns about the safety and quality of care, noting that the limited number of staff made it difficult to receive timely assistance, particularly during emergencies. The facility's assessment did not adequately address staffing needs, contributing to the ongoing issues with insufficient care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 16% due to 5 errors out of 30 opportunities. This involved two residents, Resident #17 and Resident #18, who did not receive their medications as scheduled. LVN F administered Trazadone and Nortriptyline to Resident #17 nearly two hours late and failed to administer Melatonin entirely. For Resident #18, Donepezil and Trazadone were administered three and two hours late, respectively. Resident #17, diagnosed with Dementia, Schizoaffective Disorder, Major Depressive Disorder, and Insomnia, was supposed to receive Melatonin, Nortriptyline, and Trazadone at specific times. However, the medications were administered late, and Melatonin was not given at all due to the unavailability of the correct dosage form. LVN F acknowledged the lateness and the omission, citing a busy shift and the absence of the medication cart as reasons for the delay. Resident #18, with diagnoses including Dementia, Schizoaffective Disorder, Major Depressive Disorder, and Bipolar Disorder, experienced similar issues with medication timing. The medications Donepezil and Trazadone were administered late, and LVN F attributed the delay to a busy shift and the need to prioritize other resident care tasks. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not adhered to in these instances.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. This deficiency was observed in three medication carts, where medications were left unattended and accessible to unauthorized individuals. Specifically, a medication cart by the nurses' station was found unlocked with a medication cup containing pills on top of it, and no staff or residents were present in the area. LVN F admitted to preparing medications in advance and acknowledged that the cart should not have been left unlocked and unattended. Additionally, LVN F left another medication cart unlocked while attending to a resident in a room, with another resident standing next to the cart, potentially allowing access to the medications. Similar observations were made with medication carts on the 300 hall, where they were found unlocked and unattended, with residents nearby. The facility's policy clearly states that medication carts must be locked when not in use, and medications should not be removed from their packaging until administration. The DON confirmed that these expectations had been communicated to the nursing staff multiple times.
Failure to Provide Prescribed Nutritional Support to Residents
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of three residents. Resident #7, who had diagnoses including dementia, iron deficiency anemia, and weight loss, did not receive a prescribed health shake or a red glass during a meal observation. The resident's dietary plan included a mechanical soft diet and a health shake with meals due to weight loss, but these were not provided during the observed meal. Resident #11, with severe cognitive impairment and dysphagia, was on a pureed diet. During an observation, the resident was served a portion of pureed spaghetti and meatballs that was not in accordance with the facility's recipe, which specified a #6 scoop. Instead, a smaller #16 scoop was used, resulting in an inadequate portion size. The staff member responsible for serving the meal was unable to confirm the correct scoop size and admitted to using a smaller scoop for purees. Resident #15, who had severe cognitive impairment and a stage 4 pressure ulcer, was on a mechanical soft diet with a house shake prescribed for supper. During an observation, the resident did not receive the house shake with their dinner. The facility's policy on the red glass and fortified food program, which aims to alert staff to residents needing additional monitoring, was not followed, as evidenced by the absence of the red glass on the meal trays of the affected residents.
Deficient Documentation of Wound Care for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically regarding the documentation of wound care treatments as ordered by physicians. Resident #5, who was admitted with severe cognitive impairment and a Stage 4 pressure ulcer, did not have documented wound care on several specified dates in April. Similarly, Resident #15, also with severe cognitive impairment and a Stage 4 pressure ulcer, had missing documentation for wound care on specified dates in March and April. Interviews with facility staff, including the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), revealed lapses in the auditing process for wound care records. The DON and LVN were responsible for ensuring wound care was completed, but both were unaware of the missed treatments. The LVN admitted to not consistently auditing the Wound Care Administration Records when working on the floor and was unsure if she worked on the days when treatments were missed. The DON stated that the LVN reported no missed treatments during morning meetings, despite the blanks in the records indicating otherwise. The facility's policies on infection control and hand hygiene were reviewed, emphasizing the importance of proper hygienic practices in preventing infection spread. However, the report does not indicate any corrective actions or follow-up measures taken by the facility to address the deficiencies in record-keeping and wound care documentation.
Resident Dignity Compromised During Wound Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during wound care. Specifically, during an observation of wound care for a resident with severe cognitive impairment and multiple diagnoses, including dementia and hemiplegia, a Licensed Vocational Nurse (LVN) left the resident exposed while retrieving a trash can. This action occurred after the LVN had removed the resident's dressing, leaving the resident's buttocks and sacral wound exposed. Interviews conducted with facility staff, including another LVN and the Director of Nursing (DON), confirmed that the resident should not have been left exposed during wound care. The facility's policy on resident rights, which emphasizes the importance of treating residents with respect and dignity and ensuring personal privacy during medical treatment, was not adhered to in this instance.
Failure to Provide Accessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident #5 and Resident #15, were able to press the call light when assistance was needed, which is a violation of their right to reasonable accommodation of needs. Resident #5 was admitted with multiple diagnoses, including dementia, hemiplegia, and severe cognitive impairment, and was dependent on others for all self-care and mobility. Despite the care plan indicating the need for a reachable call light, observations and interviews revealed that Resident #5 was unable to press the call light due to physical limitations, and staff were aware of this issue but did not provide an alternative solution. Similarly, Resident #15, who was readmitted with conditions such as Alzheimer's disease, dementia, and functional quadriplegia, also faced challenges in using the call light due to severe cognitive impairment and physical limitations. The care plan for Resident #15 also emphasized the importance of having a reachable call light, yet observations showed that the resident was unable to use it. Interviews with staff confirmed that Resident #15 was unable to press the call light, and there was no evidence of alternative accommodations being provided. The facility's policy on resident rights emphasizes the need for reasonable accommodation of resident needs, yet the failure to provide accessible call lights for these residents indicates a deficiency in adhering to this policy. Interviews with staff, including the Director of Nursing, revealed a lack of evaluation and provision of suitable call light alternatives for these residents, despite their known limitations. This oversight could potentially place residents at risk of not receiving timely care or attention when needed.
Failure to Update Resident Care Plan for Edema
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident within seven days of the comprehensive assessment and did not revise the care plan after each assessment. Specifically, the care plan for a resident was not updated to reflect the presence of edema in the left hand and the need for elevation, despite these conditions being documented in the resident's progress notes and order summary report. This oversight could potentially place residents at risk of having their current needs unmet. The resident in question had a complex medical history, including Alzheimer's Disease, Dementia, Type 2 diabetes, COPD, Cognitive Communication Deficit, Dysphagia, Functional Quadriplegia, a Stage 4 pressure ulcer, Depression, and Anxiety. The resident was severely cognitively impaired, with a BIMS score of 5, and was dependent on others for all self-care and mobility. Despite these significant health challenges, the care plan was not updated to address the edema and the prescribed intervention of elevating the left arm. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for updating care plans. The LVN and RN responsible for care plans stated that updates should occur during morning meetings when changes in resident conditions are discussed. However, the edema and elevation requirement for the resident's left arm were not communicated effectively, leading to the care plan not being updated. The Director of Nursing expected care plans to be updated on the day changes occurred, but this expectation was not met in this instance.
Failure to Update Resident Care Plan for Weight Loss and Diet
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by an interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for a resident who had multiple diagnoses, including dementia, malnutrition, dysphagia, cognitive communication deficit, depression, and GERD. The resident experienced significant weight loss over several months, which was not adequately addressed in the care plan. The resident's care plan, last revised several months prior, did not reflect the prescribed diet and interventions for weight loss, despite the resident being on a mechanically altered and therapeutic diet. The care plan aimed for the resident to maintain stable weight and adequate nutrition, but it did not include the specific dietary orders and supplements that were being provided, such as a mechanically soft diet, nectar thick liquids, pureed meats, and nutritional supplements like ReadyCare 2.0 and Magic Cup. The facility's records showed a consistent trend of weight loss, yet the care plan was not updated to reflect these changes. Interviews with facility staff, including LVN A, RN A, and the DON, revealed that care plans were supposed to be updated with any changes in the resident's condition or orders. However, there was a lack of clarity and consistency in the process, as the care plan for the resident in question was not updated to include the current diet and weight loss interventions. The facility's policy required that care plans be revised based on changing needs, but this was not adhered to in this case.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for Resident #15, who was readmitted with multiple diagnoses including Alzheimer's Disease, Dementia, Type 2 diabetes, and a Stage 4 pressure ulcer. The resident's care plan indicated the need for pain management, especially during wound care procedures. However, observations revealed that the nursing staff did not assess or manage the resident's pain effectively during wound care sessions. Despite the resident's verbal expressions of pain, the staff continued the procedures without conducting pain assessments or administering pain relief. The resident's medical records showed a history of opioid use for pain management, but the medication was discontinued due to non-use. At the time of the observations, the resident did not have an active order for pain medication, except for a PRN order for Tylenol, which was not consistently administered prior to wound care. Interviews with the nursing staff, including LVN C and RN B, confirmed the lack of pain assessment and management during wound care, and the Director of Nursing was unsure if pain management assessments were conducted for the resident. The facility's policies on dressing changes and pain management emphasized the need for pre-medication and pain assessment, but these were not followed. The failure to adhere to these policies resulted in the resident experiencing unnecessary pain during wound care procedures, highlighting a deficiency in the facility's pain management practices for residents with severe cognitive impairments and significant medical needs.
Failure to Provide Mechanically Altered Diet
Penalty
Summary
The facility failed to provide meals prepared in a form designed to meet the individual needs of a resident, specifically Resident #6, who was prescribed a mechanical ground meat diet. Despite the dietary order change being communicated to the dietary department, Resident #6 was served a whole piece of chicken fried steak that was not cut up or ground, contrary to the prescribed diet. This oversight was observed during a meal service, where the resident expressed difficulty in eating the meat due to having no teeth. Resident #6 had a complex medical history, including diagnoses of hypokalemia, malnutrition, muscle wasting, dysphagia, and cognitive communication deficit, which necessitated a mechanically altered diet. The facility's policy required food to be prepared to meet individual needs, yet the dietary staff were unaware of the resident's specific dietary requirements. Interviews with staff revealed a lack of awareness and communication regarding the resident's dietary order, leading to the deficiency in meal preparation.
Failure to Accommodate Resident's Food Allergy
Penalty
Summary
The facility failed to provide food that accommodated the allergies of a resident, specifically Resident #16, who was allergic to onions. Despite the resident's care plan and order summary clearly indicating an allergy to onions, the resident was served a meal containing chicken salad with onions. This oversight occurred during a dinner service, where the resident was unable to consume the meal due to the presence of onions, which she identified as an allergen that causes her to break out in hives. The deficiency was further highlighted by the fact that the staff member responsible for preparing the meal was not informed of the resident's allergy. During an interview, the staff member admitted to using onions in the chicken salad and was unaware of any resident having an onion allergy. The facility's policy on food preparation, which emphasizes serving food in a form that meets individual resident needs, was not adhered to in this instance, leading to the resident not receiving an appropriate alternative meal.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN C and RN B during wound care procedures for two residents. For Resident #5, LVN C did not adhere to proper hand hygiene protocols. After gathering treatment supplies, LVN C left the treatment cart to retrieve a laptop and upon returning, did not wash or sanitize hands before preparing the tray and supplies. LVN C then donned gloves without washing or sanitizing hands, which is a breach of infection control practices. Similarly, for Resident #15, RN B did not follow proper hand hygiene protocols during wound care. RN B washed her hands for only 5 seconds before donning gloves, despite knowing the recommended duration is 20-30 seconds. After applying a silicone dressing, RN B changed gloves without washing or sanitizing her hands. This failure to maintain hand hygiene could contribute to the risk of infection and delayed wound healing for the residents. Both residents had severe cognitive impairments and were admitted with unhealed Stage 4 pressure ulcers. The facility's policies on infection control and hand hygiene were not followed, as evidenced by the observations and interviews conducted. The Director of Nursing expected nurses to provide wound care according to physician orders and maintain infection control, but the practices observed did not align with these expectations.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the current nurse staffing information at the designated entrances on two consecutive days, 4/19/24 and 4/20/24. Observations revealed that the required staffing information was not available at entrance #1 and entrance #2 on both days. During an interview, the Director of Nursing (DON) acknowledged that the staffing pattern was not posted and stated that it was supposed to be displayed on the entrance #1 bulletin board. The Assistant Director of Nursing (ADON B), who was responsible for posting the staffing patterns, admitted that she was off duty and did not know who was responsible for the postings in her absence. Additionally, the DON mentioned that the facility did not have a staffing policy in place.
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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