Vidor Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Vidor, Texas.
- Location
- 470 Moore Dr, Vidor, Texas 77662
- CMS Provider Number
- 676108
- Inspections on file
- 34
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Vidor Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with anoxic brain injury and epilepsy was maintained on phenytoin after a dose reduction ordered for a previously high level, with subsequent lab monitoring showing a subtherapeutic phenytoin level of 5.6 ug/ml. Nursing staff notified the NP about the abnormal level and documented "no new orders," but there was no evidence of further assessment, timely repeat labs, dose adjustment, or escalation to the attending physician or medical director, despite the care plan requiring monitoring and follow-up of subtherapeutic labs. The resident continued on the same phenytoin dose, later developed altered mental status and severe pain, and was transferred to the hospital, where he was diagnosed with status epilepticus and a very low/undetectable Dilantin level. Interviews with facility staff and family confirmed that the low level was recognized but not acted upon beyond NP notification, and that the abnormal lab was not effectively addressed in accordance with professional standards and facility policy for abnormal lab notification.
A resident with severe cognitive impairment alleged sexual abuse by another resident, but a CNA who overheard the allegation failed to report it to the appropriate facility leadership or state agency as required. The incident was not reported or investigated until surveyors intervened, resulting in a delay in protective measures and investigation.
Two staff members, an activity aide and a dietary aide, were found preparing food without current Texas Food Handler's Licenses. Personnel files lacked evidence of valid certifications, and interviews with the DM and Administrator confirmed the absence of current food handler credentials and a facility policy to ensure compliance. The facility's infection control policy required valid food handler cards, but this was not followed for these staff.
Surveyors identified multiple deficiencies in kitchen operations, including improper food storage with unlabeled, undated, and expired items, unsanitary conditions such as standing water and ice build-up in coolers, and inadequate cleaning of pots and pans. Additionally, several staff members failed to fully contain their hair with hairnets while preparing food, despite having received training on proper hygiene practices. These failures were confirmed by the Dietary Manager, Administrator, and Maintenance Supervisor during interviews.
The facility did not notify physicians when two residents experienced significant changes in condition: one resident had consistently high blood glucose levels without physician consultation or adjustment of insulin orders, and another had multiple instances of low heart rate resulting in held medication doses without physician notification or documentation. Staff interviews and facility policy confirmed that physician notification was required in these situations.
The facility did not maintain water temperatures at or below 110°F at hand sinks and a shower room, exposing several residents who required assistance with bathing and personal hygiene to water that exceeded the facility's documented standard. Although no residents reported burns or discomfort, and staff were aware of monitoring procedures, the absence of a written policy and inconsistent temperature control resulted in water temperatures above the recommended range.
A resident with multiple respiratory conditions and severely impaired cognition was diagnosed with pneumonia and prescribed antibiotics, but the care plan was not updated to address the new diagnosis or treatment. The DON, responsible for care plan updates, did not revise the plan after the previous Infection Control Nurse left, resulting in the omission of pneumonia-specific interventions.
Expired over-the-counter medications, including antacids, laxatives, supplements, and vitamins, were found in the main medication storage room after their expiration dates. An LVN discovered 11 unopened bottles during an observation, and staff interviews revealed that the Medical Records Clerk was responsible for removing expired stock, with the Pharmacy Consultant as backup. The process for checking and organizing medications failed to prevent expired items from remaining in stock, and the most recent pharmacy review did not include the medication supply room.
Staff failed to accurately document and obtain daily vital signs for a resident with dementia, hypertension, and diabetes. Instead, identical vital sign readings were repeatedly entered into the MAR over several days, with staff and leadership confirming that actual assessments were not performed and previous values were copied or reused.
A wound care nurse failed to perform proper hand hygiene and change gloves during wound care for two residents with open wounds, resulting in contamination of clean fields and supplies. Despite being trained and aware of infection control protocols, the nurse did not follow required procedures, as confirmed by both the nurse and the DON. Facility policy mandates hand hygiene and glove changes during such care, but these were not adhered to during the observed incidents.
Surveyors found that the kitchen floors, including areas under the hand sink and behind the stove, had significant dust, grime, and food particle buildup. The Dietary Manager confirmed that deep cleaning had not yet been completed, and facility records showed that such cleaning should occur biweekly.
Two residents with significant physical and cognitive impairments did not receive scheduled bed baths as required by their care plans. Documentation and interviews confirmed that multiple scheduled baths were missed due to staffing shortages, despite both residents being unable to perform bathing independently and having no behaviors of care rejection that would prevent staff from providing assistance.
A resident with multiple chronic conditions did not receive her preferred breakfast sandwich with egg, bacon, and cheese as documented on her meal ticket, resulting in her not eating breakfast when her preferences were not met. The dietary manager confirmed the omission of the egg substitute, and the issue had occurred multiple times previously despite facility procedures to accommodate food preferences.
The facility failed to address grievances raised during residents' council meetings over three months. Complaints included staff using personal phones, untimely call light responses, and issues with food and bed making. Staff interviews revealed a lack of awareness and communication regarding grievance responsibilities, and residents reported dissatisfaction with the facility's handling of complaints.
The facility failed to provide palatable and attractive meals, serving cold and unappetizing food on disposable foam plates, contrary to policy. Staff used foam dishes to avoid using the dishwasher due to high kitchen temperatures, without informing management. Residents reported consistently cold meals, leading to potential decreased food intake.
A resident with multiple health conditions did not receive a scheduled shower, as required by her care plan, due to staff running out of time and failing to notify the charge nurse. The resident, at high risk for skin issues, reported not receiving a shower until three days later. The facility's policy highlights the importance of regular bathing for skin integrity and infection prevention.
A facility failed to ensure safe electrical outlet use in a resident's room, where a 6-outlet adapter powered multiple devices, risking circuit overload. The resident expressed concern about sparks, and the administrator was unaware of the non-compliance, attributing responsibility to the previous maintenance supervisor.
The facility failed to report abuse allegations in a timely manner, including a verbal abuse incident involving a resident and an LVN, and two separate incidents involving residents. The delays in reporting to the Abuse Coordinator and the State Agency could have placed residents at risk of continued abuse.
A facility failed to investigate and report a verbal abuse allegation involving a resident with Alzheimer's disease. A CNA reported that an LVN verbally abused the resident, but the incident was not communicated to the Administrator or the state promptly. The LVN continued working the next day, failing to protect the resident from potential further abuse. The delay in reporting and investigation placed residents at risk of undetected abuse.
A resident with severe cognitive impairment and specific care needs fell from the bed during a treatment due to inadequate supervision. The LVN, unaware of the requirement for two staff members for bed mobility, attempted the procedure alone, resulting in the resident sustaining injuries. The incident highlighted a failure in adhering to the care plan and facility policies.
The facility failed to designate a qualified infection preventionist with specialized training, as the current Infection Preventionist (LVN IC) had not completed the necessary training. The DON and Regional Compliance Nurse acknowledged the lack of training, which posed a risk to the facility's infection surveillance capabilities. The previous infection preventionist had completed the training but resigned months ago.
The facility failed to employ a qualified dietary manager, as the designated Dietary Supervisor did not have the necessary certification. Despite being appointed in June 2023, the Dietary Supervisor was still in school and expected to complete the certification by September 2024. This non-compliance was confirmed through interviews and record reviews.
The facility failed to provide a functioning call light system for residents in multiple halls, leading to the use of alternative methods like whistles and bells for calling assistance. Staff made frequent rounds to monitor residents, especially those with cognitive impairments, while the facility awaited repairs.
The facility failed to ensure proper storage and security of medications in two medication carts and one medication room, including expired medications and a non-affixed lock box for controlled drugs in the refrigerator. Staff interviews confirmed the lapses in following facility policies and procedures.
The facility failed to ensure that a dietary staff member had a current Food Handler's Certificate while working in the kitchen. This deficiency was confirmed through record review and interviews with the Administrator and Regional HR, who acknowledged the facility's responsibility to maintain such certificates to prevent foodborne illness.
The facility failed to maintain an infection prevention and control program. An LVN did not wash or sanitize her hands when entering a resident's room and between glove changes during medication administration. Additionally, two LVNs did not clean the glucometer device according to the required contact time of the disinfectant before and after use on three residents.
The facility failed to ensure resident privacy during incontinent care when two CNAs did not pull the privacy curtain, exposing a resident with severe cognitive impairment to her roommate. Both CNAs admitted to forgetting the procedure, despite being trained to provide privacy.
The facility failed to ensure comprehensive care plans were reviewed and revised for two residents. One resident's care plan did not address the need for a fire-resistant smoking apron, and another resident's care plan did not include the diagnosis related to an indwelling urinary catheter. These oversights were acknowledged by various staff members, including the MDS Nurse, SW, DON, and Administrator.
The facility failed to provide appropriate respiratory care for two residents. One resident received oxygen therapy without physician orders, and another received an incorrect oxygen dose. Both issues were confirmed by an LPN and the DON.
The facility failed to ensure proper medication administration for two residents. One resident did not have their g-tube placement checked before medication administration, and another received the wrong type of insulin. These deficiencies were observed and confirmed through interviews and record reviews.
Failure to Follow Up on Subtherapeutic Phenytoin Level Leading to Status Epilepticus
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, specifically related to management of an anti-seizure medication (phenytoin/Dilantin) and associated lab monitoring. The resident was an adult male with anoxic brain damage, epilepsy with status epilepticus, and severe cognitive impairment. His care plan identified a seizure disorder and directed staff to administer seizure medication as ordered, monitor and document side effects and effectiveness, monitor labs, report any subtherapeutic or toxic results to the physician, and obtain and follow up on lab/diagnostic work as ordered. The resident had an order for phenytoin, initially at 250 mg daily, with phenytoin levels to be checked every three months. After a critically high phenytoin level of 23.4, the physician decreased the dose from 250 mg to 200 mg daily and increased lab monitoring to every two months. A subsequent phenytoin lab result showed a level of 5.6 ug/ml, below the therapeutic range of 10.0–20.0 ug/ml. This low result was documented on the lab report and in the record, including a medication regimen review noting the low level and recommending a redraw and possible dose adjustment, with the physician checking a box agreeing with the recommendation. Progress notes indicated that the NP reviewed the resident’s BMP, CBC, and phenytoin labs and documented “no new orders” at that time. Despite the documented subtherapeutic phenytoin level of 5.6, there was no evidence in the record that nursing staff implemented additional assessments, obtained repeat labs in a timely manner, or followed up beyond notifying the NP. Interviews with the DON and nursing staff confirmed that the NP was contacted twice regarding the abnormal lab value and that no new orders were received, with no further escalation to the attending physician or medical director. The DON stated that the lab value was low but not critical and that it was beyond the nurse’s scope to question the NP’s response. The NP later stated she had missed the low level and that, given the resident’s seizure history and low level, she would normally have ordered a repeat lab and subsequent dose adjustment. The resident continued to receive 200 mg of phenytoin daily as documented on the MAR, and there was no documentation of seizure symptoms prior to his transfer to the hospital for screaming in severe pain, where he was diagnosed with status epilepticus and a subtherapeutic/undetectable Dilantin level. Interviews with family members indicated they were told by a hospital neurologist that the hospitalization and seizures were preventable and related to the decrease in medication and low phenytoin levels. The attending physician acknowledged that the first recheck level after the dose decrease was “5 something,” which he described as on the low side, and stated that the NP had missed the lab. He also stated he did not recall being notified of this specific lab value and that he would not “chase the numbers” in the absence of symptoms. Another physician interviewed stated that changes in phenytoin dosing or lab values should be followed by more frequent lab monitoring and that changes should not be based on old labs. The facility had a policy requiring physician notification of abnormal labs and documentation of such notifications and interventions, but there was no documentation that the low phenytoin level was escalated beyond the NP or that any clinical interventions or additional monitoring were implemented in response to the subtherapeutic result prior to the resident’s hospitalization. An Immediate Jeopardy (IJ) was identified related to this failure, based on the facility’s lack of follow-up after notifying the NP twice about the subtherapeutic phenytoin level and the absence of interventions or assessments in response to that abnormal lab value. The IJ was later removed, but the facility remained out of compliance at a lower severity level while it continued to monitor implementation and effectiveness of its corrective actions.
Removal Plan
- Transferred Resident #1 to the hospital for treatment of status epilepticus and subtherapeutic Dilantin level.
- Completed a 100% audit of anticonvulsant medications to ensure therapeutic lab values and communicated any abnormal findings to the attending physician.
- Notified the provider of an abnormal lab identified during the audit, awaited new orders, and monitored the resident for signs/symptoms of seizures.
- Provided 1:1 in-service to the DON and ADON by the Regional Compliance Nurse on provider notification of abnormal lab values, documentation of provider notification for changes in condition including abnormal labs, escalation process when the NP/attending does not address non-therapeutic labs, and abuse/neglect implications of failure to intervene on abnormal labs.
- Notified the Medical Director of the Immediate Jeopardy.
- Completed an ad hoc QAPI meeting with the interdisciplinary team including the Medical Director.
- Initiated facility-wide in-services for all charge nurses and ensured staff not present would not be permitted to work until in-serviced, new hires would be in-serviced during orientation, and agency staff would be in-serviced prior to working floor assignment, covering provider notification of abnormal labs, documentation of provider notification for changes in condition including abnormal labs, escalation process when the NP/attending does not address non-therapeutic labs, and abuse/neglect implications of failure to intervene on abnormal labs.
- Reviewed the facility-wide anticonvulsant audit, reviewed documentation of Resident #2’s follow-up to an abnormal lab, reviewed in-service documentation for the ADON/DON/all staff, and ensured any incomplete in-services would be completed before the staff member’s next shift.
- Conducted individual staff interviews across shifts/weekends/PRN to confirm staff understanding of training and reporting requirements for lab results including reporting to the DON, MD, and family.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required. Specifically, a resident with severe cognitive impairment and a history of dementia alleged that another resident touched her breast. This allegation was overheard by a CNA, who did not report the incident to the charge nurse, Administrator, or DON, despite having been trained to do so. The CNA admitted to overhearing the allegation one to two weeks prior but did not act, believing the resident was confused. The incident was not reported to the facility's abuse coordinator or to the state agency within the required timeframe. The deficiency was identified when a non-staff person relayed the resident's allegation to surveyors, prompting further investigation. Interviews confirmed that neither the Administrator nor the DON had been informed of the allegation until surveyor intervention. The facility's own policy required immediate reporting of abuse allegations, especially those involving serious bodily injury or abuse, within two hours. However, the required notifications and investigation were not initiated until the surveyors became involved. The residents involved both had severe cognitive impairment and were admitted to a secure unit due to elopement risk and dementia. The alleged perpetrator denied the incident, and the alleged victim was unable to provide specific details about when the event occurred or which staff were aware. The lack of timely reporting and investigation meant that no interventions were initiated to protect the resident or prevent further abuse until after the surveyor's discovery.
Failure to Ensure Dietary Staff Maintained Required Food Handler Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, one activity aide and one dietary aide were found to be preparing food in the kitchen without having a current Texas Food Handler's License. Observations confirmed that the activity aide was preparing shredded cheese at the prep table, and record reviews of both aides' personnel files showed no evidence of current or prior food handler certifications at the time of review. Interviews with the Dietary Manager and Administrator confirmed that these staff members did not have current food handler certifications and that there was no facility policy in place to ensure compliance with food handler certification requirements. The Administrator acknowledged the importance of food handler certification for all staff involved in food preparation to ensure adherence to best practices, proper sanitation, and prevention of cross-contamination. The activity aide also confirmed that her certification was expired at the time she was preparing food and recognized the risk this posed to residents. The facility's infection control policy required valid food handler cards for dietary associates, but this was not followed for the staff in question.
Multiple Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as evidenced by multiple observations in the kitchen. Food items in Icebox #1 were found to be unlabeled, undated, unsealed, and in some cases, expired. Specific items included cantaloupe slices and pudding in unmarked containers, undated tomatoes, an opened and exposed bag of broccoli, and sliced tomatoes with visible spoilage. Additionally, the dry pantry contained expired juice containers, dented cans stored with non-dented cans, an unsealed bag of vanilla wafers, and an expired jar of horseradish. The Dietary Manager (DM) confirmed these findings and acknowledged that expired or spoiled foods had not been removed as required by facility policy. The facility also failed to maintain sanitary conditions in food storage and preparation areas. Icebox #2 had standing water on the floor, with cases of milk cartons sitting in the water, and unpackaged food present. The milk box cooler exhibited a significant ice build-up and accumulation of food crumbs and debris along the wall and rubber gasket. The DM and Maintenance Supervisor confirmed these conditions, with the Maintenance Supervisor attributing the issues to a clogged drain and a dirty rubber seal. Additionally, the storage area for pots and pans contained multiple items with baked-on black and brown residue, indicating inadequate cleaning practices. Staff hygiene and use of hair restraints were also deficient. Observations revealed that Activity Aide B, Dietary Aide G, and another dietary staff member were working in the kitchen with hairnets that did not fully contain their hair, leaving portions of hair exposed around the face and nape. Staff interviews confirmed that they had received training on proper hair restraint use, but were unaware that their hair was not fully covered. The DM and Administrator both acknowledged the importance of proper hair restraint to prevent contamination, and the DM stated it was her responsibility to ensure compliance with these standards.
Failure to Notify Physician of Changes in Condition and Medication Holds
Penalty
Summary
The facility failed to consult with physicians regarding significant changes in condition for two residents. For one resident with diabetes and severe cognitive impairment, blood glucose levels were consistently elevated on multiple dates, as documented in the medication administration record. Despite these abnormal readings, there was no evidence that the physician was notified or that sliding scale insulin was considered or ordered. Nursing staff and the DON confirmed that physician notification should have occurred for these abnormal results, and that an order for sliding scale insulin was needed to manage the resident's blood glucose levels. For another resident with congestive heart failure and hypertension, the medication Digox was held on several occasions due to low heart rates, as per physician orders. However, there was no documentation that the physician was consulted about the repeated low heart rates or the pattern of the medication being withheld. Staff interviews confirmed that the physician should have been notified and that such notifications should be documented in the resident's medical record. Facility policy also required physician notification when a dose of medication was not given.
Failure to Maintain Safe Water Temperatures for Resident Use
Penalty
Summary
The facility failed to maintain safe water temperatures at or below 110 degrees Fahrenheit at hand sinks and a shower room used by several residents. During observations, the Maintenance Supervisor measured water temperatures ranging from 111.3 to 115 degrees at the hand sinks in the rooms of three residents and in the shower room between two halls. These temperatures exceeded the facility's stated standard for water temperature, which was documented as 100 to 110 degrees in the water temperature logs. The Maintenance Supervisor acknowledged that water temperatures had been fluctuating and that a plumber had provided an estimate for a new mixing valve, but the issue persisted at the time of the survey. The residents involved had varying degrees of cognitive function and required substantial or maximal assistance for bathing and personal hygiene. None of the residents reported having been burned or experiencing discomfort from the water temperature, and no burns or pressure wounds were documented in their medical records. Staff interviewed were aware of the need to monitor water temperatures to prevent burns and stated they routinely checked water temperatures when assisting residents with grooming or showering. Despite these precautions, the facility did not have a written policy regarding water temperature, and the Administrator relied on external resources for guidance. Water temperature logs from earlier in the month showed compliance, but logs from the days of the survey indicated temperatures above the acceptable range. The lack of a consistent and documented approach to monitoring and maintaining safe water temperatures led to the deficiency, as residents were exposed to water temperatures above the recommended maximum.
Failure to Update Care Plan for New Pneumonia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's recent diagnosis of pneumonia. The resident, an elderly female with a history of pleural effusion, chronic obstructive pulmonary disease, and severely impaired cognition, was admitted with multiple respiratory conditions and was dependent on continuous oxygen therapy. Despite a physician's order for Doxycycline to treat pneumonia and documentation of the resident's ongoing respiratory symptoms, the care plan was not updated to include interventions specific to the new pneumonia diagnosis or the antibiotic treatment. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for updating care plans for new infections but had not done so for this resident following the resignation of the previous Infection Control Nurse. The DON acknowledged being aware of the pneumonia diagnosis and the antibiotic order but did not revise the care plan, believing existing respiratory care plans were sufficient. The administrator confirmed that the omission occurred during the transition between staff roles. The facility's policy requires comprehensive care plans with measurable objectives and timeframes for all identified needs, but this was not followed in this case.
Expired Over-the-Counter Medications Found in Main Medication Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals in the main medication storage room were labeled and stored in accordance with professional standards, specifically by allowing 11 unopened over-the-counter medication bottles to remain in stock past their expiration dates. During an observation, an LVN identified these expired medications, which included antacids, laxatives, supplements, and vitamins, all with expiration dates ranging from several months prior to the survey. The LVN explained that the process for organizing medications involved placing older stock in front, but acknowledged that expired items may have been overlooked or accessed out of order. Interviews with facility staff revealed that the Medical Records Clerk was responsible for ordering, stocking, and removing expired medications, with the Pharmacy Consultant serving as a backup. The DON confirmed this arrangement and stated that the expired medications were likely missed during routine checks. The Medical Records Clerk reported conducting monthly checks for expired medications, with the last check occurring the previous month, and noted that nurses were also expected to help identify and remove expired stock. The Pharmacy Consultant indicated that her inspections of the medication rooms were periodic and not comprehensive, with her most recent check of the medication carts occurring the previous month. The Executive Summary of the Consultant Pharmacist's Medication Regimen Review documented a medication cart audit but did not indicate a review of the medication supply room. Staff interviews consistently acknowledged the risk that expired medications could be administered to residents, potentially resulting in reduced effectiveness.
Failure to Accurately Document and Obtain Daily Vital Signs
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not properly documenting daily vital signs as required by physician orders. Review of the resident's Medication Administration Record (MAR) for May 2025 revealed that staff repeatedly documented identical vital sign readings over consecutive days, rather than recording new measurements. Both the LVN and the DON confirmed during interviews that the vital signs were not being taken daily as ordered, and staff appeared to be copying previous entries or using an electronic record feature to repeat prior values instead of performing actual assessments. The resident involved had diagnoses including dementia, hypertension, and diabetes, and was severely cognitively impaired according to a recent assessment. Physician orders required daily vital signs to be obtained on the morning shift, and the care plan specified regular blood pressure monitoring. Despite these requirements, the MAR showed repeated, identical entries for vital signs over multiple days, indicating that staff did not follow proper procedures for assessment and documentation.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper wound care practices observed for two residents. For one resident, a 66-year-old male with diabetes, edema, kidney disease, and an arterial ulcer of the left great toe, the wound care nurse donned gloves and prepared a clean field but then contaminated the field by touching the resident's wound and subsequently retrieving clean supplies with the same gloves. The nurse placed used gauze and dirty gloves on the same surface as clean dressings and did not perform hand hygiene before donning new gloves and continuing care. For another resident, a female with a stage 4 pressure ulcer on the coccyx and a history of surgery, anxiety disorder, and kidney failure, the wound care nurse did not perform hand hygiene before starting care and failed to change gloves or wash hands at multiple points during the dressing change. The nurse removed a soiled dressing, handled clean supplies with contaminated gloves, and applied medication and a new dressing without appropriate hand hygiene or glove changes, thereby contaminating the clean field and supplies. Interviews with the wound care nurse confirmed awareness of the correct procedures, including the need for hand hygiene and glove changes, but acknowledged these steps were not followed during the observed care. The Director of Nursing, who also serves as the Infection Control Preventionist, stated that staff are expected to follow hand hygiene protocols and that training is provided during orientation and as needed. Facility policy also requires hand hygiene before and after dressing changes and after removing gloves.
Failure to Maintain Kitchen Floor Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to maintain clean floors in the kitchen, specifically under the hand washing sink, juice area, and behind the stove. There was a buildup of dust, grime, and food particles along the floor under the hand sink area, which extended the length of the wall, and behind the stove, which extended approximately six inches from the baseboard. The Dietary Manager acknowledged that she had not yet had the opportunity to deep clean the floors and confirmed that the kitchen should not have grime or buildup to prevent contamination of food. The Administrator also stated a desire for the kitchen to be clean. Review of the facility's deep clean list indicated that cleaning under sinks and scrubbing floors with a floor machine should occur every two weeks.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, to two residents who were unable to perform these tasks independently. One resident, a female with diagnoses including cardiomegaly, dementia with behavioral disturbance, morbid obesity, urogenital candidiasis, and rheumatoid arthritis, required substantial to maximal assistance for bathing and had no behaviors of care rejection. Her care plan specified a bed bath on Monday, Wednesday, and Friday with one staff assist. However, CNA flowsheets and resident interviews confirmed that scheduled bed baths were missed on multiple occasions, with only one bath documented over a one-week period. Staffing shortages were cited by CNAs as a reason for not completing all scheduled baths. Another resident, also a female with heart disease, dementia, morbid obesity, schizophrenia, and heart failure, required moderate assistance from two staff for bathing and was noted to be occasionally resistive to care. Her care plan included strategies for negotiating ADL times and re-approaching if she was initially resistive. Despite this, CNA documentation and resident interviews indicated that scheduled bed baths were not consistently provided, with only two baths given in a week and several missed on scheduled days. The DON acknowledged staffing challenges and the impact on the ability to provide scheduled baths, while the administrator confirmed the expectation that residents receive their scheduled hygiene care.
Failure to Provide Resident with Preferred Breakfast Items
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's stated preferences. Specifically, a resident with diagnoses including cardiomegaly, dementia with behavioral disturbance, morbid obesity, urogenital candidiasis, and rheumatoid arthritis, who was on a regular diet, did not receive a breakfast sandwich with egg, bacon, and cheese as requested and documented on her meal ticket. During breakfast service, the resident received a sandwich without egg, which she reported had happened one to two times per week previously. The resident stated that when her breakfast was not prepared as requested, she would not eat breakfast. The dietary manager confirmed that the omission was due to forgetting the egg substitute, which was used in place of real eggs due to supply issues. The resident's care plan included offering the diet as ordered and updating food preferences as needed. The facility's meal service policy required dietary staff to interview residents about food preferences upon admission and periodically thereafter, and to serve breakfast to order. Despite these procedures, the resident's preferences were not consistently met.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances over a three-month period. During this time, grievances voiced during residents' council meetings were not thoroughly investigated or addressed. Specific complaints included staff using personal phones while providing care, call lights not being answered timely, lack of fresh water and evening snacks, untimely bed making, food not matching meal tickets, cold food, incorrect meals, and irregular provision of clean bedsheets. Despite these issues being raised in meetings, no grievances were documented or addressed in the facility's records for the months reviewed. Interviews with staff revealed a lack of awareness and communication regarding the grievance process. The Social Worker (SW) was unaware of any unaddressed grievances and did not know she was responsible for writing up or addressing grievances from the residents' council meetings. Similarly, the Activity Director did not document grievances from the meetings and only emailed the minutes to the Administrator, without informing the SW. The Administrator admitted to not reviewing the residents' council minutes to ensure complaints were addressed, attributing the oversight to the SW being new and possibly unaware of her responsibilities. Residents expressed dissatisfaction with the facility's handling of grievances, stating that complaints were not addressed and that issues such as cold and unappetizing food, particularly on weekends, persisted. The facility's grievance policy mandates that residents have the right to voice grievances without fear of reprisal and that the facility must make prompt efforts to resolve them. However, the facility did not adhere to this policy, as evidenced by the lack of documented grievances and unresolved complaints from the residents' council meetings.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to provide palatable and attractive food for residents, as evidenced by observations, interviews, and record reviews. Over a period from December 19, 2024, to February 8, 2025, meals were consistently served cold and unappetizing, often on disposable foam plates and bowls, contrary to the facility's policy. Photos and interviews revealed meals such as cold grilled cheese sandwiches, flavorless tuna on unbuttered bread, and cold, unseasoned meat, all served in disposable foam containers. These meals were described as lacking flavor and being served at inappropriate temperatures, which could lead to decreased food intake and potential weight loss among residents. Interviews with staff and residents confirmed the issues with meal temperatures and presentation. Dietary staff admitted to using disposable foam dishes to avoid using the dishwasher due to high kitchen temperatures, without informing management of the air conditioning issues. Residents consistently reported that food served on disposable foam was always cold. The facility's policy stated that meals should be served on regular dining plates and bowls with warmer covers to maintain proper temperatures, but this was not adhered to, leading to the deficiencies noted in the report.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received necessary services to maintain good hygiene. Specifically, the resident did not receive a scheduled shower or bath on February 7, 2025, as per her care plan, which required assistance from one staff member. The resident, who had multiple diagnoses including cardiomegaly, dementia, morbid obesity, and rheumatoid arthritis, was at high risk for skin issues due to her impaired mobility and co-morbid conditions. The resident reported not receiving a shower until February 10, 2025, and expressed concern about her skin breaking out due to missed showers. Interviews with staff revealed that the CNA responsible for the resident's care on February 7, 2025, ran out of time and did not complete the shower, failing to notify the charge nurse or the Director of Nursing (DON). The subsequent shift also did not complete the shower, and the charge nurse was not informed. The DON confirmed that it was the facility's expectation for residents to receive showers as scheduled and acknowledged the risk of skin breakdown and infections when showers are missed. The facility's policy emphasized the importance of regular bathing for maintaining skin integrity and preventing infections.
Improper Use of Electrical Outlets in Resident Room
Penalty
Summary
The facility failed to ensure the safe use of electrical outlets in a resident's room, leading to a potential risk of overloading the electrical circuit. Observations revealed that a duplex outlet was equipped with a 6-outlet adapter to power multiple devices, including an electric bed, mini refrigerator, television, cell phone charger, oxygen humidifier, and fans connected through extension cords. The resident expressed concern about the potential for sparks but had not witnessed any. The facility's administrator was unaware of the non-compliance with regulations and indicated that the previous maintenance supervisor was responsible for ensuring electrical safety. The new maintenance supervisor, hired recently, was expected to address these issues.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report a verbal abuse allegation immediately to the Abuse Coordinator. A CNA alleged witnessing an LVN verbally abusing a resident, but the incident was not reported to the Administrator, who was the Abuse Coordinator, until the following day. The CNA reported the incident to two ADONs, who did not immediately inform the Administrator. This delay in reporting resulted in the LVN continuing to work until the next day, potentially placing residents at risk of continued abuse. In another incident, the facility failed to report an allegation of abuse to the State Agency within the required 2-hour timeframe. A resident was reported to have hit another resident with a soft plastic urinal, but the incident was not reported to the state until 12 hours later. The delay in reporting such incidents could lead to residents being at risk of further harm or abuse. Additionally, the facility did not report a verbal abuse allegation involving another resident within the required timeframe. A CNA was reported to have spoken rudely to a resident, but the incident was not reported to the state until more than 16 hours later. These failures in timely reporting of abuse allegations highlight significant lapses in the facility's procedures for handling and reporting such incidents, potentially compromising resident safety.
Removal Plan
- Resident #1 was assessed for emotional distress by the DON. A trauma informed care assessment was completed by the DON. No additional emotional distress was noted.
- LVN B was terminated and ADON D resigned. Both are no longer employed at the facility.
- The Administrator, DON, and ADON C were in-serviced 1:1 by the Area Director of Operations and Regional Compliance Nurse on following topics: Abuse and Neglect, reporting immediately to the abuse coordinator, suspension of alleged perpetrators, reporting to HHS, investigation delegation, and notification procedures if the Administrator is unavailable.
- The medical director was informed of the immediate jeopardy citation by DON.
- An ADHOC QAPI meeting was held to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal.
- All staff will be in-serviced on abuse and neglect, reporting procedures, and the role of the abuse coordinator. Staff not present will not assume duties until in-serviced. PRN staff will be in-serviced prior to assignments. New hires will be in-serviced on hire date. Agency staff will be in-serviced prior to assignment. Completion date.
Failure to Investigate and Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with Alzheimer's disease, anxiety, and heart failure. The incident occurred when a CNA reported that an LVN verbally abused the resident after finding her on the floor. The CNA reported the incident to two ADONs, but the allegation was not immediately communicated to the Administrator or the state as required. The resident, who was cognitively impaired with a BIMS score of 5, did not recall the incident when interviewed. The facility's records did not document the fall or any concerns on the day of the incident, and no incident report was completed. The LVN involved continued to work at the facility the following day, which failed to protect the resident from potential further abuse. The Administrator was not informed of the incident until the day after it occurred, delaying the investigation and reporting process. The ADONs did not ensure the allegation was reported to the Administrator, leading to a delay in suspending the LVN and initiating a thorough investigation. This failure placed residents at risk of undetected abuse and compromised their feelings of safety and well-being.
Removal Plan
- Resident #1 was assessed for emotional distress by the DON. A trauma informed care assessment was completed by the DON. No additional emotional distress was noted.
- LVN B was terminated and ADON D resigned. Both are no longer employed at the facility.
- The Administrator, DON, and ADON C were in-serviced 1:1 by the Area Director of Operations and Regional Compliance Nurse on following topics: Abuse and Neglect, reporting immediately to the abuse coordinator, suspension of alleged perpetrators, reporting to HHS, thorough investigation, delegation of responsibilities, and notification procedures if the Administrator is unavailable.
- The medical director was informed of the immediate jeopardy citation by DON.
- An ADHOC QAPI meeting was held to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal.
- All staff will be in-serviced on abuse and neglect, reporting procedures, and suspension of alleged perpetrators. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment.
Failure to Provide Adequate Supervision and Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to an accident. The resident, who had severe cognitive impairment and required two staff members for bed mobility, fell from the bed during a pressure ulcer treatment. The incident occurred when an LVN attempted to perform the treatment alone, without the required assistance, resulting in the resident sustaining a skin tear and bruises. The resident, who had a history of high blood pressure, kidney disease, stroke, and morbid obesity, was admitted to the facility with specific care needs documented in her care plan and Kardex. Despite these documented needs, the LVN proceeded with the treatment without assistance, citing an inability to find help. This action was contrary to the facility's policy and the resident's care plan, which clearly indicated the necessity of two staff members for bed mobility. Interviews with staff revealed that the LVN was not adequately oriented to the Kardex system, which led to the misunderstanding of the resident's care requirements. The incident was witnessed, and the resident was assessed for injuries before being sent to the hospital. The facility's failure to provide the necessary supervision and adhere to the care plan placed the resident at risk of harm, as evidenced by the injuries sustained during the fall.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist with specialized training in infection prevention and control. The designated Infection Preventionist (LVN IC) had not completed the necessary specialized training, which was acknowledged by both the Director of Nursing (DON) and the Regional Compliance Nurse. The LVN IC, who was also serving as the Assistant Director of Nursing (ADON), admitted to not having completed the specialized training and expressed concerns about the potential risk this posed to the facility's infection surveillance capabilities. The DON, who was new to the facility, also confirmed that she had not completed the specialized training and was unsure if the LVN IC had done so. Interviews revealed that the previous infection preventionist, LVN E, had completed the specialized training but had resigned from the role two to three months prior. The facility's infection control policy required the Infection Preventionist, DON, and Administrator to complete a CDC training course for infection control and prevention, which had not been fulfilled. The Regional Compliance Nurse acknowledged the importance of having a certified individual responsible for the infection control program and noted that both the DON and LVN IC had only started the training recently.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not designate a person to serve as the dietary manager who met the required qualifications. The designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials from 06/14/23 to 04/10/24. This deficiency was identified through interviews and record reviews, which revealed that the Dietary Supervisor was still in school and expected to complete the certified Dietary Manager course by September 2024. Despite being appointed as Dietary Supervisor on 06/14/23, she had not yet completed the necessary certification at the time of the survey. During interviews, the Dietary Supervisor confirmed that she had not completed the dietary manager classes and was working in the role until she became certified. The Administrator acknowledged that her expectation was for the Dietary Manager to be certified to oversee dietary services, monitor staff's dietary certifications, and ensure diets were followed. The Regional HR also confirmed that the Dietary Supervisor was not a certified dietary manager. The facility's policy for the Dietary Manager was requested but not provided prior to the exit. The Texas Food Establishment Rules require at least one employee with supervisory and management responsibility to be a certified food protection manager, which the facility failed to comply with.
Facility Fails to Provide Functioning Call Light System
Penalty
Summary
The facility failed to provide a functioning call light system for residents in Halls 100, 200, 300, 500, and 600 from 04/05/24 to 04/10/24. During this period, residents were using alternative methods such as whistles, bells, and maracas to call for assistance. Staff members were observed responding to these alternative call tools and making frequent rounds to monitor residents, especially those with cognitive impairments. The lack of a functioning call light system was confirmed through multiple observations and interviews with staff and the Administrator, who acknowledged the issue and mentioned that the facility was in the process of obtaining bids to repair or replace the system. The Administrator stated that the call lights went out on a Friday, and the facility had implemented temporary measures such as extra staffing and frequent monitoring to ensure residents' needs were met. Despite these efforts, the call light system remained non-functional throughout the survey period. The Administrator also mentioned that the regional office had decided to repair the old call light system, with repairs scheduled to be completed by the following Tuesday. However, there was no existing policy on call lights available at the time of the survey.
Improper Storage and Security of Medications
Penalty
Summary
The facility failed to ensure proper storage and security of drugs and biologicals in two medication carts and one medication room. Specifically, the Hall 6 Nurse Cart contained an opened Insulin Glargine kwik pen with an open date of 03/08/24, two cards of expired Acetaminophen with codeine, two opened inhalers of Trelegy without open dates, and an opened bottle of fluticasone nasal spray without an open date. Additionally, the MA cart had a card of expired escitalopram. The facility also failed to provide a separately locked, permanently affixed compartment for controlled drugs in the refrigerator of the medication room, which contained a removable locked metal box for controlled medications that had not been affixed since a new refrigerator was installed three months prior. Interviews with staff, including an LVN, MA, and the DON, confirmed that expired medications should be removed from the carts to prevent administration to residents and potential drug diversion. The LVN acknowledged that insulin should be used within 28 days of opening, and inhalers and nasal sprays should have open dates to ensure timely disposal. The DON and Administrator confirmed that the lock box in the refrigerator should be permanently affixed to prevent drug diversion. The facility's policies and procedures for medication storage and controlled substances were not followed, leading to the observed deficiencies.
Failure to Ensure Dietary Staff Had Required Food Handler's Certificate
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, Dietary Staff G did not have a current Food Handler's Certificate while working in the facility's kitchen from April 8, 2024, to April 10, 2024. This deficiency was identified through record review and interviews. The Administrator confirmed that Dietary Staff G's certificate was not found, and the Regional HR acknowledged that the facility was responsible for ensuring all dietary staff had the necessary certificates to prevent foodborne illness. The Texas Food Establishment Rules require that food handler training certificates be maintained on the premises, effective since September 1, 2016. The facility's policy on food handler certificates was requested but not provided prior to the survey exit.
Infection Control Deficiencies in Hand Hygiene and Glucometer Cleaning
Penalty
Summary
The facility failed to ensure an infection prevention and control program was maintained for four residents. Specifically, LVN C did not wash or sanitize her hands when entering Resident #31's room and between glove changes during medication administration via g-tube. LVN C acknowledged that she should have washed her hands upon entering the room and sanitized her hands between glove changes. Additionally, LVNs J and K did not clean the glucometer device according to the required contact time of the disinfectant before and after use on Residents #72, #7, and #82. Both LVNs acknowledged that the disinfectant wipes required a 1-minute contact time, which they did not adhere to. The facility's Glucometer policy and procedure indicated that the meter should be cleaned with a germicidal and allowed to air dry between patient testings.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure resident rights for personal privacy for one resident. During an observation, two CNAs provided incontinent care to a resident without pulling the privacy curtain between the resident and her roommate. The resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene, was exposed during the care procedure. The CNAs admitted to forgetting to pull the privacy curtain, despite being trained to do so. The Director of Nursing confirmed that the expectation was for all nursing staff to provide privacy when exposing residents' private areas. The facility's policy on resident rights emphasized the importance of treating residents with respect and dignity, including ensuring personal privacy. The failure to pull the privacy curtain during the care procedure was a clear violation of this policy.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident, the care plan did not accurately address the need for a fire-resistant smoking apron despite multiple assessments indicating its necessity. This oversight was acknowledged by various staff members, including the LVN, MDS Nurse, SW, DON, and Administrator, who all admitted that the requirement for the fire-resistant smoking apron was overlooked in the care plan updates. The risk identified was that staff might be unaware of the need for the apron, potentially leading to safety hazards during smoking activities. For another resident, the care plan failed to address the diagnosis of benign prostatic hyperplasia and urinary retention related to his indwelling urinary catheter. Although the resident had an indwelling catheter and no cognitive impairment, the care plan did not include the necessary diagnosis, which was also acknowledged as an oversight by the MDS Nurse, DON, and Administrator. The risk identified was that staff might not be aware of the reason for the catheter, which could affect the quality of care provided. The facility's policies on comprehensive care plans and smoking safety were not followed, leading to these deficiencies. The interdisciplinary team, including the MDS Nurse, SW, ADON, and DON, were responsible for ensuring care plans were accurate and updated, but failed to do so in these instances. The Administrator confirmed that the care plans should be accurate and updated appropriately, but acknowledged that the care plans for these residents had not been reviewed properly.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that two residents who needed respiratory care were provided such care consistent with professional standards of practice and their comprehensive person-centered care plans. Resident #14, who had multiple sclerosis and neoplasm of the meninges and was on hospice services, was observed receiving oxygen therapy without any physician orders. Despite receiving oxygen for several months, there were no orders documented for the administration of oxygen, and the care plans did not reflect the oxygen therapy. LVN A confirmed that the resident had been receiving oxygen without orders and acknowledged that it was the nurse's responsibility to ensure orders were in place and to check the oxygen settings every shift. Similarly, Resident #41, who had heart failure and emphysema, was ordered oxygen at 2L nasal cannula continuously but was observed receiving oxygen at 3L nasal cannula on multiple occasions. LVN A confirmed that the resident's oxygen was set incorrectly and should have been at 2L as ordered. The DON acknowledged that Resident #14 should have had orders for oxygen and that Resident #41 should have received the correct dose of oxygen. The facility's Oxygen Administration policy indicated that oxygen therapy should be administered as ordered by the physician, but this was not followed in these cases.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for two residents. For Resident #31, a male with a gastrostomy tube, the Licensed Vocational Nurse (LVN) did not check the placement of the g-tube before administering medications. The LVN claimed to have checked the placement earlier in the day, but this did not align with the facility's policy, which requires checking the placement before each medication administration. This oversight was observed during a medication administration session and confirmed through interviews and record reviews. For Resident #72, a female with type 2 diabetes mellitus, the facility failed to administer the correct type of insulin as per physician orders. The LVN administered Humulin N instead of the prescribed regular insulin. The Director of Nursing (DON) confirmed that the resident should have received regular insulin and was unaware of why the pharmacy sent Humulin N. The discrepancy was discovered during an observation and subsequent interviews with the LVN and DON, who later contacted the pharmacy consultant to clarify the issue.
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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