Vista Hills Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 1599 Lomaland Dr, El Paso, Texas 79935
- CMS Provider Number
- 455493
- Inspections on file
- 44
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Vista Hills Health Care Center during CMS and state inspections, most recent first.
A resident with advanced dementia and severe osteopenia, fully dependent on staff for care, sustained a spiral femur fracture during routine repositioning by a CNA using a one-person assist. The injury was discovered after the CNA heard a popping sound, and although a STAT x-ray was ordered, there was a delay in reviewing the results due to the night nurse's workload. The resident was later transferred to the hospital after the fracture was confirmed.
A resident with advanced dementia and recent orthopedic surgery experienced swelling and pain in the right knee, prompting a STAT x-ray that revealed a spiral femur fracture. Although the radiologist confirmed the fracture late at night, nursing staff did not review the results or arrange hospital transfer until the following morning, resulting in a seven-hour delay in emergency care. Facility staff and leadership acknowledged that the delay was due to lack of follow-up on critical diagnostic results.
A resident with heart failure did not receive four scheduled doses of Entresto due to the medication being unavailable, and staff failed to notify the physician or document the missed doses as required by facility policy. The medication aide recorded the missed doses in the MAR but did not inform the nurse, and the nurse did not notify the physician, resulting in a lack of physician awareness and intervention.
A resident with heart failure did not receive ordered Entresto due to lack of weekend pharmacy delivery and the medication not being available in the facility or from the family. The medication aide did not inform the nurse of the missed doses, and the nurse did not notify the physician or document the incident, contrary to facility policy.
A resident with an indwelling catheter did not have their catheter secured with a leg strap, as required by their care plan and physician's order. The resident reported discomfort due to the unsecured catheter, which had been an issue for two days. Nursing staff, including an RN and a CNA, were trained to secure catheters but failed to do so in this instance. The DON emphasized the importance of regular checks, which were not performed, increasing the risk of catheter-related injury.
The facility failed to address grievances and recommendations from the resident council, particularly regarding cold food temperatures and interference with council elections. Residents felt unheard as their concerns were not documented or acted upon, and they were denied access to meeting minutes. The administrator and staff did not effectively follow the grievance policy, leading to a lack of proper documentation and follow-up on resident issues.
The facility conducted care plan meetings in residents' rooms, compromising privacy and confidentiality. Residents felt embarrassed as discussions were overheard by roommates, staff, and visitors. An LVN and the Administrator were unaware of these concerns, despite the facility's policy emphasizing privacy rights.
The facility failed to resolve grievances, particularly those about cold meals, voiced during Resident Council Meetings. The Activities Director did not initiate grievance reports, and the Administrator did not document or resolve these issues. Residents consistently reported cold meals, but the facility lacked a system to ensure proper food temperatures. The grievance policy was not followed, and the Local Ombudsman confirmed residents felt their concerns were ignored.
A resident with a history of intracerebral hemorrhage and hemiparesis required assistance with ADLs, including nail care. Despite the care plan's instructions, the resident's fingernails were long and dirty, posing a risk of injury due to hand contractures. The DON and staff were either unaware or did not follow through with the necessary nail care, as confirmed by observations and interviews.
A resident with significant medical conditions, including diabetes and limited mobility, did not receive proper foot care due to the facility's failure to provide access to a podiatrist. Observations showed the resident had long, discolored toenails, and staff were not trained or aware of who was responsible for toenail care. The facility's policy required podiatrist care for diabetic residents, which was not provided, placing the resident at risk.
The facility failed to ensure proper documentation of controlled substance counts during shift changes, as three licensed staff members did not follow the established procedure. ADON L did not sign the Controlled Drugs-Count Record immediately after verifying the count, while RN A and LVN C signed the record before conducting the count. This deviation from policy could risk residents not receiving the intended therapeutic response and increase the risk of drug diversion.
The facility failed to ensure proper storage of medications, with oral and topical medications mixed in medication carts and opened Acidophilus Probiotic Dietary Supplements not refrigerated as required. Medication carts were also found to be unclean. In the medication room, oral and topical medications, as well as oral medications and ear drops, were improperly stored together. Staff interviews revealed a lack of awareness regarding proper storage protocols.
The facility failed to serve food at appropriate temperatures, as residents reported meals being delivered cold. The Director of Food and Nutrition confirmed improper food temperatures, and staff interviews revealed a lack of communication and documentation regarding grievances. The facility lacked insulated meal carts and a system to ensure prompt meal delivery, contributing to the issue.
The facility failed to maintain food safety standards, with issues such as unclean shelving, expired foods, and improper food storage. Dietary staff did not use gloves or sanitize thermometers when checking food temperatures. Residents reported cold food, and meal carts were left open, affecting food temperatures.
The facility failed to maintain a safe and sanitary environment, with splintered wood shelves in linen closets, missing baseboards, and chipped walls in the laundry room, and broken tiles and rusted drains in the shower room. Staff interviews revealed a lack of awareness and reporting of these issues, despite existing protocols for maintenance requests.
A facility failed to accurately document a resident's behaviors in her MDS assessment, despite her comprehensive care plan noting behaviors such as requesting HIPAA information and making false allegations against staff. Interviews with staff revealed awareness of these behaviors, but they were not included in the assessment due to their nature. This oversight could lead to inaccurate assessments and affect the care provided.
A facility failed to include a physician-ordered intervention in a resident's care plan, specifically the elevation of the head of the bed to at least 30 degrees during enteral feeding. This oversight was identified during a review of the care plan, despite the resident's medical condition requiring it to prevent aspiration. Observations and interviews revealed that the nursing staff were responsible for ensuring the correct positioning, but the care plan lacked this critical intervention, posing a risk to the resident.
A resident receiving continuous enteral feeding was found lying flat in bed, contrary to physician orders requiring a 30-degree head elevation to prevent aspiration. Despite training, staff failed to maintain this position, as observed during a survey. The facility's policy lacked specific guidance for continuous feeding, contributing to the deficiency.
A facility failed to ensure a resident's feeding tube bags were properly labeled, leading to potential risks. The resident's feeding tube was set correctly, but the enteral feeding bag lacked necessary information, and the water bag was mislabeled. The LVN admitted the mistake, and the DON confirmed no complications but acknowledged the risks.
Failure to Provide Adequate Supervision and Safe Handling During Repositioning
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, severe osteopenia, and a history of multiple comorbidities, including PEG-tube dependence and prior bilateral knee and hip arthroplasties, sustained a spiral fracture of the distal right femur during routine repositioning in bed by a CNA. The resident was completely dependent on staff for activities of daily living and ambulation, and was nonverbal, rarely or never understood, and always incontinent. During incontinence care, the CNA reported hearing a popping sound from the resident's right knee while using a one-person assist technique, after which the resident did not vocalize pain but was later found to have swelling, redness, and pain in the right knee. The CNA had previously performed care for the resident independently and was unaware of the subsequent hospital transfer. Following the incident, the nurse on duty was notified and assessed the resident, noting signs of pain and swelling in the right knee. A STAT x-ray was ordered, and pain medication was administered. However, there was a delay in reviewing the STAT x-ray results, as the night shift nurse did not access the provider portal to check for results, citing workload and being the only nurse for 30 patients. The x-ray provider did not call the facility with critical findings during the night shift, and the results were not reviewed until the following morning by the incoming nurse, who then promptly contacted the provider and arranged for the resident's transfer to the hospital. Interviews with staff confirmed that the resident did not fall and that the injury likely resulted from minimal movement due to underlying bone fragility. The facility's policies required prompt notification of changes in resident status and timely review of diagnostic results. The delay in reviewing the STAT x-ray and the use of a one-person assist for a highly dependent, nonverbal resident contributed to the failure to provide adequate supervision and safe handling techniques, resulting in the resident's injury.
Delay in Emergency Transfer Following Missed STAT X-ray Result
Penalty
Summary
A deficiency occurred when facility staff failed to act in a timely manner to transfer a resident to the hospital after a radiologist confirmed a spiral femur fracture. The resident, an elderly female with advanced dementia, PEG tube dependence, and a history of recent right distal femur fracture, was identified as having swelling, redness, and pain in her right knee during evening care. A STAT x-ray was ordered, and the radiologist signed off on the diagnosis of a spiral femur fracture late that night. However, the resident was not transferred to the hospital until the following morning, resulting in a delay of approximately seven hours from the time the critical finding was available. The delay was due to a lack of follow-up by the night shift nurse, who did not check the x-ray provider portal for results during his shift, despite being aware that STAT x-rays had been ordered and that the resident had a significant change in condition. The nurse stated he was the only nurse for 30 patients and was busy, but acknowledged that it was good clinical practice to follow up on pending x-ray results. The morning shift nurse discovered the x-ray results, contacted the provider, and arranged for the resident's transfer to the hospital. Interviews with other staff confirmed that all nurses had access to the x-ray provider portal and were trained to check for STAT results, and that a fracture was considered a critical finding requiring immediate action. Facility policies required staff to provide timely care and follow up on significant changes in condition, including obtaining and acting on diagnostic results. The failure to review and act on the STAT x-ray results in a timely manner resulted in a delay in emergency care for the resident, who remained in the facility with a confirmed femur fracture for several hours before being transferred for appropriate medical treatment. This delay was acknowledged by facility leadership and staff as not meeting the standard for rapid response to critical findings.
Failure to Notify Physician of Missed Heart Failure Medication Doses
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's physical status, specifically when four doses of a prescribed heart failure medication (Entresto) were not available and therefore not administered as ordered. The resident, an elderly female with diagnoses of congestive heart failure and sick sinus syndrome, was admitted from home and required Entresto twice daily. Documentation showed that the medication was not administered on four occasions, and the Medication Administration Record (MAR) indicated this with a code, but there was no written documentation in the resident's electronic progress notes that the physician or nurse practitioner was notified of the missed doses. Interviews with facility staff revealed that the process for handling unavailable medications involved notifying the family to bring in medications from home and checking the facility's medication supply system (pyxis). In this case, the family did not provide the medication, and it was not available in the pyxis. The medication aide documented the missed doses in the MAR but did not inform the assigned nurse, and the nurse did not notify the physician. Both the Director of Nursing (DON) and the regional compliance nurse confirmed that staff were trained to notify physicians when medications were not administered as ordered and to document this notification, but this did not occur in this instance. Further interviews with the medical doctor and medical director confirmed that they were not notified about the missed doses, and facility policy required physician notification when medications were not administered. The lack of communication and documentation regarding the missed medication doses resulted in the physician not being able to provide alternative instructions or treatment for the resident.
Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering Entresto Oral Tablet as ordered for a resident with congestive heart failure and sick sinus syndrome. The resident was admitted on a Friday evening, and the facility's pharmacy did not deliver medications on weekends. The facility requested the resident's family to bring in the medication from home, but the Entresto was not provided. The medication was also not available in the facility's pyxis system. As a result, the medication was not administered on multiple scheduled occasions, as documented in the Medication Administration Record (MAR). Interviews with the DON, LVN, and medication aide revealed that the medication aide did not inform the nurse that the medication was not administered, and the nurse did not notify the physician or document the missed doses as required by facility policy. The facility's policy states that if a regularly scheduled medication is withheld or refused, an explanatory note must be entered in the nursing notes or the PRN nurses notes section of the MAR. The medical director confirmed that staff are required to notify physicians when medications are not administered as ordered.
Failure to Secure Catheter Leg Strap
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence. Specifically, the facility did not secure the resident's catheter with a leg strap, as required by the physician's order and the resident's care plan. The resident, who was alert and oriented, reported that the catheter strap had not been in place for two days, causing discomfort due to the catheter shifting. Despite the resident's ability to communicate, the issue was not addressed by the nursing staff, who were responsible for ensuring the catheter was secured. Interviews with the nursing staff, including an RN and a CNA, revealed that they were trained to secure catheters with leg straps and check them regularly. However, the RN admitted to forgetting to verify the leg strap during her assessment, and the CNA was not assigned to the resident but had assisted with perineal care. The Director of Nursing (DON) stated that all staff were required to conduct regular rounds and check catheter placement, but this was not done in this case. The failure to secure the catheter properly increased the risk of it being pulled out accidentally, potentially causing injury or trauma to the urethra.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to consider the views of the residents and act promptly upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. The residents felt that the administrator did not make any efforts to address their concerns and grievances discussed in previous months at the resident council meetings. The residents requested copies of the Resident Council minutes to see what efforts had been made to resolve the grievances but were denied access by the administrator. It was reported that the administrator retaliated against the Resident Council President for reporting concerns about her interference with Resident Council Elections, concerns with cold food temperatures, and requests to review Resident Council Minutes. The Activities Director stated that after the resident council meetings, she would complete the grievance form for all concerns voiced and give them to the administrator. However, the administrator claimed to be unaware that not all concerns were being documented in the Resident Council Minutes. The Director of Food and Nutrition acknowledged receiving sporadic concerns about cold food temperatures but did not document these concerns or conduct regular checks on food temperatures. The facility's grievance policy outlines that the administrator is responsible for maintaining a system to keep records of all complaints and ensuring timely responses, but this was not effectively implemented. The facility's QAPI meetings, which are supposed to address various concerns, did not consistently include all relevant department heads, and the issues discussed did not reflect the residents' grievances about cold food temperatures. The review of Resident Council Minutes from May to October did not document any concerns related to cold food temperatures, indicating a lack of proper documentation and follow-up on resident grievances. The facility's failure to document and address the residents' concerns could lead to residents feeling unheard and unvalued in their place of residence.
Violation of Resident Privacy During Care Plan Meetings
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by conducting care plan meetings in residents' rooms. This practice was revealed during a confidential group interview with residents, who expressed feelings of embarrassment and a violation of their privacy due to the presence of roommates, staff members, and visitors who could overhear the discussions. An interview with an LVN MDS Nurse confirmed that care plans were conducted in resident rooms, and she was unaware of any resident concerns about this practice. The facility's Administrator was also unaware of the issue and acknowledged that care plans should be discussed individually and in private. The Nursing Facility Residents' Rights document from November 2021 emphasizes the right to privacy and confidentiality, which was not upheld in this instance.
Failure to Address Resident Grievances and Cold Meal Service
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances, particularly those voiced during Resident Council Meetings. The Activities Director did not initiate grievance reports for concerns raised by residents, and the Administrator did not document or resolve grievances related to quality of care. This lack of action resulted in residents not receiving responses to their grievances, which included ongoing issues with meals being delivered cold. Interviews with residents revealed that meals were consistently served cold, a problem that had not been addressed despite being reported. The Administrator was unaware of these grievances, and the Director of Food and Nutrition acknowledged occasional complaints but lacked a system to ensure food was served at appropriate temperatures. The facility did not have insulated meal carts, and meal trays were not promptly served, contributing to the issue. The facility's grievance policy was not followed, as the Administrator did not complete grievance forms for all concerns expressed by residents. The policy required that all adverse events be investigated and documented, but this was not done. The Local Ombudsman confirmed that residents felt their grievances were not being addressed, and the facility's QAPI meetings did not document concerns about cold food, indicating a failure in the grievance resolution process.
Failure to Provide Adequate Nail Care for Resident with ADL Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform them independently. The resident, a 61-year-old female with a history of intracerebral hemorrhage, non-verbal status, and hemiparesis, required maximal assistance with personal hygiene and bathing. Despite the care plan indicating the need for regular nail care, the resident was observed to have long and dirty fingernails, which had not been trimmed since her admission. This oversight was confirmed by the resident's family member, who expressed concern about potential injury from the long nails. During observations and interviews, the Director of Nursing (DON) and other staff members acknowledged the resident's long fingernails and the associated risk of injury due to her hand contractures. The DON was unaware of any doctor's order for hand rolls to alleviate pressure on the resident's palms. Additionally, staff members, including an LVN and a CNA, were either unaware of the responsibility for nail care or confirmed the need for trimming. The facility's policy on nail care, which emphasizes regular maintenance to prevent infection and injury, was not adhered to in this case.
Failure to Provide Proper Foot Care for Resident
Penalty
Summary
The facility failed to provide proper foot care for a resident, identified as Resident #27, who was at risk due to her medical conditions. Resident #27, a 61-year-old female with a history of intracerebral hemorrhage, diabetes, and other significant health issues, required assistance with personal hygiene and bathing. Despite her need for specialized foot care due to her diabetes and limited mobility, the facility did not provide access to a podiatrist. The Director of Nursing (DON) confirmed that there was no in-house podiatrist and that Resident #27 had not been seen by one since her admission, as her tracheotomy prevented her from leaving the facility. Observations and interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), revealed that Resident #27 had long, discolored toenails, which posed a risk of injury. The LVN admitted to not being trained in toenail care and was unaware of who was responsible for trimming the resident's toenails. The facility's policy stated that nail care, especially for residents with diabetes, should be performed by a podiatrist. However, this standard was not met, placing Resident #27 at risk of poor foot hygiene and potential physical decline.
Failure to Properly Document Controlled Substance Counts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that controlled substances were properly accounted for and documented during shift changes. Specifically, three licensed staff members, including ADON L, RN A, and LVN C, did not adhere to the established procedure of signing the Controlled Drugs-Count Record immediately after verifying the controlled substances with the on-coming or off-going nurse. This lapse in procedure was observed during a record review and interviews, where it was noted that ADON L did not sign the record immediately after the count, while RN A and LVN C signed the record before conducting the count, contrary to the facility's policy. The facility's policy, revised in 2017, mandates that a narcotics audit be conducted at each shift change to prevent discrepancies, with the involved nurses signing the Narcotic Checklist at the time of the audit. However, the actions of the staff members deviated from this policy, potentially placing residents at risk of not receiving the intended therapeutic response of prescribed medications and increasing the risk of drug diversion. The report highlights the failure of the staff to follow proper procedures for controlled substance counts, which is crucial for ensuring the safety and well-being of the residents.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications across multiple areas, including three medication carts and one medication room. Observations revealed that oral and topical medications were not stored according to their routes of administration in the medication carts on halls E, B, and C. Additionally, opened bottles of Acidophilus Probiotic Dietary Supplement were not refrigerated as required, and medication cart drawers were found to be dusty and filled with paper particles. Interviews with staff, including LVNs and Medication Aides, confirmed a lack of awareness regarding the need to refrigerate certain medications after opening, despite the manufacturer's instructions. In the medication room, medications were also improperly stored, with oral and topical medications mixed together, as well as oral medications and ear drops stored in the same container. The facility's Pharmacy policy and procedure manual from 2003 was reviewed, which outlined the proper storage requirements for medications, including the separation of orally administered medications from those used externally. The Regional Compliance Nurse acknowledged that it is the responsibility of the nursing staff to ensure proper medication storage, highlighting a systemic issue in adherence to established protocols.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature, as evidenced by observations, interviews, and record reviews. During a confidential interview with 13 residents, it was revealed that meals were consistently delivered cold, and this issue had not been addressed by the facility. The Director of Food and Nutrition confirmed that the guacamole was not at the appropriate temperature, measuring 43.3 degrees F instead of less than 41 degrees F. Additionally, a test tray revealed that the pozole was 125 degrees F, the quesadilla was 104 degrees F, and the cheesecake was 62 degrees F, indicating that the food was not served at the correct temperatures. Interviews with staff members, including the Activities Director and the Administrator, highlighted a lack of communication and documentation regarding residents' grievances about cold food. The Activities Director mentioned that residents had voiced concerns during council meetings, but these were not documented in the meeting minutes. The Administrator was unaware of these grievances and stated that the corporate staff did not allow residents to review the council minutes, which may have contributed to the lack of awareness and action on the issue. The Director of Food and Nutrition admitted to occasionally receiving complaints about cold food but could not recall when food temperatures were last checked on a test tray. The facility lacked insulated meal carts and a system to ensure prompt meal delivery to residents eating in their rooms. Additionally, it was noted that CNAs were leaving meal carts open, which could affect food temperatures. The facility's Dietary Services Policy & Procedure Manual outlined procedures for maintaining food temperatures, but these were not being followed, as evidenced by the temperature logs and interviews.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed multiple deficiencies, including the presence of food particles on metal shelving in the food preparation area, expired perishable foods in the refrigerator, and improperly stored food in unsealed containers. Additionally, food containers in the refrigerators were not labeled, and the tile floor in the dry food storage area was covered with dust, white stains, and food particles. Containers in the dry storage room were also found to be dusty and unsealed, and a water bottle was found on the floor under the metal shelving. Further observations highlighted that dietary staff did not use gloves while taking food temperatures and failed to sanitize the food thermometer between uses. The Director of Food and Nutrition was observed not washing hands before checking food temperatures and inconsistently cleaning the thermometer, sometimes using a paper towel or stabbing the plastic cover on food trays. Interviews revealed that residents occasionally complained about cold food temperatures, and there was no system in place to ensure meal trays were promptly served. The facility lacked insulated meal carts, and meal carts were left open in resident halls, potentially affecting food temperatures.
Environmental Deficiencies in Facility's Laundry and Shower Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in several areas, including the laundry room, linen closets, and shower room. Observations revealed that the wood shelves in the clean linen closets had splintered edges, which could potentially cause injury to staff or contaminate linens. Additionally, the laundry room was found to have missing floor baseboards and walls with chipped paint and multiple holes. In the shower room, multiple tiles were either missing or broken, and the water drains were rusted, posing a risk of injury to residents. Interviews with facility staff, including the Housekeeping Supervisor, Maintenance Supervisor, and Administrator, indicated a lack of awareness and reporting of these environmental issues. The Housekeeping Supervisor was unaware of the splintered shelves, while the Maintenance Supervisor, who was new to the role, acknowledged the challenges in addressing these issues due to limited assistance. The Administrator expressed concern over the potential harm to residents from the broken tiles and rusted drains and noted that staff had been trained to report such issues using a QR code system. However, it was unclear why these specific issues had not been reported, suggesting a gap in the reporting process or staff adherence to the protocol.
Failure to Accurately Reflect Resident Behaviors in MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding her behaviors. The resident, a female with diagnoses of generalized anxiety, major depressive disorder, and mild cognitive impairment, was not listed as having behaviors on her annual MDS assessment. Despite having a BIMS score indicating intact cognition, her comprehensive care plan noted behaviors such as frequently requesting HIPAA information on other residents and attempting to get staff in trouble. These behaviors required interventions like providing clear explanations of daily care activities and redirecting the resident. Interviews with the MDS Nurse, DON, and Administrator revealed that they were aware of the resident's behaviors, which included asking questions about other residents and making false allegations against staff. The MDS Nurse admitted to not including these behaviors in the MDS assessment, as they were not considered aggressive or combative enough to warrant a medical diagnosis with medication. The Administrator, although not well-versed in MDS assessments, acknowledged the resident's behaviors and the need for redirection and education. The failure to document these behaviors in the MDS assessment could lead to inaccurate and incomplete assessments, potentially affecting the care and services provided to the resident.
Failure to Include Critical Intervention in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to include the physician-ordered intervention of elevating the head of the bed to at least 30 degrees during enteral feeding. This oversight was identified during a review of the resident's care plan, which did not address this critical intervention despite the resident's medical condition requiring it. The resident, who was severely cognitively impaired and on continuous enteral feeding, had a physician's order mandating the head of the bed elevation to prevent aspiration. Observations and interviews revealed that the nursing staff, including CNAs and charge nurses, were responsible for ensuring the resident's head of bed was elevated as required. However, during an observation, it was noted that the resident's head of bed was not elevated as per the physician's order. The ADON acknowledged the risk of aspiration if the head of the bed was not elevated and stated that staff were trained to maintain the correct positioning during their rounds. Interviews with the MDS nurse and the DON confirmed that the care plan lacked the necessary intervention for head of bed elevation, which was an oversight. The MDS nurse admitted to overlooking this intervention, and the DON emphasized the importance of including all physician-ordered interventions in the care plan to ensure proper monitoring and prevent risks such as aspiration. The facility's policy on comprehensive care planning mandates the inclusion of all necessary interventions to meet the resident's needs, which was not adhered to in this case.
Failure to Maintain Proper Bed Elevation for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding had their head of bed elevated at least 30 degrees as per physician's orders. This deficiency was observed during a survey when the resident was found lying flat in bed while receiving continuous enteral feeding. The resident, who was severely cognitively impaired and had a history of dysphagia, was at risk of aspiration due to this oversight. Interviews with staff, including the Assistant Director of Nursing (ADON), Registered Nurse (RN), and Director of Nursing (DON), revealed that it was the responsibility of CNAs and charge nurses to maintain the head of bed elevation for residents on continuous enteral feeding. Despite receiving training on enteral feeding care, the staff failed to ensure the resident's bed was properly positioned, which was a critical component of the care plan to prevent complications such as aspiration. The facility's policy on gastronomy tube care required residents to be maintained in a semi-high Fowler's position for a specified time following feeding, but did not specify positioning for continuous feeding. The lack of adherence to the physician's order and facility policy contributed to the deficiency, as staff did not consistently check and maintain the required bed elevation during their rounds, increasing the risk of aspiration for the resident.
Failure to Properly Label Feeding Tube Bags
Penalty
Summary
The facility failed to ensure that a resident's feeding tube bags were properly labeled with the resident's name, date, and time the administration began. This deficiency was observed in a resident who had a feeding tube due to dysphagia and gastrostomy status. The resident's feeding tube was set at the correct rate of 60 ml/hr, but the enteral feeding bag was not labeled with the necessary information. Additionally, the water bag had an incorrect label indicating a different feeding formula and rate. The LVN responsible for changing the feeding bag admitted that the label might have fallen off and acknowledged the mistake in labeling the water bag incorrectly. The Director of Nursing (DON) confirmed that the resident had not experienced any significant weight loss or gain or any complications related to the tube feeding. However, the DON acknowledged the risks associated with failing to label the enteral feeding bag, including the possibility of using an expired or incorrect product. The facility's policy on gastrostomy tube care, which requires labeling and dating of formula and feedings, was not followed in this instance.
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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