West Houston Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 13428 Bissonnet, Houston, Texas 77083
- CMS Provider Number
- 676381
- Inspections on file
- 32
- Latest survey
- January 31, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Houston Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of cerebral infarction, hypertension, and diabetes mellitus was found to have her call light on the floor, out of reach, contrary to her care plan and facility policy. Staff interviews confirmed the oversight, despite training on the importance of call light accessibility to prevent falls and ensure timely care.
A resident with multiple health issues was not provided with necessary grooming services, resulting in long facial hair on her chin. Despite her request for hair removal, the staff did not address this need, leading to a deficiency in maintaining her personal hygiene and dignity. Interviews with staff indicated that charge nurses were responsible for ensuring grooming, but this was not fulfilled.
A resident with a history of cerebral infarction and dysphagia did not receive gastrostomy feedings at the prescribed rate of 50 ml/hr, instead receiving 45 ml/hr, due to staff relying on a 24-hour report sheet rather than physician orders. This placed the resident at risk of not meeting nutritional goals. The facility's policy on maintaining nutritional status was not adhered to.
A facility failed to manage oxygen equipment properly for a resident, as an undated humidifier bottle was found at the bedside, risking infection. The resident, with a history of dementia and other conditions, was not coded for oxygen therapy in their care plan. Interviews revealed that equipment should be dated and changed weekly, but this was not consistently monitored. The facility could not provide their infection control policy when requested.
A resident in a LTC facility did not receive Dorzolamide Hydrochloride Ophthalmic solution correctly, as a medication aide administered the drops directly onto the eyeball instead of the lower eyelid. The resident, who was cognitively intact, instructed the aide not to touch her eyes, leading to improper administration. The facility's policy requires drops to be placed in the conjunctival sac for effectiveness, which was not followed.
A facility experienced a 7% medication error rate due to incorrect dosages administered by a Medication Aide. A resident with vitamin B12 deficiency received a lower dose than prescribed, another with malnutrition received half the required Vitamin D, and a third with allergies received double the Cetirizine Hydrochloride dose. The errors were acknowledged by the DON, who emphasized the importance of following medication rights.
The facility failed to label medications on the 300 hall medication carts with the resident's name and opening date, as observed during a survey. Medications such as topical gels and nasal sprays were found open without proper labeling. LVN C was unaware of the requirement, and the DON confirmed the absence of a facility policy on medication labeling. The pharmacist indicated that open date stickers are used to help nurses track medication potency.
A resident with multiple health conditions, including anoxic brain damage and pressure ulcers, did not receive adequate skin care in an LTC facility. Despite being dependent on staff for ADLs, the resident's skin was observed to be dry and flaky, indicating a failure to follow the care plan. Staff interviews revealed inconsistencies in applying lotion and a lack of communication about the resident's refusal of care, leading to inadequate monitoring and intervention.
A resident with a stage 4 pressure ulcer on the sacrum did not receive proper wound care due to the Wound Care Nurse's failure to follow professional standards. The nurse used the same gauze multiple times, did not clean the peri-wound area, and lacked wound care certification. Interviews with facility staff confirmed that these actions were against the facility's wound care policy, potentially impacting the resident's healing process.
A Wound Care Nurse in an LTC facility failed to follow proper infection control procedures during the treatment of a resident with a stage 4 pressure ulcer. The nurse used a single gauze for multiple cleaning strokes and did not clean the peri-wound area, potentially leading to infection. The nurse lacked wound care certification and training, and the facility's infection control policies were not adhered to, as confirmed by the DON and ADON.
A resident with multiple medical conditions, including a risk for pressure ulcers, did not have their care plan updated to address wound care and ADL needs. Despite a physician's order for wound treatment, the care plan was not revised, leading to a risk of inadequate care. Facility staff interviews revealed a lack of clear responsibility for updating the care plan within the required timeframe.
A resident with impaired cognitive skills was found with unexplained vaginal bleeding on two occasions, leading to a hospital transfer where semen was found in her urine. Facility staff failed to report the incidents as potential abuse, and the facility's open-door policy and lack of monitoring contributed to the deficiency.
A resident with impaired cognitive function was found with vaginal bleeding and signs of potential sexual abuse, but the facility failed to report or investigate the incidents. Staff did not notify the Administrator or complete incident reports, and the resident was eventually transferred to a hospital where semen was found in a urine sample. The facility's open-door policy and lack of monitoring contributed to the oversight, resulting in an Immediate Jeopardy finding.
A resident with cognitive impairment was found with unexplained vaginal bleeding on two occasions, and semen was later found in her urine, indicating possible sexual abuse. Facility staff, including CNAs, RNs, and the Interim DON, failed to report the incidents to the Abuse Coordinator as required by policy. The Administrator was unaware of the situation until informed by the State Survey Agency, leading to an Immediate Jeopardy situation due to the risk of further abuse.
A resident with impaired cognitive function was found with unexplained vaginal bleeding and other signs of potential sexual abuse, but the facility failed to thoroughly investigate or report the incidents. The resident was later transferred to a hospital, where semen was found in a urine sample, indicating possible sexual assault. The facility's Administrator and staff did not follow policies for investigating and reporting abuse, leading to an Immediate Jeopardy situation.
The facility failed to notify the hospice nurse, EMS, and hospital staff about a resident's need for assessment for sexual abuse after observing vaginal bleeding. The resident was transferred to the hospital without this critical information, delaying the assessment. Additionally, the facility did not arrange emergency transportation for another resident in respiratory distress, causing a significant delay in hospital arrival.
A resident with a history of dementia and Down syndrome experienced difficulty breathing and signs of a seizure, but the facility failed to notify the primary care physician and responsible party. Despite being alerted by a family member and a CNA, the LVN did not take immediate action, leading to a delay in emergency care. The resident was eventually transferred to a hospital, where she was diagnosed with severe conditions and later died.
The facility failed to investigate and report abuse allegations involving two residents, compromising their safety and well-being. The Administrator, also the abuse coordinator, did not thoroughly investigate or report a sexual abuse allegation involving a resident with signs of abuse, including vaginal bleeding and semen in a urine sample. Another resident was allegedly abused by a hired sitter, but the facility did not conduct a thorough investigation or report the incident. Staff interviews revealed a lack of communication and reporting, with no immediate skin assessments or increased monitoring initiated.
A medication cart was left unlocked while an LVN was asleep at a desk, posing a risk of unauthorized access to medications. The incident was observed for about five minutes before the LVN was awakened and locked the cart. Interviews with facility staff confirmed the importance of keeping medication carts locked to prevent unauthorized access and potential harm.
A resident with a full code status was found unresponsive, but CPR was delayed by three minutes due to staff inaction. Despite the presence of staff, CPR was not initiated promptly, violating the facility's policy to provide immediate life support. The resident had a history of dementia and other medical conditions, and the delay in CPR was contrary to her care plan and physician orders.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs. The resident, a female with a history of cerebral infarction, hypertension, and diabetes mellitus, was found to have her call light on the floor, out of reach. This resident was moderately cognitively impaired and dependent on staff for activities of daily living, including being incontinent for bowel and bladder. The care plan for the resident specifically noted the need for the call light to be within reach to prevent falls and ensure prompt assistance. Interviews with staff, including CNAs, an LVN, the DON, the Administrator, and the ADON, revealed that the call light was not placed within reach, contrary to the facility's policy. Staff acknowledged the importance of having the call light accessible to prevent falls and ensure timely care, especially in emergencies. Despite having received training and in-service education on the importance of call light accessibility, the staff failed to adhere to these guidelines, resulting in a deficiency in accommodating the resident's needs.
Failure to Provide Necessary Grooming Services
Penalty
Summary
The facility failed to provide necessary grooming services to a resident who was unable to perform activities of daily living independently. The resident, a female with multiple diagnoses including hypotension, muscle weakness, glaucoma, osteoarthritis, and cerebral infarction, was observed with a significant amount of facial hair on her chin. Despite the resident expressing her desire for the hair to be removed, the staff had not addressed this grooming need. The resident's care plan indicated a need for assistance with personal care, but this was not adequately provided. Interviews with staff, including a CNA and an LVN, revealed that the responsibility for ensuring residents were groomed and presentable fell on the charge nurses. However, this responsibility was not fulfilled in the case of the resident, leading to a deficiency in maintaining her personal hygiene and dignity. The facility's policy on activities of daily living emphasized the importance of providing care to assist residents in achieving the highest practicable outcome, which was not met in this instance.
Failure to Administer Correct Gastrostomy Feeding Rate
Penalty
Summary
The facility failed to administer gastrostomy feedings to Resident #66 at the prescribed rate of 50 ml/hr, instead providing feedings at 45 ml/hr. This discrepancy was observed on two separate occasions, with the resident receiving Jevity 1.5 cal at 45 ml/hr along with a water flush at 30 ml/hr. The resident, a female with a history of cerebral infarction, dysphagia, and other medical conditions, was at risk of not receiving the required daily nutritional intake, potentially leading to weight loss. The resident's care plan and physician orders specified the correct feeding rate, but the facility did not adhere to these instructions. Interviews with facility staff revealed that the error occurred because the nurse on duty relied on the facility's 24-hour report sheet rather than checking the physician's orders. The nurse admitted to not following the six rights of medication administration, which contributed to the oversight. The Director of Nursing confirmed that the resident's feedings should have been administered at 50 ml/hr, and the dietician corroborated that the feedings were ordered at this rate. The facility's policy on nutritional and dietary supplements emphasized maintaining residents' nutritional status, but this policy was not followed in this instance.
Failure in Oxygen Management and Infection Control
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in the management of oxygen equipment. An undated oxygen humidifier bottle was found at the bedside of a resident who was not coded for oxygen therapy in their care plan or physician orders. This oversight placed the resident at risk for cross-contamination and infections. The resident, a male with a history of dementia, Tourette's disorder, adult failure to thrive, and sepsis, was observed with an oxygen machine and humidifier bottle that lacked proper dating, indicating when it was last changed. Interviews with the Director of Nursing (DON) and the Licensed Vocational Nurse (LVN) responsible for the unit revealed that respiratory equipment should be dated and changed weekly for infection control purposes. However, the LVN admitted to monitoring the equipment daily without a specific schedule. The facility was unable to provide their infection control policy when requested by the surveyor, further highlighting the deficiency in managing respiratory care and infection control protocols.
Improper Administration of Eye Drops
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident, specifically in the administration of Dorzolamide Hydrochloride Ophthalmic solution. During a medication administration observation, a medication aide (MA A) was seen administering the eye drops directly onto the resident's eyeball instead of the lower eyelid, which is necessary for proper absorption and effectiveness. The resident, who was cognitively intact, instructed the aide not to touch her eyes, leading the aide to administer the medication incorrectly. The aide acknowledged that she knew the improper administration could be ineffective and potentially harmful. The Director of Nursing (DON) confirmed that eye drops should be administered to the lower eyelid for proper absorption and effectiveness. The facility's policy on the administration of eye drops was not followed, as it clearly states that drops should be placed in the conjunctival sac, not directly on the eyeball. The DON mentioned that the system for monitoring medication administration accuracy was conducted by the Pharmacy Consultant, but no log was available. The facility's training document showed that the aide had been marked satisfactory in medication pass competency, yet the deficiency occurred.
Medication Administration Errors Lead to 7% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7% error rate based on three errors out of 40 opportunities. These errors involved three residents who did not receive their medications as prescribed. Medication Aide (MA A) was responsible for these errors, which included incorrect dosages of Cyanocobalamin, Vitamin D, and Cetirizine Hydrochloride being administered to the residents. Resident #13, a cognitively intact female with multiple health conditions including type 2 diabetes and vitamin B12 deficiency anemia, was given a 500mg dose of B12 instead of the prescribed 1000mg. Resident #43, also cognitively intact and suffering from severe protein-calorie malnutrition and major depressive disorder, received a 25mcg dose of Vitamin D instead of the prescribed 50mcg. Resident #18, who has acute respiratory failure and bipolar disorder, was administered a 10mg dose of Cetirizine Hydrochloride instead of the prescribed 5mg. Interviews with MA A revealed that she was aware of the importance of correct medication dosages but was nervous during administration. The Director of Nursing (DON) and other staff members confirmed the expectation of following medication rights and acknowledged the potential for harm if incorrect dosages are given. The facility's policy requires medications to be administered as prescribed, with checks to ensure the right resident, medication, dosage, time, and method of administration.
Medication Labeling Deficiency in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with professional principles. Specifically, the medication carts on the 300 hall contained nasal spray, topical gels, and ointments that were opened but not labeled with the resident's name or the date they were opened. This oversight was observed during a survey, where several medications, including Diclofenac Sodium Topical Gel, Triamcinolone Acetonide, Nystatin Ointment, Clobetasol Propionate, Voltaren Arthritis Pain Gel, Tacrolimus Ointment, and Fluticasone Propionate Nasal Spray, were found to be open without the required dating. During interviews, LVN C was unaware that the gels were not dated upon opening, which is necessary to track the opening date and ensure the medication's potency within the 30-day period. The Director of Nursing (DON) confirmed that the facility lacked a policy regarding medication labeling, and the open date stickers were placed by the pharmacist as a requirement to help nurses know when to discard the medications. The facility pharmacist reiterated the importance of placing open dates on gels and ointments to assist nurses in managing medication potency and safety.
Failure to Provide Adequate Skin Care for Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living (ADLs), specifically in maintaining personal grooming and skin care. The resident, a male with anoxic brain damage, pressure ulcers, diabetes mellitus, and hypertension, was dependent on staff for ADLs. Observations revealed that the resident had dry, patchy, and flaky skin on his left leg and foot, which was not adequately addressed by the facility staff. Interviews with the wound care nurse, Director of Nursing (DON), and other staff members indicated that the aides were responsible for showering residents and applying lotion to their skin. However, the resident's skin remained dry and flaky, suggesting that the care plan was not being followed consistently. The wound care nurse and other staff members were unaware of the resident's refusal to shower or apply lotion, and the DON was not informed about the resident's skin condition until it was observed during the survey. The facility's policy required weekly skin assessments and the application of moisturizer as needed, but these measures were not effectively implemented. The Licensed Vocational Nurse (LVN) acknowledged that the lotion used was not effective and had not informed the physician about the resident's skin condition. The Assistant Director of Nursing (ADON) and other staff members were also unaware of the resident's refusal of ADL care, indicating a lack of communication and monitoring within the facility.
Improper Wound Care Procedures for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the Wound Care Nurse did not follow proper wound care procedures during a dressing change for a resident with a stage 4 pressure ulcer on the sacrum. The resident, who had a history of anoxic brain damage, diabetes mellitus, and hypertension, was dependent on staff for activities of daily living and had recently completed a course of antibiotics for a wound infection. During an observation, the Wound Care Nurse was seen using the same gauze multiple times to clean different sections of the wound bed, which is against proper wound care protocol. The nurse also failed to clean the peri-wound area, which was covered with drainage, before applying a new dressing. The nurse admitted to forgetting to clean the wound bed and acknowledged that improper cleaning could lead to infection. The nurse also mentioned a lack of wound care certification and training, as well as uncertainty about who monitored her wound care practices. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Manager revealed that the Wound Care Nurse did not adhere to the facility's wound care policy, which requires using a new gauze for each cleaning stroke and cleaning the peri-wound area. The DON and ADON confirmed that improper wound cleaning could slow the healing process and increase the risk of infection. The facility's policy on wound treatment management emphasizes the importance of following physician orders and using the correct cleansing methods and dressings.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of the Wound Care Nurse during the treatment of a resident with a stage 4 pressure ulcer. The resident, a male with a history of anoxic brain damage, diabetes mellitus, and hypertension, was dependent on staff for activities of daily living and had a significant pressure ulcer on the sacrum. During an observation, the Wound Care Nurse did not follow proper infection control procedures, such as using a single gauze for multiple cleaning strokes and failing to clean the peri-wound area, which could lead to infection. The Wound Care Nurse admitted to not realizing the improper cleaning technique and acknowledged the potential for causing injury and infection to the wound. The nurse also mentioned a lack of wound care certification and training, as well as uncertainty about who monitored the wound care practices. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the nurse's actions were not in line with the facility's infection control policies, which require using a new gauze for each cleaning stroke and ensuring the peri-wound area is cleaned to prevent cross-contamination. Interviews with the DON, ADON, and Unit Manager highlighted the importance of proper wound cleaning techniques to prevent infection and promote healing. The facility's policy on infection control and wound treatment management emphasizes the need for adherence to physician orders and proper cleansing methods. Despite the facility's established policies, the Wound Care Nurse's actions during the wound care treatment did not align with these guidelines, potentially compromising the resident's health and safety.
Failure to Update Resident Care Plan for Wound Care and ADLs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as CR #1, who was admitted with multiple medical conditions including end-stage renal disease, Type 2 Diabetes, and an acquired absence of the right leg below the knee. The resident's Minimum Data Set (MDS) assessment indicated a need for supervision and assistance with activities of daily living (ADLs), as well as a risk for developing pressure ulcers. Despite these identified needs, the resident's care plan did not address wound care or ADL self-care performance deficits. On November 6, 2024, a physician's order was received to treat a pressure injury on the resident's left medial heel. However, the care plan was not updated to include this new wound care requirement. Interviews with facility staff, including two Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that the responsibility for updating the care plan was not clearly executed. The wound care nurse was expected to inform the DON of any changes, and the DON was responsible for ensuring the care plan was updated within 24 hours. This lack of timely updates posed a risk of inadequate care for the resident. The facility's policy mandates the development and implementation of a comprehensive, person-centered care plan that includes measurable objectives and timeframes. The policy also requires the care plan to be reviewed and revised after each comprehensive and quarterly MDS assessment. Despite these guidelines, the facility did not adhere to its policy, resulting in a deficiency in the care provided to the resident, as the care plan was not updated to reflect the resident's current needs and conditions.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by the resident being found with unexplained vaginal bleeding on two occasions. The resident, who had a primary diagnosis of cerebral infarction due to embolism and severely impaired cognitive skills, was first noted to have vaginal bleeding on September 14, 2024. Despite this, the facility did not take immediate action to investigate the cause or report the incident as potential abuse. The resident was later found with more severe bleeding on September 24, 2024, which led to her being transferred to a hospital where semen was found in her urine culture, and an acute injury was identified during a genital exam. Interviews and record reviews revealed that the facility staff, including nurses and CNAs, observed the bleeding but did not report it as a potential abuse case to the Administrator or follow the facility's policy for abuse prevention and investigation. The staff failed to recognize the signs of potential sexual abuse, such as the resident's refusal of peri care and fear of being touched, which were not adequately addressed or reported. The facility's open-door policy for visitors and lack of proper monitoring further contributed to the failure to protect the resident from potential abuse. The facility's Administrator and IDON were not made aware of the severity of the situation until after the resident was transferred to the hospital and the State Survey Agency notified them of the findings. The facility's lack of immediate and appropriate response to the initial signs of abuse, as well as the failure to follow established protocols for reporting and investigating potential abuse, resulted in a deficiency that placed the resident at risk of serious harm.
Removal Plan
- The facility administrator completed a self-report incident to HHSC due to allegation of sexual abuse.
- A police report was made, they arrived at the facility to collect resident demographics.
- The facility nursing management staff initiated skin assessment focusing on peri-area to ensure no trauma or signs of physical injuries were present in all residents - no issues noted.
- The facility DON/Designee assessed male residents who can ambulate, self-transfer, and who wander in the facility and other residents' rooms. One resident was placed on 1:1 supervision due to wandering. Discharge process initiated due to wandering behaviors.
- The facility Adm/DON/SW or designee initiated 1:1 interviews with facility staff and residents focusing on observation prior to the resident transfer to the hospital. Questionnaire revealed no unusual circumstances noted by staff or residents.
- The facility Social Worker/Designee conducted life safety interviews with all interviewable residents. Interviews revealed no new negative events.
- The IDON/Designee initiated an in-service with the facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect, and sexual abuse and symptoms.
- The IDON/Designee initiated an in-service with the facility staff on Possible Signs and Symptoms of Sexual Abuse including indicators, how to detect sexual abuse.
- The IDON/Designee initiated an in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting, and documentation.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, as evidenced by the case of a resident who was assessed with vaginal bleeding and other signs of potential sexual abuse. The resident, who had impaired cognitive function and thought processes, was found with vaginal bleeding on two separate occasions. Despite these findings, the facility staff did not report the incidents to the Administrator or conduct a thorough investigation. The resident was eventually transferred to a hospital, where a urine sample revealed the presence of semen, and a forensic examination indicated signs of potential sexual abuse. Interviews and record reviews revealed that the facility staff, including nurses and CNAs, were aware of the resident's condition but failed to recognize or report it as a potential case of abuse. The staff did not complete incident reports or notify the Administrator, who was the designated abuse coordinator. The facility's open-door policy for visitors and lack of monitoring further contributed to the oversight. The Administrator and IDON were not informed of the situation until after the resident was transferred to the hospital, and the facility did not take immediate steps to investigate or prevent further incidents. The facility's failure to adhere to its abuse prevention policies placed residents at risk for abuse, neglect, and mistreatment. The lack of timely reporting and investigation of the resident's condition resulted in an Immediate Jeopardy finding, indicating a serious threat to resident safety. The facility's inaction and inadequate response to the situation highlight significant deficiencies in its abuse prevention and reporting protocols.
Failure to Report Suspected Abuse in a Timely Manner
Penalty
Summary
The facility failed to report suspected abuse, neglect, or mistreatment in a timely manner, as required by state law and facility policy. A resident, who was cognitively impaired and unable to make decisions, was found with unexplained vaginal bleeding on two separate occasions. On the first occasion, the bleeding was noted by a CNA and reported to an RN, who then notified the Nurse Practitioner and the Assistant Director of Nursing but failed to report the incident to the facility's Abuse Coordinator. On the second occasion, the resident was found with significant vaginal bleeding and was transferred to a hospital, where semen was found in her urine sample, indicating possible sexual abuse. Despite these findings, the incident was not reported to the Abuse Coordinator or other authorities as required. Interviews with facility staff revealed a lack of understanding and adherence to the facility's abuse reporting policies. Several staff members, including CNAs, RNs, and the Interim Director of Nursing, failed to recognize the signs of potential sexual abuse and did not report the incidents to the facility's Abuse Coordinator. The Administrator, who was also the Abuse Coordinator, was unaware of the incidents until informed by the State Survey Agency. The facility's policy required immediate reporting of suspected abuse to the Administrator and other officials, but this was not followed, leading to a delay in addressing the potential abuse. The facility's failure to report the incidents promptly resulted in an Immediate Jeopardy situation, as identified by the surveyors. The lack of timely reporting and investigation of the incidents placed residents at risk for further abuse, neglect, or mistreatment. The facility's policies and procedures for reporting and investigating abuse were not effectively implemented, as evidenced by the staff's failure to report the incidents and the Administrator's lack of awareness of the situation.
Removal Plan
- The facility administrator completed a self-report incident to HHSC due to allegation of sexual abuse.
- A police report was made, they arrived at the facility to collect resident demographics.
- The facility nursing management staff initiated skin assessment focusing on peri-area to ensure no trauma or signs of physical injuries were present in all residents - no issues noted.
- The facility DON/Designee assessed male residents who can ambulate, self-transfer and who wander in the facility and other residents' rooms. One resident was placed on 1:1 supervision due to wandering. Discharge process initiated.
- The facility Adm/DON/SW or designee initiated 1:1 interviews with facility staff and residents focusing on observation prior to the resident transfer to the hospital. Questionnaire revealed no unusual circumstances noted by staff or residents.
- The facility Social Worker/Designee conducted life safety interviews with all interviewable residents. Interviews revealed no new negative events.
- The President of Operation conducted an in-service with the facility Administrator: Review of State Reportable guidelines Provider Letter to ensure understanding of reportable incidents including timeline, i.e.: Abuse is to be reported immediately but no later than 2 hours.
- The IDON/Designee initiated an in-service with the facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect and sexual abuse and symptoms.
- The IDON/Designee initiated an in-service with the facility staff on Possible Signs and Symptoms of Sexual Abuse including indicators, how to detect sexual abuse.
- The IDON/Designee initiated an in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting, and documentation.
- The IDON/Designee initiated an in-service with facility staff on: Who is the facility abuse prevention coordinator, notifications of suspected abuse and neglect including sexual abuse signs and symptoms are to be reported to the administrator immediately.
- The DON/Designee initiated an in-service with staff on immediately reporting any new residents' unusual behaviors, fear, crying, guarding, complaint of pain in pelvic area, isolation, etc.
- Any staff member not present or in service will not be allowed to assume their duties until in-serviced. Ongoing in-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, PRN, and agency staff is completed.
- The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire.
- An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report alleged violations of abuse or mistreatment for a resident who was assessed with unexplained vaginal bleeding and other signs of potential sexual abuse. The resident, who had impaired cognitive function and was unable to make decisions, was found with vaginal bleeding on two separate occasions. Despite these findings, the facility's Administrator, who was responsible for investigating and reporting abuse incidents, did not initiate a thorough investigation or report the incidents as potential abuse. The resident was eventually transferred to a local hospital, where a urine sample revealed the presence of semen, and a forensic examination indicated signs of potential sexual assault. However, the facility did not have any incident or accident reports for the resident during the time frame of the alleged incidents. Interviews with staff revealed that many were not aware of the need to report the bleeding as a potential sign of abuse, and several staff members who had contact with the resident were not interviewed or asked to provide witness statements as part of the investigation. The facility's failure to investigate and report these incidents in a timely and thorough manner placed the resident at risk of continued abuse and further harm. The Administrator and other staff members did not follow the facility's policy for investigating and reporting abuse, which requires immediate investigation and documentation of all allegations. This lack of action and oversight led to an Immediate Jeopardy situation, as identified by the State Survey Agency.
Failure to Communicate Suspected Abuse and Arrange Timely Transport
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not notify the hospice nurse, EMS, and local hospital that a resident required assessment for sexual abuse after being observed with vaginal bleeding, a potential sign of sexual abuse. The resident was transferred to the hospital without the necessary information being communicated, leading to a delay in the assessment for sexual abuse. The resident in question was an elderly female on hospice care with a primary diagnosis of traumatic subdural hemorrhage. During routine care, a nurse and a CNA observed vaginal bleeding with clots, but there were no signs of distress. The facility's staff failed to communicate the suspicion of sexual abuse to the hospital, EMS, or hospice, which was crucial for the hospital to conduct a proper assessment upon the resident's arrival. The hospital staff was not informed of the potential for sexual abuse until later, which could have impacted the timeliness and accuracy of the assessment. Additionally, the facility failed to arrange emergency transportation for another resident in respiratory distress, resulting in a significant delay in the resident's arrival at the hospital. This delay in transportation and the lack of communication regarding the potential for sexual abuse in the first case highlight deficiencies in the facility's processes for handling emergencies and suspected abuse cases.
Removal Plan
- The facility administrator completed a self-report incident to HHSC due to suspected sexual abuse case.
- A Police report was made to the HCSO Case#:535847, Deputy: [name of Deputy]
- The facility nursing management staff initiated assessments focusing on peri-area to ensure no trauma of s/s of physical injuries were present in all residents- no issues noted.
- The Admin/Don/Designee collected statements from staff who had worked with the resident indicating observation of resident status and any other unusual events. No unusual events were reported.
- The facility Social Worker/Designee initiated Life safety interviews with all interviewable residents. Interviews revealed no new negative events.
- The Adm/Don conducted a 1:1 in-service with the licensed nurse assigned to Resident #2 to ensure understanding of facility expectation to call and give report to the hospital/EMS/responsible party and hospice is provided prior to the transfer. Report should include status of the resident and reason for transfer.
- The administrator established communication with the resident attending physician and the facility medical director to inform her about the vaginal bleeding with suspected sexual abuse.
- The administrator and DON met with resident #2 responsible party to ensure understanding of reason for transfer and the vaginal bleeding with suspected sexual abuse.
- The facility DON verbally informed resident #2 hospice nurse of the reason for transfer, vaginal bleeding with suspicion of sexual abuse.
- The facility marketing director went to the hospital to follow up on resident #2 status.
- The facility DON/Designee initiated a 1:1 in-service with the licensed nurses to ensure understanding on facility expectations to call report the hospital on reference to the resident status and reason for the transfer. This in-service included reporting and disclosing suspicion of sexual abuse to the hospital, EMS, MD/NP, Responsible Party and Hospice.
- The DON/Designee initiated 1:1 in-service with each license nurse on the steps to follow when a resident is suspected to be the victim of sexual abuse, report required prior transferring residents to the hospital, and who to disclose that information.
- The DON/Designee initiated in-service with the facility licensed nurses on Transfer/discharged Report. This report is printed out by the nurse/designee, the nurse then writes the reason for transfer at the bottom of the page and turns it into EMS who is to submit to the hospital.
- The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility licensed nurses. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire.
- An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval.
Failure to Notify Physician and Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the primary care physician and the responsible party of a resident's change in condition, specifically difficulty breathing and signs of a seizure. The resident, a female with a history of mild unspecified dementia, Down syndrome, hypothyroidism, generalized anxiety disorder, and unspecified convulsions, was observed having difficulty breathing and was not promptly provided with emergency medical care. The resident was eventually transferred to a local hospital at the family's request, where she was diagnosed with a massive intracerebral hemorrhage, acute hypoxic respiratory failure, pneumonia, and other conditions, leading to her death. The report details that the Licensed Vocational Nurse (LVN) G did not notify the resident's primary care physician or the responsible party about the resident's respiratory distress and seizure activity. Despite being alerted by a family member and a Certified Nursing Assistant (CNA) about the resident's labored breathing, LVN G did not take immediate action to contact emergency services or the physician. Instead, non-emergency transportation was arranged, which delayed the resident's transfer to the hospital. Interviews with staff and family members revealed that the resident's condition was not adequately assessed or communicated to the necessary parties. The facility's policy required immediate notification of the physician and responsible party in the event of a significant change in condition, which was not followed. The delay in addressing the resident's respiratory distress and the failure to use emergency medical services contributed to the resident's deteriorating condition and eventual death.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to effectively and efficiently use its resources to ensure the highest practicable well-being of its residents, as evidenced by the mishandling of abuse allegations involving two residents. The Administrator, who also served as the facility's abuse coordinator, did not thoroughly investigate or accurately report an allegation of sexual abuse concerning a resident who exhibited signs of potential abuse, including vaginal bleeding and the presence of semen in a urine sample. Despite these alarming findings, there was no immediate investigation or reporting to the appropriate authorities, leaving the resident at risk. Another resident was allegedly abused by a hired sitter, but the facility again failed to conduct a thorough investigation or report the incident. The resident had a history of seizures and was at risk for injury, yet there were no progress notes or skin assessments completed by the assigned nurse on the date of the alleged abuse. The facility's records did not reflect any investigation or reporting to the State Survey Agency, further indicating a lack of proper administrative oversight and response to potential abuse incidents. Interviews with staff revealed a lack of communication and reporting regarding the incidents. Many staff members were unaware of the ongoing investigations and had not been interviewed or asked to provide witness statements. The facility did not initiate immediate skin assessments or increased monitoring, and there was no evidence of efforts to exclude potential perpetrators from the facility. The Administrator and other key personnel failed to take timely and appropriate actions to address the serious allegations of abuse, compromising the safety and well-being of the residents involved.
Medication Cart Left Unlocked While Nurse Asleep
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional principles, specifically in locked compartments. During an observation, LVN AJ was found asleep at a desk on the 400 hall with the medication cart for the 100/400 hall left unlocked. This situation persisted for approximately five minutes until LVN AJ was awakened and proceeded to lock the cart. The unlocked cart posed a risk as it could have allowed unauthorized access to medications, potentially leading to drug diversion or accidental administration to residents. Interviews with the IDON, Medical Director, and Consultant Pharmacist confirmed the importance of keeping medication carts locked when not in use. The IDON stated that LVN AJ was terminated for sleeping while the cart was unsecured, emphasizing the risk of unauthorized individuals, including residents, accessing the medications. The Consultant Pharmacist conducted an in-service and checked the carts to ensure locks were functioning, confirming that no medications were missing. The facility's policy on medication storage mandates that all drugs and biologicals be stored in locked compartments to ensure security and prevent unauthorized access.
Delayed CPR Response for Unresponsive Resident
Penalty
Summary
The facility failed to ensure that personnel provided basic life support, including CPR, to a resident requiring emergency care prior to the arrival of medical personnel. This deficiency was identified when a resident, who was a full code, was found unresponsive, and there was a delay in initiating CPR. The incident occurred at 3:41 p.m. when the resident was discovered unresponsive, but CPR was not initiated until 3:44 p.m., resulting in a three-minute delay. The resident involved was an elderly female with a history of dementia, psychotic disturbance, paroxysmal atrial fibrillation, aphasia, and contracture. Her care plan indicated she had a guardianship and was a full code, meaning she should have received CPR immediately upon being found unresponsive. However, despite the presence of staff, CPR was not initiated promptly. Video surveillance showed that staff members entered the room, but CPR was not started until several minutes later. Interviews with staff revealed discrepancies in their accounts of the events. A CNA reported notifying an LVN about the resident's difficulty breathing, but the LVN claimed she was only informed once. Another LVN did not initiate CPR, citing the resident's air mattress as a barrier. The facility's policy required staff to follow American Heart Association guidelines and provide CPR before emergency services arrived, which was not adhered to in this case.
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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