Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Settlement Nursing Center during CMS and state inspections, most recent first.
A resident with severe contractures, hemiplegia, and total ADL dependence developed a stage 3 pressure ulcer on the right palm after staff inconsistently used ordered hand offloading and positioning measures. Observations found no offloading device or washcloths in place at times, and staff gave mixed accounts about who was responsible for applying them. The facility also failed to date and initial a dressing on the resident’s left hip, and the LVN stated she forgot to do so.
A resident’s room had missing vertical blinds covered by a blanket, and two hallways had persistent odors from the soiled utility room and urine. The Housekeeping Supervisor, DON, ADON, Maintenance Director, and Interim Administrator acknowledged the conditions, and the Housekeeping Supervisor stated the resident’s blinds had been broken for months.
Failure to provide needed nail care for two dependent residents. One resident with CVA, vascular dementia, aphasia, and DM had long, jagged fingernails on repeated observations, and staff said the nurse was responsible for trimming them because he was diabetic, but it had not been done. Another resident with stroke, hemiplegia/hemiparesis, and encephalopathy also had long nails on both hands, with staff stating the nurse was responsible for trimming them and that the nails needed to be cut. Progress notes showed no documentation that nail care was provided or attempted for either resident.
A resident with stroke, hemiplegia/hemiparesis, encephalopathy, severe cognitive impairment, and contractures of all extremities did not consistently receive ordered/expected contracture management. Observations showed no washcloths or offloading devices in place on the hands or wrists, while staff gave conflicting accounts about whether the devices were ordered, who was responsible for applying them, and whether they were used all the time. Therapy staff said the resident had become more contracted after returning from the hospital and that they were trying to maintain ROM, but the resident’s hands and arms were not consistently positioned with the devices described in the care plan.
Smoking Supervision and Assessment Deficiencies: The facility failed to ensure adequate supervision and required smoking assessments for three residents. Two residents with significant cognitive and medical impairments were observed smoking with tubing devices, and one of them was not wearing the smoking apron at the time of observation. A third resident was observed smoking independently, but none of the three charts contained the required smoking assessment, and the DON stated the assessments were supposed to be completed quarterly.
Improper food storage and staff hygiene were observed in the kitchen. A large piece of meat in the refrigerator was not securely sealed and leaked onto unsealed, unlabeled, and undated bacon below it, leaving visible stains and a puddle in the refrigerator. In addition, a Maintenance Assistant entered the kitchen without hand hygiene, used the wrong net for his hair, and returned without washing his hands while staff were preparing dessert for lunch trays.
Pest control was not effective in key areas of the facility, including a hallway, a resident room, and the kitchen. Staff and leadership observed flies in the kitchen, on a snack box, and around a resident during wound care, and the Dietary Manager said the back door did not seal properly. The Maintenance Director, RN, DON, and Interim Administrator all acknowledged ongoing fly sightings and pest control concerns, and vendor reports noted the need to repair or replace the kitchen rear exit door and replace fly light bulbs and starters.
Care plan did not include a resident’s smoking apparatus use or a smoking assessment. The resident had multiple diagnoses including dementia, Parkinson’s disease, COPD, and psychiatric conditions, and was identified as a dependent smoker needing supervision and protective equipment. During smoking breaks, staff observed the resident using a tubing device connected to a lit cigarette, and on one occasion her apron was on the ground while she smoked. The CNA and DON both acknowledged the resident required protective equipment and that the smoking apparatus should have been included in the care plan.
An LVN failed to verify G-tube placement before giving a resident’s medications and did not administer the crushed tablets separately as ordered. The resident had encephalopathy, dysphagia, malnutrition, severe cognitive impairment, and required tube feeding for nutrition. The LVN prepared multiple meds together, flushed the tube, administered the medications and supplements, and restarted the feeding without checking placement, despite the care plan, physician’s orders, and facility policy requiring placement checks and separate medication administration.
Medication administration and storage failures were identified when staff left a resident’s meds unattended in his room instead of observing him take them, despite documentation that he could not safely self-administer. In addition, an LPN cart contained expired ondansetron and OTC famotidine for another resident with dementia and N/V, and staff acknowledged the meds were expired and remained in the cart.
Medication Error Rate Exceeded Standard During G-Tube Medication Administration. Surveyors found a 27.59% medication error rate during observation of medication administration. An LPN crushed multiple meds together, mixed them with water, and administered them through a resident’s g-tube without giving each medication separately. The resident had encephalopathy, dysphagia, malnutrition, severe cognitive impairment, and required tube feeding for nutrition. The resident’s orders did not include permission to combine the tablets, and the DON and ADON stated meds for tube administration should not be cocktailed.
The facility failed to follow professional food safety standards when the main dishwasher was out of service and staff relied on a compartment sink and paper products. A Dishwasher Aide washed reusable cups in the compartment sink without testing sanitizer levels and reported he had not been trained in proper sanitization. Another kitchen staff member acknowledged that although sanitizer test strips were available, she did not test sanitizer levels for her utensils and there was no sanitation log. Despite instructions to use paper goods, regular cups were used for drinks and then washed in the compartment sink without documented sanitizer monitoring, contrary to the facility’s Food Safety and Sanitation Plan, which requires maintaining sanitizing solution at appropriate strength.
Surveyors found that the facility did not maintain an effective pest control program in the kitchen dishwashing area, where standing water, gnats, and roaches were observed. A dishwasher aide reported pests had been present for several weeks and that the Dietary Manager was aware. The Maintenance Supervisor acknowledged ongoing water leak issues, standing water, and the appearance of gnats and roaches associated with plumbing repairs. The Administrator confirmed an ongoing pest issue and monthly pest control visits but was not aware of roaches. Pest control logs showed only periodic vendor visits, and despite a written Pest Control Program policy requiring effective eradication and containment of pests, gnats and roaches remained present in the kitchen, placing residents at risk for infection, cross-contamination, food-borne illness, and decreased quality of life.
A resident with severe cognitive and physical impairments did not consistently receive required two-hour rounding, incontinence care, or assistance with ADLs as outlined in their care plan and facility policy. Staff failed to ensure the call light was within reach, did not always respond to requests for help, and sometimes left the resident in soiled briefs for extended periods. Observations and interviews confirmed that staff were sometimes inattentive and did not follow established rounding and care protocols.
A resident with severe cognitive and physical impairments was found with their call light on the floor and out of reach, despite care plans and facility policy requiring accessibility. Staff interviews and observations confirmed that call lights were not consistently kept within reach, rounds were not performed as expected, and call light responses were delayed or ignored, resulting in unmet care needs.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that a resident received treatment and supports for daily living in a safe manner. The report does not include further details about the specific circumstances or individuals involved.
Several residents were housed in rooms where temperatures exceeded comfortable levels, with some rooms reaching up to 82°F. Despite the use of multiple fans and residents relocating to cooler common areas, many reported discomfort and signs of overheating. The facility was aware of ongoing HVAC issues, but adequate cooling was not consistently provided.
Two residents with cognitive and behavioral health diagnoses were involved in a physical altercation over a purse, during which one resident struck the other in the face despite staff intervention. The incident revealed a failure to prevent resident-to-resident abuse, as required by facility policy, and resulted in a deficiency related to resident protection from abuse and neglect.
The facility did not follow the prescribed menu for a lunch meal, omitting pureed dinner rolls for residents on pureed diets and substituting greens for broccoli florets without proper documentation or posting. Dietary Managers confirmed the oversight and acknowledged that facility policy requires all residents to receive the same meal and for substitutions to be documented and reviewed by the Dietician.
Several residents did not have full visual privacy in their rooms due to missing or malfunctioning privacy curtains and window blinds. Some residents lacked curtains at the foot of their beds, while others had curtains that did not fully extend or were tied up, and one resident had broken window blinds exposing them to an outside area. Staff interviews revealed that maintenance only addressed these issues when reported, and there was no routine check for privacy coverage, despite facility policy requiring privacy and dignity for all residents.
The facility did not maintain an effective pest control program, as evidenced by repeated observations of live cockroaches in a resident room, a community bathroom, and the activity room. Staff and residents reported ongoing issues with roaches despite regular pest control treatments, and facility records showed repeated need for treatment in multiple areas. The administrator and maintenance director acknowledged persistent problems, with contributing factors including food storage in resident rooms and inconsistent housekeeping.
A resident with severe cognitive impairment and blindness did not receive necessary nail care, resulting in excessively long fingernails. Despite care plans and facility policy requiring regular nail care, staff failed to trim the resident's nails due to confusion over responsibility and lack of assessment during scheduled showers.
A resident with a gastrostomy tube was not provided enteral nutrition according to physician orders, as nursing staff administered an additional two hours of feeding downtime each day that was not prescribed. This deviation was not identified due to lack of review of updated orders after the resident's hospital readmission, resulting in the resident receiving only 20 hours of feeding instead of the ordered 22 hours. The issue was discovered after significant weight loss was noted and staff interviews revealed confusion about the correct feeding schedule.
A resident with a tracheostomy did not have an emergency trach kit, including a bag valve mask and the next lower size trach tube, readily available at the bedside as required by facility policy and the care plan. Nursing staff and administration confirmed the absence of these supplies and acknowledged their responsibility to ensure their presence and accessibility, with facility policy mandating these items always be at the bedside for residents with tracheostomy status.
A resident with a feeding tube received five medications mixed together and administered at once by an RN, rather than each medication being given separately with water flushes as ordered. This resulted in an 11% medication error rate, exceeding the acceptable threshold, and was confirmed by both staff and the resident as a routine practice. The RN acknowledged combining medications to save time, and the DON stated the RN had not been checked off on proper tube medication administration.
CNAs failed to wear required PPE, including gowns and gloves, while transferring a resident with a urinary catheter who was on Enhanced Barrier Precautions. One CNA wore only gloves, while the other wore no PPE, despite clear signage and facility policy requiring both gown and gloves for high-contact care activities. The DON confirmed that proper PPE should have been used during the transfer.
A resident with a history of hypertension had an extremely high blood pressure reading of 216/114, which was not reported to the physician or responsible party by the facility staff. The resident, who had multiple health conditions, later called 911 due to feeling unwell and was hospitalized with pneumonia. The facility's policy to notify the physician of significant changes in condition was not followed.
A resident with multiple health issues, including hypertension, had an extremely high blood pressure reading that was not reported to the nurse by the medication aide, leading to a lack of immediate medical evaluation. The resident later called 911 and was hospitalized with pneumonia. The facility's failure to follow protocols for abnormal vital signs placed residents at risk of delayed treatment.
A resident with a history of mental health issues received a mentally and emotionally abusive text message from an LVN's phone, causing fear for her personal safety. The facility failed to prevent this abuse, leading to the resident feeling scared and unprotected.
The facility failed to maintain a sanitary environment, with persistent urine odors on Station 1, dirty privacy curtains for two residents, and unclean wheelchairs. Staff interviews revealed inconsistent cleaning practices and a lack of effective systems to address these issues, contributing to unsanitary conditions.
The facility failed to provide adequate pharmaceutical services, including maintaining accurate narcotic records and removing expired medications from carts. An expired bottle of Aspirin was found, and a nurse failed to log the administration of a narcotic, leading to potential drug diversion.
The facility failed to ensure that insulin pens on two medication carts were dated with an opening date. Observations revealed that insulin vials on the station 1 South and station 3 medication carts were opened and partially used without an opening date. Interviews with the responsible LVNs and the Interim DON confirmed that this oversight could lead to the use of expired and ineffective insulin.
A resident with severe cognitive impairment and multiple diagnoses had an ophthalmology referral that was not scheduled by the responsible LVN. The Interim DON and Administrator confirmed that the referral was not made, and the facility's policy mandates staff education on resident rights and proper care.
A resident with a Stage 4 pressure ulcer was found without a dressing, despite having informed staff. The facility staff, including the LVN and CNA, were unaware or forgot to address the issue, and the Interim DON had not conducted wound care in-services. This failure to follow wound care protocols placed the resident at risk of infection and delayed healing.
The facility failed to complete post-dialysis assessments for two residents, despite care plans and physician's orders requiring monitoring of vital signs. Interviews revealed a lack of awareness and oversight among nursing staff and management, leading to serious health risks for the residents.
The facility failed to act upon the pharmacist's recommendation for a gradual dose reduction (GDR) of a resident's psychotropic medication, Duloxetine HCl. The resident had not had a GDR attempt within the last six months, and the procedure was not completed due to the absence of a DON from October 2023 to February 2024, leading to the risk of over-medication.
A facility failed to provide a working call light system for a resident with significant medical conditions, leading to potential delays in assistance. Staff removed the call light due to frequent accidental activations, but acknowledged that every resident should have one within reach. The issue was not addressed until identified during a survey, despite the facility's policy requiring call lights for all residents.
Pressure ulcer care and dressing documentation failures
Penalty
Summary
The facility failed to ensure a resident with severe contractures received consistent interventions to reduce pressure on the right hand and palm, and a stage 3 pressure ulcer developed on the right palm. The resident had a history of stroke, hemiplegia/hemiparesis, encephalopathy, severe cognitive impairment, and dependence for all ADLs. The care plan identified the resident as at risk for impaired skin integrity related to contractures in all extremities and included interventions such as a circular limb offloader, pillows or foam wedges, pressure-relieving devices, and daily washcloth placement in the right hand and against the shoulder and hand. The resident’s skin note documented a new wound on the right palm on 06/03/26, and the wound physician later described it as a stage 3 pressure wound with severe contracture limiting debridement. Subsequent wound notes showed the wound remained full thickness with moderate serous drainage and later had hypergranulation tissue and was not at goal due to contractures. During observations on 07/28/26 and 07/29/26, the resident was seen lying in bed without an offloading device on the hand or wrist, and no washcloths or other hand positioning devices were observed in or around the hands or wrists. Interviews showed inconsistent understanding and use of the positioning interventions. Staff stated that CNAs were responsible for placing washcloths or the blue offloading device, while other staff said they had not received instructions that the device was to be worn all the time or did not know an order was needed. Some staff reported using towels, pillowcases, or washcloths, while others stated the resident did not have anything in the hands at times. The wound care physician stated the resident was very contracted and that more could have been done to prevent the wound on the right palm. The facility also failed to ensure a dressing on the resident’s left hip was dated and initialed. During wound care on 07/30/26, the dressing on the left hip was observed without a date. The LVN stated she had applied it the day before but forgot to date it, and acknowledged that dressings were supposed to be dated and initialed so staff would know when they were done. The DON and ADON also stated wound dressings should be dated and initialed.
Unsafe and Unpleasant Environmental Conditions
Penalty
Summary
The facility failed to provide a clean, safe, and functional environment in Resident #27’s room and on Station 1 and Station 2 halls. In Resident #27’s room, a red and green blanket was hanging over the left side of the window, and vertical blinds were missing behind it. Resident #27 stated the blanket and broken blinds did not bother him. The facility’s Resident Rights policy stated residents have a right to a safe, clean, comfortable, and homelike environment. On Station 1, a staff member opened the soiled utility room door to put away soiled linen and trash, and a foul odor was noted in the hallway and lingered after the door was opened. On Station 2, a strong urine odor was observed in the hallway between Resident #28, Resident #16, and Resident #85’s rooms. The Housekeeping Supervisor, DON, ADON, Maintenance Director, and Interim Administrator all acknowledged the odors and stated staff were expected to report needed cleaning or repairs to housekeeping or maintenance. The Housekeeping Supervisor stated Resident #27’s blinds had been broken for three to four months and new ones were ordered.
Failure to Provide Needed Nail Care for Two Dependent Residents
Penalty
Summary
The facility failed to ensure nail care, including trimming, was provided for two residents who were unable to perform activities of daily living. Resident #26 had diagnoses including cerebral infarction, vascular dementia, aphasia, and diabetes mellitus, and the MDS reflected severe cognitive impairment and dependence for all ADLs. His care plan directed staff to provide shower, shave, oral care, hair care, and nail care per schedule and when needed, but July 2026 progress notes contained no documentation of refusal of fingernail care. On observations on 07/28/26, 07/29/26, and 07/30/26, his fingernails were observed to be about 1/2 inch long with jagged, sharp edges or corners. During interview, CNA G stated Resident #26’s nails were very long and needed to be trimmed, but she did not cut them because he was diabetic and she believed only the nurse should do it. She stated LVN H had commented the previous day that she was going to trim them, but it had not been done. LVN H stated she was responsible for cutting his nails because he was diabetic, that she noticed how long they were that morning, and that she had not gotten to it yet. She also stated his nails had been cut last month but could not recall the date. Both staff identified scratching and self-harm as risks associated with the long nails. Resident #6 had diagnoses including stroke, hemiplegia or hemiparesis, and encephalopathy, with severe cognitive impairment and dependence for all ADLs. His care plan identified an ADL self-care deficit, and progress notes from 05/25/26 through 07/29/26 contained no entries showing nail care was provided or attempted. On observation, his left hand was contracted and the thumb nail was long, and later his right-hand nails were observed to be long, with most nails about an inch and a half long. LVN F stated he was responsible for cutting Resident #6’s nails and said he had cut them a couple of weeks earlier, but when he examined the hand he stated the nails needed to be trimmed. The ADONs and DON stated staff were expected to check nails, with nurses responsible for diabetic residents’ nail trims, and identified self-injury, skin tears, infection, and skin issues as concerns when nails were left long.
Failure to Consistently Implement Contracture Management
Penalty
Summary
The facility failed to ensure a resident with severe contractures received appropriate treatment and services to maintain range of motion and prevent further decline in the right and left hands and arms. Resident #6 had diagnoses including stroke, hemiplegia/hemiparesis, and encephalopathy, with severely impaired cognitive skills, upper and lower extremity impairment on both sides, and dependence for all ADLs. The resident’s care plan included interventions for contractures, including weekly ROM by therapy and use of washcloths in the right thumb and index finger and against the shoulder and hand on the right. Observation on 07/28/26 and 07/29/26 showed the resident lying in bed with no offloading device observed on the arms or wrists and no washcloths observed in or around the hands or wrists. On one observation, bordered gauze was on the right palm, and on another, a blue round offloading device was seen in the wheelchair rather than on the resident. Staff interviews showed inconsistent understanding and implementation of the resident’s contracture management measures. One LVN stated the resident was supposed to wear the devices all the time, while another LVN stated there was no order for an offloading device and that therapy applied it. A CNA stated she had used towels or the blue device, while another CNA stated she did not put anything in the resident’s hands and that the blue brace was only sometimes present. Therapy and management staff also described differing approaches to the resident’s contractures. The DOR stated the resident was receiving PT, OT, and ST through PASARR services and that staff had been in-serviced on positioning devices and using a pillowcase in the hands or between the arm and chest. OT staff stated the resident had become more contracted since returning from the hospital and that they were trying to maintain ROM, but splinting could rest against the thumb and cause a wound. The DON stated CNAs and nurses were responsible for placing washcloths and the round foam device, and that the washcloths should be changed daily. The facility’s contracture management guidance stated that repositioning devices and adaptive devices were used to reduce the risk of pressure injury development.
Smoking Supervision and Assessment Deficiencies
Penalty
Summary
The facility failed to ensure adequate supervision during smoking breaks for three residents who were reviewed for accidents and supervision. Resident #7 had severe cognitive impairment with a BIMS of 06 and diagnoses including anxiety disorder, bipolar disorder, schizophrenia, respiratory failure, and lack of coordination. His care plan identified him as a dependent smoker who required staff supervision, but his chart did not contain a smoking assessment. During observation, he was outside smoking with a tubing device connected to a lit cigarette, and he indicated he was waiting for staff to provide the tube. Resident #10 had diagnoses including stroke, non-Alzheimer’s dementia, Parkinson’s disease, anxiety disorder, bipolar disorder, psychotic disorder, PTSD, COPD, and muscle weakness. Her care plan identified her as a dependent smoker who required staff supervision and included use of a smoking apron and staff assistance to the smoking area, but her chart did not contain a smoking assessment. During observation, she was outside smoking with a tubing device connected to a lit cigarette and an apron across the front of her body. She stated staff assisted her to the smoking patio and provided the apron and smoking apparatus during each smoking break. Resident #62 had diagnoses including high blood pressure, high blood sugar, anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, respiratory failure, and nicotine dependence. Her care plan identified her as an independent smoker and stated she did not require a smoking apron or direct staff supervision, but her chart did not contain a smoking assessment. During observation, she was outside smoking and was able to maintain her cigarette and use an ashtray appropriately. Staff later stated that all residents required supervision during smoking breaks, that Resident #7 and Resident #10 required a smoking tube, and that Resident #10 did not need an apron if she used the smoking tube. The DON stated smoking assessments were to be completed quarterly, but the assessments for these residents could not be located in the chart.
Improper Food Storage and Staff Hygiene in Kitchen
Penalty
Summary
Food was not stored in accordance with professional standards in the facility’s only kitchen. During observation, a large piece of meat on a sheet pan in the refrigerator was wrapped in plastic and lightly covered with foil, but the pan was tilted on top of bacon that was unsealed, unlabeled, and undated in white parchment paper. Red ring stains were seen on the parchment paper, showing that liquid from the meat had leaked and created a puddle at the bottom of the refrigerator. The Dietary Manager stated she did not know how long the meat had been in the refrigerator and said she was responsible for daily refrigerator walk-throughs and cleaning spills when they occurred. She also stated the cooks were responsible when she was not working and that open food should have been removed and the spill cleaned. The facility also failed to ensure proper hygiene for staff entering the kitchen. A Maintenance Assistant entered the kitchen without hand hygiene and initially attempted to use a beard net as a hair net, despite having a long ponytail that was not fully covered. He then left the kitchen to get a proper hair net and returned without performing hand hygiene, standing near staff preparing dessert for lunch trays. The Dietary Manager stated she expected all staff entering the kitchen to use proper hygiene, including hair nets and hand washing, and the Maintenance Assistant stated he did not think the beard net was the right hair net and forgot to wash his hands after entering the kitchen.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program to keep Station 1 hallway, Resident #6's room, and the kitchen free of flies. On observation, 2 flies were seen flying and landing on the wall near the soiled utility room on Station 1 hallway. In the kitchen, 3-5 flies were observed on the snack box and another 4-5 flies were flying around the kitchen. The Dietary Manager stated she was aware of the fly problem in the kitchen and attributed it to the back door not having a proper seal, and said the Administrator was aware and in the process of purchasing a blower over the door. She also stated staff were responsible for keeping the door closed at all times to prevent flies from entering the kitchen. During wound care in Resident #6's room, a fly was observed flying around the room while the resident was in bed and unable to answer questions. RN J stated she had noticed the fly in the room and said staff were to write pest sightings down for the exterminator. The Maintenance Director stated he had noticed flies and that staff were to record sightings in the pest control book for treatment by pest control. The Interim Administrator stated the facility was trying to address the pest control issue and that a new frame and door had been approved for the kitchen. The DON stated flies could irritate residents and that pest control had come out to treat some resident rooms for flies. The facility's pest control reports noted recommendations to repair or replace the kitchen rear exit door to ensure proper closure and to replace fly light bulbs and starters, and a later report documented specialized fly control service and bulb replacement in the kitchen light unit.
Care Plan Did Not Address Smoking Apparatus Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was a smoker and required supervision during smoking breaks. The resident’s MDS documented multiple diagnoses, including stroke, non-Alzheimer’s dementia, Parkinson’s disease, anxiety disorder, bipolar disorder, psychotic disorder, PTSD, COPD, and muscle weakness. Her undated care plan identified her as a dependent smoker at risk for injury and included interventions such as assisting her to and from the smoking area, performing a smoking assessment, reminding family about the need for a smoking apron for an unsafe smoker, and providing direct supervision, but it did not address the use or requirement of a smoking apparatus, and there was no smoking assessment in her clinical record. During observation, the resident was seen outside during smoking breaks using a tubing device connected to a lit cigarette, with an apron across the front of her body on one occasion. On another observation, she was holding the smoking apparatus and administering it to her mouth while the apron was on the ground underneath the table where the CNA was standing. The resident stated staff assisted her to the smoking patio and provided the apron and smoking apparatus during each smoking break. The CNA stated the resident required supervision and protective equipment, including the smoking tube and ashtray connected to her wheelchair, and said both the smoking apparatus and apron were used to protect against burns if the resident dropped her cigarette. The DON stated the resident now used a smoking apparatus and that this should have been included in the care plan so staff would know how to assist her during smoking breaks.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident receiving enteral feeding when an LVN did not check G-tube placement before administering medications and did not give the medications separately as ordered. The resident had diagnoses of encephalopathy, dysphagia, and malnutrition, had severely impaired cognitive skills, and required a feeding tube for nutrition. The care plan directed staff to check tube placement per facility protocol, and the physician’s orders required checking G-tube placement before medication and enteral feeding administration, flushing with water before and after medications, and flushing between each medication. During observation, the LVN prepared multiple medications together, crushed the tablets into one cup, mixed them with water, disconnected the tube feeding, and administered the crushed medications, Prostat, and multivitamin through the G-tube without first checking placement. The LVN then restarted the tube feeding. In interview, the LVN stated he forgot to check placement and acknowledged the risk of giving medication if the tube was dislodged. The ADON and DON stated they expected nurses to check placement before administering medications and to crush and administer each medication separately, consistent with the facility policy that required individual preparation of each medication and checking enteral tube placement before any fluids or medication were administered.
Medication administration and storage failures
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when medications were not handled according to facility expectations for administration and storage. For one resident with a history of diffuse traumatic brain injury, hypertension, and need for assistance with personal care, the record showed he was not able to safely self-administer medications. Although his care plan directed staff to administer medications per physician orders, a medication aide left his morning medications in his room on the bedside table and did not remain to observe him take them. The resident was observed with multiple medications in a cup on the table, stated he was going to take them himself, and said staff had just dropped them off and left the room. The medication aide confirmed she left the medications on the resident’s table and did not watch him take them, stating he told her to leave them and that he would not take them if she watched. She also stated she was not supposed to leave medications at the bedside because another resident could take them instead, and that she had been trained not to do so. Nursing leadership stated staff should always watch residents take medications and that the resident could not self-administer medications. The DON stated that if the resident did not want to take the medications, they should be taken out of the room. For another resident with dementia and nausea with vomiting, the medication cart on Station 2 contained expired medications. Observation of the cart revealed a bubble pack of ondansetron 8 mg tablets prescribed to the resident with two tablets remaining that had expired, along with OTC famotidine 10 mg that had also expired. The LVN acknowledged both medications were expired and stated she had not given the ondansetron in a while. She and facility leadership stated nurses were responsible for checking expiration dates and ensuring there were no expired medications in the carts, and the DON stated pharmacy came monthly and ADONs did random audits, but the expired medications remained in the cart at the time of observation.
Medication Error Rate Exceeded Standard During G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure the medication error rate was not 5% or greater. Surveyors found a medication error rate of 27.59%, based on 8 errors out of 29 opportunities, involving 1 of 5 residents and 1 of 3 staff observed during medication administration. The deficiency centered on Resident #6, a male with diagnoses including encephalopathy, dysphagia, and malnutrition, whose cognitive skills were severely impaired and who required a feeding tube for nutrition. His care plan reflected the need for tube feeding for all nutrition and checking tube placement per facility protocol. During observation, LVN F prepared multiple medications together in one medication cup, including Vitamin D3, acetaminophen, ascorbic acid, zinc sulfate, thiamine, Eliquis, tizanidine, and atorvastatin, then crushed the tablets together and mixed them with water. LVN F entered the resident’s room and administered the medications through the g-tube without giving the tablets separately. The nurse also administered multivitamin and Prostat through the tube during the same medication pass. The resident’s order summary reflected no physician order to combine medication tablets or cocktail medications. In interview, LVN F stated he typically crushed medications together if they were not enteric coated and acknowledged that giving the medications together could put the resident at risk of medication interaction and cause an adverse reaction. The ADON and DON both stated that medications for g-tube administration should be crushed and administered separately and not cocktailed.
Improper Dish Sanitization and Failure to Monitor Sanitizer Levels During Dishwasher Outage
Penalty
Summary
The facility failed to ensure that dishware was sanitized according to professional food safety standards when the main dishwasher was inoperable and the kitchen was using a compartment sink and paper products. On the morning of the survey, the Dishwasher Aide was observed washing breakfast cups in the compartment sink and acknowledged he had not tested the sanitizer level. He stated he had been employed for four weeks and had never been trained to properly sanitize dishes. When asked, another kitchen staff member stated there were test strips available to check sanitation but identified herself as just the cook and reported she did not test sanitizer levels for her own cooking utensils. She also reported there was no sanitation log to show a history of sanitizer levels. The Administrator reported that paper goods had been purchased several days earlier to be used once repairs to the dishwashing area began and stated she was unaware that residents were using anything other than paper goods. The kitchen logbook sheet did not indicate the required ppm of sanitizer for the compartment sink. Another kitchen staff member reported receiving a text message instructing staff to use paper goods for meals due to dishwashing repairs, but stated that the evening shift had prepared drinks for the morning meal using regular cups, which the Dishwasher Aide then washed in the compartment sink. This staff member stated the Dishwasher Aide was responsible for logging sanitation levels but confirmed he had never been trained and had never tested sanitizer levels. The facility’s Food Safety and Sanitation Plan policy required sanitizing solution to be maintained at appropriate strength per manufacturer’s instructions and changed routinely to ensure proper strength.
Failure to Maintain Effective Pest Control in Kitchen Dishwashing Area
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the only kitchen, specifically the dishwashing area, free of gnats and roaches. During observation and interview with the dishwasher aide, surveyors noted standing water on the floor, gnats flying, and roaches crawling in the dishwashing area. The dishwasher aide reported that pests had been present in this area since he started working about four weeks earlier and attributed the issue to the standing water. He stated that the Dietary Manager had been notified and was aware of the pest issues in the dishwashing area. In a separate interview, the Maintenance Supervisor confirmed there had been ongoing attempts to correct a water leak causing standing water in the dishwashing area and acknowledged awareness of pests there. He stated that gnats appeared with the standing water and roaches appeared when the floor was dug up to repair a busted pipe. The pest control vendor logbook showed visits on three specific dates over the prior three months. The Administrator stated there had been an ongoing pest issue in the dishwashing area and that pest control vendors came monthly and had been called additional times for gnats during repair phases, but she reported she was not aware of roaches. The facility’s Pest Control Program policy required maintaining an effective pest control program, obtaining services as indicated between scheduled visits, and using appropriate methods to control pests, but the presence of gnats and roaches in the kitchen demonstrated that the program was not effectively implemented. The report stated that this failure could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.
Failure to Provide Timely ADL and Incontinence Care Due to Missed Rounds and Inaccessible Call Light
Penalty
Summary
Facility staff failed to provide necessary services for a resident who was unable to carry out activities of daily living (ADLs), as required by both facility policy and the resident's care plan. The resident, a male with severe cognitive impairment and multiple diagnoses including cerebral infarction, epilepsy, ALS, and incontinence, required extensive to total assistance with mobility, hygiene, and toileting. The care plan specified that two staff members were needed for assistance, frequent rounding was required to anticipate needs, and incontinent care was to be performed every two hours. Despite these requirements, interviews and observations revealed that staff did not consistently perform two-hour rounds or ensure the resident's call light was within reach. The resident and his roommate reported that staff often failed to respond to call lights, sometimes turned off the call light without addressing needs, and left the resident in soiled briefs for extended periods. The roommate frequently had to use his own call light or seek staff assistance in the hallway. Observations confirmed that staff were sometimes seated in the hallway using their cell phones instead of attending to residents' needs, and the resident was unable to reach his call light when assistance was needed. Staff interviews indicated a lack of consistent adherence to rounding schedules and responsibilities. While some CNAs described their routines, there was confusion about assignments and a lack of follow-through in ensuring call lights were accessible and needs were met. Facility in-service records confirmed that staff were trained to perform rounds and incontinent care every two hours and to keep call lights within reach, but these practices were not consistently implemented for this resident.
Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident's call light was found on the floor, out of reach, while the resident was in bed. The resident, who had significant medical conditions including cerebral infarction, epilepsy, severe cognitive impairment, dysphagia, muscle weakness, and a history of repeated falls, was dependent on staff for activities of daily living and required frequent assistance. The care plan for this resident specifically included interventions to keep the call light within reach and to anticipate and meet the resident's needs due to their high risk for falls and impaired communication. Observations and interviews revealed that staff did not consistently ensure the call light was accessible to the resident. The resident reported that staff did not round every two hours as expected and did not always ensure the call light was within reach. There were also instances where staff entered the room, turned off the call light, and left without addressing the resident's needs. The resident's roommate corroborated these statements, noting that staff did not always answer the call light and sometimes left the resident unattended for extended periods. The roommate often had to use his own call light or seek staff assistance in the hallway for the resident. Further interviews with CNAs, the DON, ADON, and the facility administrator confirmed that staff were expected to check call lights during rounds and ensure they were within reach, but these expectations were not consistently met. Staff acknowledged the importance of timely call light response and accessibility but admitted to lapses in practice. Facility policy required call lights to be placed near residents and never on the floor, but this was not followed in the case of the resident in question.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels within the required range of 71 to 81 degrees Fahrenheit for 16 out of 26 residents reviewed. Multiple observations revealed that residents' rooms were being cooled with several fans, some of which were purchased by the residents or their families, while others were provided by the facility. Despite these efforts, ambient temperatures in affected rooms ranged from 75 to 82 degrees Fahrenheit, with several residents reporting discomfort, sweating, and the need to leave their rooms during the warmer parts of the day. Residents frequently relocated to common or dining areas where the air conditioning was functioning, as their own rooms became too hot to occupy comfortably. Interviews with residents confirmed that the air conditioning in certain sections had not been working for several weeks, and the facility was aware of the issue. The Maintenance Director stated that the HVAC unit servicing the affected rooms had been partially repaired but was still not cooling adequately, pending further repairs. The Administrator acknowledged the ongoing HVAC issues and indicated that staff were providing ice and water to residents in the affected areas. The facility's policy required living spaces to be comfortable and temperature-controlled, but this standard was not met for the residents in the impacted rooms.
Failure to Prevent Resident-to-Resident Abuse During Altercation
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, misappropriation of property, and exploitation, as evidenced by an incident involving two residents. One resident, who had dementia, bipolar disorder, and schizoaffective disorder with moderate cognitive impairment, was involved in a physical altercation with another resident who was cognitively intact but had a history of schizophrenia and impaired vision. The altercation began when the cognitively intact resident believed the other resident had taken her purse, leading to a verbal dispute and a physical struggle over the purse. During the incident, staff observed the two residents tugging on the purse and intervened to separate them. Despite staff intervention, the cognitively intact resident struck the other resident in the face with a closed fist. Immediate assessment by nursing staff found no pain or injury, and the incident was reported to the appropriate facility leadership. The resident who was struck had no recollection of the event, and her responsible party reported no visible injuries or concerns about her care. Interviews with staff and review of care plans indicated that the resident who initiated the physical contact had no prior history of aggression, and the resident who was struck had a known pattern of entering other residents' rooms and taking items. The facility's policy required prevention and prohibition of abuse, neglect, and exploitation, but the incident demonstrated a failure to prevent resident-to-resident abuse in this instance.
Failure to Follow Prescribed Menu and Document Substitutions for Pureed Diets
Penalty
Summary
The facility failed to follow the prescribed menu for one observed lunch meal, specifically for residents on pureed diets. During the lunch service, pureed dinner rolls were not prepared or served to residents who required pureed meals, and greens were substituted for broccoli florets without proper documentation or posting of the substitution. Both the Dietary Manager and a visiting Dietary Manager from a sister facility confirmed that the omission of the pureed dinner roll was due to staff oversight and that facility policy requires all residents to receive the same meal and for any substitutions to be posted and documented. Review of the facility's menu confirmed that the planned meal included pork roast loin, buttered broccoli florets, boiled potato, dinner roll, and chocolate pudding. The facility's policy on menu changes and substitutions requires that any variation from the planned menu be documented and reviewed by the Dietician, with substitutions made using foods of equivalent nutritive value. No documentation or posting of the substitution was observed, and the Dietary Managers acknowledged the importance of following the menu to ensure residents receive adequate nutrition.
Failure to Ensure Full Visual Privacy in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident rooms provided full visual privacy for five residents, as required for maintaining dignity and personal space. Observations revealed that several residents either lacked privacy curtains at the foot of their beds, had curtains that did not fully extend due to missing hangers or malfunctioning tracks, or had curtains tied up and not in use. In one case, a resident was also missing multiple slats from window blinds, resulting in a lack of privacy from an outside smoking area. Residents expressed dissatisfaction with the lack of privacy, noting that it had persisted for extended periods, and some stated a preference for full privacy, especially when changing clothes. Interviews with staff indicated that maintenance was responsible for hanging and repairing curtains, while housekeeping handled cleaning and replacement when needed. However, maintenance only addressed curtain or track issues when they were reported, and there was no routine check for coverage or functionality. Nursing staff and supervisors acknowledged the importance of privacy curtains and window blinds for resident dignity, but also indicated that missing or broken items were not always promptly reported or addressed. Review of the facility's policy confirmed the requirement to maintain privacy and dignity for residents.
Failure to Maintain Effective Pest Control Program Resulting in Cockroach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live cockroaches in multiple areas, including one resident room, a community bathroom, and the activity room. Observations over several days revealed live roaches running in a resident's room, in the community bathroom adjacent to the activity room, and by the water dispenser in the activity room. Multiple live roaches were also seen in the community bathroom, with some moving into the hallway. Review of the pest control log indicated ongoing issues, with repeated treatments for American roaches in various locations, including staff restrooms, nurses' stations, and resident rooms. Interviews with residents and staff confirmed the persistent presence of roaches, particularly in the bathroom next to the activity room, despite regular pest control treatments. Staff noted that the problem persisted regardless of the frequency of treatments, and the administrator acknowledged ongoing difficulties in controlling the infestation, attributing some of the challenges to residents storing food in their rooms and housekeeping not maintaining cleanliness. The facility's policy requires an effective pest control program, but the observed and reported conditions indicate that the program was not successful in eradicating or containing the pest problem.
Failure to Provide Timely Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, blindness, and multiple medical diagnoses, including hyperlipidemia, seizure disorder, cataracts, glaucoma, and macular degeneration, did not receive necessary assistance with personal hygiene, specifically nail care. The resident required partial to moderate staff assistance for personal hygiene, as documented in the care plan, which included regular nail care. Observations on two consecutive days revealed the resident's fingernails were about a half-inch long, and the resident expressed discomfort and a desire to have his nails cut. Interviews with staff indicated confusion regarding responsibility for nail care, particularly concerning whether the resident was diabetic, which would require a nurse rather than a CNA to perform the task. The CNA assigned to the resident did not check or trim the resident's nails during scheduled showers, and the DON confirmed that nail care should be provided at least weekly by CNAs unless the resident is diabetic. The facility's nail care policy outlined the procedure for nail care, but it was not followed in this instance, resulting in the resident's nails remaining untrimmed.
Failure to Follow Physician Orders for Enteral Feeding Downtime
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a gastrostomy tube was provided with appropriate treatment and services in accordance with physician orders. Specifically, nursing staff did not follow the prescribed feeding downtime for the resident, instead providing an additional two hours of downtime each day that was not ordered by the physician. This deviation from the physician's orders was not identified or corrected by the nursing staff, as the nurse responsible for the resident was unaware of the updated orders following the resident's readmission from the hospital. The nurse continued to follow the previous downtime schedule and did not review the current physician orders upon the resident's return. The resident in question was a male with a history of nontraumatic intracerebral hemorrhage, chronic respiratory failure with hypoxia, unspecified cirrhosis of the liver, and gastrostomy status. He was nonverbal and unable to answer questions. His care plan and physician orders specified continuous enteral feeding for 22 hours per day, with a scheduled downtime from midnight to 2 AM. However, observations and interviews revealed that the resident was routinely given an additional two-hour downtime from 10 AM to noon, resulting in a total of four hours of downtime daily. This practice was not in accordance with the current physician orders and was not communicated to or recognized by the interdisciplinary team. The discrepancy in feeding times coincided with a significant, unexplained weight loss for the resident, as documented by multiple weight checks. While staff and the dietitian questioned the accuracy of the scale and did not attribute the weight loss solely to the additional downtime, the failure to follow physician orders for enteral feeding was confirmed. The facility's policy required that enteral feedings be administered per physician order, but this was not adhered to in the resident's case. Interviews with nursing, dietary, and therapy staff further confirmed a lack of awareness and communication regarding the resident's current feeding schedule and physician orders.
Failure to Maintain Emergency Tracheostomy Kit at Bedside
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not have an emergency tracheostomy kit, including a bag valve mask and the next lower size trach tube, readily available at the bedside as required by facility policy and the resident's care plan. The resident, a female with a history of seizure disorder, respiratory failure, tracheostomy status, and diabetes, was totally dependent on staff for activities of daily living and was rarely or never understood. Her care plan specifically directed that an extra trach tube be kept at the bedside and that staff monitor for signs of respiratory distress. During observation of tracheostomy care, it was noted that there was no emergency trach kit at the resident's bedside. The nurse providing care confirmed that the kit, which should include a bag valve mask and the next lower size trach tube, was not easily accessible due to disorganization of supplies. The nurse also stated she had not seen the emergency kit in the resident's room during her four weeks of employment and acknowledged it was her responsibility, along with others, to ensure the kit was present and accessible each shift. Interviews with the ADON and DON confirmed that facility policy required an emergency trach kit and the next lower size trach tube to be easily accessible in the rooms of residents with tracheostomy status. Both leaders recalled the kit being present earlier but believed it may have been discarded after falling on the floor during room adjustments. They agreed it was the responsibility of nursing staff and administration to check for these items daily and to report any missing supplies. Review of the facility's policy further confirmed the requirement for these emergency supplies to always be present at the bedside.
Medication Error Rate Exceeds 5% Due to Improper Administration via Gastric Tube
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent, as evidenced by an 11% error rate (5 errors out of 44 opportunities) during medication administration for one resident. Specifically, a registered nurse (RN) combined five different medications and administered them together via a gastric tube, rather than administering each medication separately with a water flush between each, as ordered by the physician and outlined in facility policy. This practice was observed during a morning medication pass, and the resident confirmed that medications were always given in this manner. The resident involved was a male with a history of stroke, cognitive impairment, and required a gastric tube for all nutrition and medication administration. Physician orders and the facility's policy required each medication to be prepared and administered separately, with water flushes before and between each medication to prevent tube clogging. The RN admitted to combining medications to save time during busy shifts, despite knowing this was not the correct procedure. The DON confirmed that the RN had not yet been checked off on proper gastric tube medication administration.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to follow established infection prevention and control protocols while transferring a resident who was on Enhanced Barrier Precautions (EBP) due to a urinary catheter and risk for urinary tract infections. During the transfer from wheelchair to bed using a mechanical lift, CNA A wore gloves but did not wear a gown, and CNA B did not wear any personal protective equipment (PPE) at all. The resident’s care plan and signage outside the room clearly indicated the need for gown and gloves during high-contact care activities, including transfers, for residents on EBP. Interviews with the CNAs revealed that CNA A was aware of the requirement but forgot to don the gown, while CNA B was unaware that the resident was on EBP and therefore did not use any PPE. The Director of Nursing (DON) confirmed that both CNAs should have worn gloves and gowns during the transfer, as per facility policy and posted instructions. Facility policy specified that EBP requires gown and gloves for high-contact activities for residents with indwelling medical devices, such as urinary catheters.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's physical status. Specifically, the facility did not notify the physician or responsible party when a resident's blood pressure was recorded at 216/114, which is considered extremely high. This oversight was identified during a review of the resident's records, which showed no documentation of a re-check of the blood pressure or any notification to the physician or responsible party. The resident involved was a male with a history of hypertension, type II diabetes, chronic kidney disease, and mild dementia, among other conditions. The resident was dependent on staff for most activities of daily living and had a care plan in place to monitor and manage his hypertension. Despite this, the elevated blood pressure reading was not addressed appropriately, and the resident later called 911 himself due to feeling unwell, leading to his transport to the hospital where he was diagnosed with pneumonia. Interviews with facility staff revealed that the medication aide who recorded the high blood pressure did not report it to the nurse, and the nurse did not take further action to notify the physician. The Director of Nursing (DON) was unaware of the elevated blood pressure until after the resident had been hospitalized. The facility's policy required immediate notification of the physician and responsible party for significant changes in a resident's condition, which was not followed in this instance.
Failure to Follow Protocols for Abnormal Vital Signs
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not follow protocols for abnormal vital signs when a medication aide did not notify the nurse after a resident's blood pressure was recorded at 216/114, and there was no re-check to ensure accuracy or determine if further treatment was needed. This oversight placed all residents at risk of a delay in medical evaluation and treatment. The resident involved was an elderly male with multiple diagnoses, including hypertension, type II diabetes, and mild dementia. His care plan indicated he was at risk for fluctuations in blood pressure and required monitoring for side effects of antihypertensive medications. On the day in question, the resident's blood pressure was recorded as extremely high, but the medication aide did not report this to the nurse, and no further action was taken to address the elevated reading. Interviews with staff revealed that the medication aide believed she had reported the high blood pressure to the nurse, but there was no documentation to support this. The nurse on duty stated that if she had been informed, she would have rechecked the blood pressure and notified the physician. The facility's policy required immediate notification of the physician for significant changes in a resident's condition, which did not occur in this instance. The resident later called 911 himself due to feeling unwell and was transported to the hospital, where he was diagnosed with pneumonia.
Failure to Protect Resident from Mental and Emotional Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when an LVN sent the resident a mentally and emotionally abusive text message. The resident, who had a history of schizophrenia, bipolar disorder, anxiety, and vascular dementia, received a text message from the LVN's phone that contained derogatory and threatening language. This incident caused the resident to experience fear for her personal safety. The abusive text message was discovered when the resident showed it to another LVN, who then reported it to the facility's administrator. The administrator confirmed that the text message was sent from the LVN's phone number and took immediate action by notifying the police and terminating the LVN's employment. The resident expressed that she felt scared and unprotected following the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, and it was found that the facility did not adequately prevent the abuse from occurring. The report highlights the failure of the facility to protect the resident from mental and emotional abuse, as well as the subsequent fear and distress experienced by the resident.
Facility Fails to Maintain Sanitary Environment and Equipment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable environment for residents. Observations revealed a strong smell of urine permeating Station 1, particularly from room [ROOM NUMBER] through room [ROOM NUMBER]. During a confidential resident group interview, several residents confirmed the persistent urine odor, stating that housekeeping did not always clean properly. Staff interviews indicated awareness of the issue but revealed inconsistent and inadequate measures to address the odor, such as spraying air fresheners instead of thorough cleaning. The Housekeeping Supervisor and Interim DON acknowledged the problem but cited staffing shortages and improper handling of soiled linens as contributing factors. The Administrator expressed expectations for a clean environment but did not provide evidence of effective solutions being implemented. The failure to maintain a sanitary environment was evident in the persistent urine odor and inadequate cleaning practices on Station 1. The facility also failed to ensure that privacy curtains for two residents were clean. Observations of Resident #15 and Resident #59's rooms revealed privacy curtains with dried brown substances. Both residents acknowledged the dirty curtains, with Resident #59 explicitly stating that it was the staff's responsibility to clean them. Staff interviews confirmed that the curtains were dirty and that there was no effective system in place for regular cleaning or replacement. The Housekeeping Manager admitted to a backlog in curtain changes due to staff shortages and outdated curtains. The DON and Administrator were unaware of the specific issues with the curtains but reiterated that housekeeping was responsible for maintaining a clean environment. The lack of a systematic approach to curtain maintenance contributed to the unsanitary conditions in the residents' rooms. Additionally, the facility failed to maintain residents' wheelchairs in a sanitary condition. During a confidential resident group interview, several residents reported that their wheelchairs were not being cleaned, with visible dust buildup on various parts of the wheelchairs. Staff interviews revealed confusion and inconsistency regarding the responsibility for cleaning wheelchairs, with night shift staff being nominally responsible but no clear system or log in place to ensure the task was completed. The Maintenance Manager and Interim DON acknowledged the issue but did not provide evidence of effective oversight or corrective measures. The Administrator was unaware of complaints about dirty wheelchairs and cited dignity concerns as a potential risk. The failure to maintain clean wheelchairs was evident in the residents' reports and observations of dirty wheelchairs during the survey.
Failure to Provide Adequate Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, specifically in the management of medication carts and narcotic records. On one occasion, a nurse's medication cart contained an expired bottle of Aspirin 81mg tablets, which had an expiration date of 09/2023. The nurse responsible for the cart admitted that it was her duty to check for expired medications every other week, but she had not done so in this instance. Additionally, the facility's Interim DON acknowledged that the process for auditing medication carts had only recently been implemented and was not yet fully operational. This lapse in procedure could result in the administration of ineffective medications to residents. In another instance, the facility failed to maintain accurate narcotic records for a resident who was prescribed Hydrocodone-Acetaminophen 5-325 mg for pain management. The narcotic administration record showed a discrepancy between the recorded and actual count of the medication. A nurse admitted to administering the medication but failing to sign off on the narcotic administration log, which could lead to potential drug diversion. The Interim DON confirmed that nurses were responsible for logging narcotic administration and that failure to do so could result in missing doses for residents. The facility's policy on medication administration and documentation was not adequately followed, leading to these deficiencies.
Failure to Date Insulin Pens Upon Opening
Penalty
Summary
The facility failed to ensure that insulin pens on two medication carts were dated with an opening date. During an observation, it was found that one insulin vial of Novolog Subcutaneous Solution 100 unit/ml on the station 1 South medication cart and one insulin vial of Novolog Subcutaneous Solution 100 unit/ml and one insulin vial of Humalog Subcutaneous Solution 100 unit/ml on the station 3 medication cart were opened and partially used without an opening date. Interviews with the LVNs responsible for these carts revealed that it was the nurses' responsibility to date the insulin pens upon opening, but this was not done. Both LVNs acknowledged the risk of not dating the insulin, which includes not knowing when the insulin expires and its potential ineffectiveness in controlling blood sugar levels. Both LVNs had completed training on medication storage and administration but failed to adhere to the protocol. The Interim DON confirmed that nurses were responsible for dating the insulin after opening and that a new auditing program had been initiated for the night shift to check the carts on weekends. However, this process had only recently started, and the Interim DON had not yet conducted an in-service training on expired medications and labeling insulin. Another LVN, who had recently changed roles, stated that she was no longer able to audit the carts and expected the new ADON to take over this responsibility. The facility's current Insulin Management Process policy, dated September 2015, did not address the requirement for opening dates on insulin vials.
Failure to Schedule Ophthalmology Appointment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistance in making an ophthalmology appointment. Resident #74, who has severe cognitive impairment and multiple diagnoses including dementia, seizures, and major depressive disorder, had an order for an ophthalmology referral dated 03/08/24. However, no progress notes indicated that any staff member attempted to schedule the appointment. LVN E, who was responsible for Resident #74, confirmed that no appointment had been scheduled since the referral was made on 02/20/24. The Interim DON revealed that the expectation was for LVN E to either make the appointment herself or ask the Social Worker or Administrator to do so. However, LVN E did not inform the Administrator, and there was no Social Worker at that time. The Administrator confirmed that it was the charge nurse's responsibility to follow up on the referral and acknowledged that failing to do so could result in the resident not receiving necessary services. The facility's Resident's Rights policy mandates that all staff members are educated on the rights of residents and the facility's responsibility to properly care for them.
Failure to Ensure Proper Wound Care for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure necessary treatment and services to promote healing for a resident with a Stage 4 pressure ulcer. The resident, who had multiple diagnoses including quadriplegia and muscle wasting, was observed without a dressing on her pressure ulcer. The resident mentioned that the wound care doctor had removed her wound vac the previous day and that she had informed the staff about the missing dressing, but no one had come to apply a new one. The observation confirmed that the pressure ulcer was not covered, and the resident's brief was wet, indicating a lack of proper wound care management. Interviews with the staff revealed a lack of awareness and communication regarding the resident's wound care needs. The LVN was unaware that the dressing had come off, and the CNA admitted to noticing the missing dressing during morning care but forgot to notify the nurse. The Interim DON acknowledged that she had not conducted any in-services on wound care since her arrival six weeks prior and emphasized the importance of following physician orders and PRN orders to prevent infection and promote healing. The Treatment Nurse confirmed that the resident had a physician's order for specific wound care treatments, including the application of Santyl and Dakin's gauze, but had not been informed that the dressing had come off. The facility's policy on wound management was reviewed, which outlined the procedures for dressing changes and emphasized the need for timely intervention if a dressing becomes soiled or dislodged. The failure to adhere to these protocols placed the resident at risk of infection and delayed healing of the pressure ulcer.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that residents who required dialysis received appropriate post-dialysis assessments. For Resident #69, the facility did not complete post-dialysis assessments after the resident returned from dialysis treatment. Despite the care plan and physician's orders indicating the need for monitoring vital signs post-dialysis, the electronic health record (EHR) showed no documentation of these assessments. Interviews with the nursing staff revealed a lack of awareness regarding the missing documentation, although they claimed to have taken the necessary vital signs. The Interim DON and ADON were also unaware of the missing documentation and emphasized the risks associated with not monitoring post-dialysis vital signs, such as low blood pressure and shortness of breath. Similarly, the facility failed to complete post-dialysis assessments for Resident #92. The resident's care plan and physician's orders also required monitoring of vital signs post-dialysis, but the dialysis communication forms lacked this information. Interviews with the nursing staff and management revealed a similar lack of awareness and oversight. The Interim DON admitted that the admitting nurse was not strong and that a seasoned ADON had been hired to address these issues. However, the Interim DON had not conducted any training since taking the position. The facility's policies on dialysis vascular access methods and following physician orders were not adhered to, as evidenced by the lack of documentation and monitoring of post-dialysis vital signs for both residents. The failure to follow these policies could lead to serious health risks for the residents, including low blood pressure, bleeding, and shortness of breath. The nursing staff and management acknowledged the importance of these assessments but failed to implement them consistently.
Failure to Follow Pharmacist's Recommendations for Drug Regimen Review
Penalty
Summary
The facility failed to act upon the recommendations of the pharmacist regarding a drug regimen review (DRR) for a resident. Specifically, the facility did not follow up on a recommendation to attempt a gradual dose reduction (GDR) for the resident's psychotropic medication, Duloxetine HCl. The resident, who had multiple diagnoses including Type 2 diabetes mellitus with diabetic nephropathy, osteomyelitis, peripheral vascular disease, heart failure, and depression, had not had a GDR attempt since 05/26/23. The interim Director of Nursing (DON) acknowledged that the resident should have had a GDR attempt within the last six months, but this was not done due to the absence of a DON from October 2023 to February 2024. The facility's policy, revised in October 2018, requires monthly drug regimen reviews and timely follow-up on pharmacist recommendations. The interim DON stated that the Assistant Directors of Nursing (ADONs) were responsible for ensuring that the pharmacist's recommendations were given to the physician for approval and then uploaded to the resident's chart. However, this procedure was not completed during the period when there was no DON, leading to the risk of over-medication and not promoting the highest function of the resident with the lowest dosage of the drug. The failure to follow up on the pharmacist's recommendation for a GDR constitutes a deficiency in the facility's drug regimen review process.
Failure to Provide Working Call Light System for Resident
Penalty
Summary
The facility failed to provide a working call light system for a resident, which could delay or prevent the resident from calling for assistance. The resident, an elderly female with significant medical conditions including nontraumatic subarachnoid hemorrhage, cognitive communication deficit, essential hypertension, hemiplegia, and hemiparesis, was observed multiple times without a call light in her room. Interviews with staff revealed that the call light had been removed because the resident accidentally activated it frequently. Despite this, staff acknowledged that every resident should have a call light within reach, even if they are unable to use it. The Maintenance Director and Interim DON were unaware of the missing call light until it was pointed out during the survey. The resident's care plan indicated the need for a call light to be within reach to ensure a safe environment and to prevent falls. However, observations and interviews confirmed that the resident did not have a call light, and staff had not taken appropriate steps to address this issue. The facility's policy on call light response, which mandates that each resident should have a call light to call for assistance, was not followed. This deficiency was identified through a combination of observations, interviews, and record reviews, highlighting a significant lapse in ensuring resident safety and timely assistance.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near White Settlement
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Ridge Wellness & Rehabilitation | 1.1 mi | ★★★★★ | 2 | 0 |
| West Side Campus Of Care | 1.5 mi | ★★★★★ | 7 | 0 |
| Ridgmar Medical Lodge | 1.6 mi | ★★★★★ | 9 | 0 |
| Lake Lodge Nursing & Rehabilitation | 3.8 mi | ★★★★★ | 12 | 0 |
| Arlington Heights Health And Rehabilitation Center | 3.9 mi | ★★★★★ | 11 | 0 |
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