Windsor Nursing And Rehabilitation Center Of Wesla
Inspection history, citations, penalties and survey trends for this long-term care facility in Weslaco, Texas.
- Location
- 721 Airport Dr, Weslaco, Texas 78596
- CMS Provider Number
- 675363
- Inspections on file
- 25
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Windsor Nursing And Rehabilitation Center Of Wesla during CMS and state inspections, most recent first.
A resident admitted with severe cognitive impairment, multiple neurologic and metabolic diagnoses, and a gastrostomy feeding tube had enteral feeding orders and a baseline care plan documenting dependence on tube feeding, but no physician order was obtained for Enhanced Barrier Precautions (EBP) from admission through the initial days of stay. Interviews with the DON, ADON, and Administrator confirmed that a feeding tube is considered an indwelling or invasive device under facility policy and that such residents require an EBP order, and record review verified that no such order was present despite staff reportedly following EBP practices.
Surveyors found that a baseline care plan for a newly admitted, tube-fed resident with severe cognitive impairment and multiple neurologic and nutritional diagnoses failed to include enhanced barrier precautions (EBP), despite the presence of an indwelling feeding tube and active enteral feeding orders. The baseline care plan noted dependence on tube feeding and water flushes but indicated no special precautions were required, and leadership (DON, ADON, ADM) later acknowledged that EBP should have been documented for residents with feeding tubes. This omission did not align with the facility’s policy requiring baseline care plans within 48 hours of admission to include essential healthcare information needed for proper care.
A resident readmitted with rhino virus/possible flu and pneumonia was ordered droplet precautions, but the facility did not promptly post droplet/isolation signage or set up PPE at the room entrance. Some CNAs and nurses learned of the precautions only by verbal report, and at least one CNA provided early-morning incontinence care using only gown and gloves based on prior EBP status, unaware that mask and face shield were also required. Staff interviews showed confusion over who was responsible for initiating and posting precautions, and leadership confirmed that signs and PPE should have been in place upon admission per the infection prevention and control policy requiring transmission-based precautions consistent with CDC guidelines.
A resident with severe cognitive impairment and behavioral disturbances was placed on physician-ordered 1:1 observation every hour, but staff failed to document this monitoring for a six-hour period on the MAR. Although the assigned nurse stated the observation was performed, she did not sign the record as required by facility policy, and the DON confirmed the omission. The nurse had received recent documentation training, but the required entries were not made.
The facility's activities program was directed by an unqualified Activity Director who lacked required certification, experience, and enrollment in an approved program, as confirmed by record review and staff interviews. This deficiency affected all residents due to the absence of a qualified professional overseeing activities.
A resident with diabetes and peripheral arterial disease was admitted and began receiving insulin and anticoagulant medications per physician orders, but the baseline care plan developed within 48 hours did not include these essential medications. Staff interviews and record reviews confirmed the omission, which was contrary to facility policy and professional standards.
A resident with paraplegia and severe cognitive impairment, who was care planned for total dependence and required two-person assistance for bathing, was observed receiving a bed bath from only one CNA. Staff interviews revealed inconsistent understanding of when two-person assistance was needed, and facility leadership acknowledged the absence of a clear policy on supervision and CNA responsibilities for assist levels.
The facility did not provide RN coverage for the required 8 consecutive hours on one day, with only 3.91 hours of RN presence documented. The DON and Administrator acknowledged responsibility for ensuring RN coverage and stated that if the scheduled RN was unavailable, it was their duty to find coverage or cover the shift themselves. Facility policy requires 8 consecutive hours of RN coverage daily, including the DON's hours, but the lapse was not documented due to salaried staff not clocking in.
A resident with severe cognitive impairment and a history of schizoaffective disorder was administered risperidone without consistent documentation of an adequate medical indication in the official records. Although some notes referenced the diagnosis, it was not uniformly present in the medical record until the day of the survey, resulting in a failure to ensure the drug regimen was free from unnecessary drugs.
A resident with a history of schizoaffective disorder had inconsistent documentation in her clinical records, with some entries incorrectly listing schizophrenia as her diagnosis. This discrepancy appeared in the care plan, physician orders, and some NP notes, despite the primary care provider's diagnosis of schizoaffective disorder. The error resulted in incomplete and inaccurate medical records, not in accordance with professional standards.
A resident with a history of amputation and chronic pain missed multiple doses of prescribed Acetaminophen-Codeine when nursing staff failed to ensure the medication was available and instead administered Tylenol 500 mg without a proper order. The resident questioned the nurse about the medication, but was incorrectly assured it was the prescribed drug. The nurse did not notify supervisors or use the emergency medication supply, and the issue was only discovered after the resident filed a grievance.
A resident with a history of amputation and chronic pain did not receive the ordered Acetaminophen-Codeine for pain management, instead receiving Tylenol 500 mg without proper documentation or notification to supervisors. The LPN failed to update the MAR and did not inform staff about the medication shortage, resulting in incomplete and inaccurate medical records.
The facility failed to obtain signed and dated consents for psychotropic medications for three residents, leading to the administration of these medications without proper informed consent. The residents had various cognitive impairments and diagnoses, and the consents were either missing, signed by the wrong party, or undated.
The facility failed to maintain clinical records in accordance with accepted professional standards for three residents, as consent forms for antipsychotic and antidepressant medications were either missing, incomplete, or improperly signed by the residents instead of their responsible parties. The residents involved had significant cognitive impairments and complex medical histories.
The facility failed to maintain an infection prevention and control program, leading to incidents where an LVN did not change gloves between tasks, a resident on contact isolation lacked proper signage, and housekeeping staff entered without PPE. Additionally, there were no biohazard or soiled laundry bins in the isolation room.
A resident with COPD and respiratory failure received oxygen at 4.0 Lpm instead of the physician-ordered 2 Lpm. Despite ongoing monitoring, the incorrect setting was observed, and staff interviews confirmed that the resident sometimes adjusted the oxygen settings herself.
A deficiency was identified in the pharmaceutical services provided to a resident receiving Zoloft and olanzapine. The care plan required strict monitoring for adverse reactions due to serious risks associated with these medications. However, the report suggests potential lapses in adhering to these monitoring protocols, leading to the noted deficiency.
A resident with Alzheimer's and dementia was administered Risperdal twice daily for vascular dementia, contrary to facility policy and standard medical guidelines. Interviews with staff confirmed the improper use of antipsychotics for such diagnoses, and attempts to contact the prescribing NP and MD were unsuccessful.
The facility failed to provide a safe and functional environment, with issues including non-functioning cold water in a resident's bathroom and cigarette butt litter in the designated smoking area. The Maintenance Director forgot to turn the water valve back on after repairs, and the Housekeeping Manager lacked a tracking log for cleaning the smoking area.
A resident with moderate cognitive impairment eloped from the facility undetected on multiple occasions by removing her wander guard bracelet. Despite being placed on 1:1 supervision and having a new wander guard applied, the resident managed to elope again, posing a significant risk to her safety. The facility conducted in-services on elopement prevention, but the measures were insufficient to prevent the incidents.
Failure to Obtain Physician Order for Enhanced Barrier Precautions at Admission
Penalty
Summary
Surveyors identified a deficiency in that the facility failed to obtain physician orders for a resident’s immediate care related to Enhanced Barrier Precautions (EBP) at the time of admission. The resident was an older male admitted with multiple significant diagnoses, including cerebral infarction, metabolic encephalopathy, dysphagia, cognitive communication deficit, muscle wasting and atrophy, and gastrostomy status with a feeding tube in place. The resident’s MDS showed severe cognitive impairment with a BIMS score of 4 and documented use of a feeding tube on admission. The baseline care plan indicated the resident required tube feeding and was dependent on staff for tube feeding and water flushes, and the order summary reflected an active enteral feeding order starting on the admission date. Record review showed that from admission through several days afterward, there were no physician orders for EBP, despite the resident having a feeding tube, which the facility’s policy defined as an indwelling medical device requiring an EBP order. The DON stated that the resident required EBP since admission due to the feeding tube and acknowledged that no EBP order was in place, although staff were aware of and followed EBP. The ADON confirmed that residents with feeding tubes required EBP because the tube was an invasive device and that the team was supposed to review physician orders for accuracy. The Administrator also stated that residents with feeding tubes needed EBP orders and that the team reviewed new admission orders to ensure they were in place. The facility’s EBP policy specified that an order for EBP would be obtained for residents with wounds or indwelling medical devices, including feeding tubes, even if they were not known to be infected or colonized with MDROs.
Baseline Care Plan Omitted Enhanced Barrier Precautions for Tube-Fed Resident
Penalty
Summary
Surveyors identified a failure to develop and implement a complete baseline care plan within 48 hours of admission for one resident, specifically omitting enhanced barrier precautions (EBP) despite the presence of an indwelling device. The resident was an older male admitted with multiple diagnoses including cerebral infarction, metabolic encephalopathy, dysphagia, cognitive communication deficit, muscle wasting and atrophy, and gastrostomy status, and had a BIMS score of 4 indicating severe cognitive impairment. The MDS reflected use of a feeding tube on admission, and the order summary showed an active enteral feeding order with Glucerna 1.5 via feeding tube at a specified rate every shift. The baseline care plan documented that the resident required tube feeding and was dependent for tube feeding and water flushes, but directed staff to see orders for current feeding orders and did not include EBP. Interviews with facility leadership confirmed that the resident required EBP from admission due to the feeding tube being considered an indwelling or invasive device. The DON stated that the baseline care plan was completed within 48 hours and that she reviewed and signed it, but acknowledged that the section asking whether the resident required special precautions was marked “no,” resulting in EBP not being reflected on the baseline care plan. The ADON and ADM both stated that residents with feeding tubes should have EBP noted on the baseline care plan and that EBP should have been included for this resident. The facility’s Baseline Care Plans policy required development and implementation of a baseline care plan within 48 hours of admission that includes the minimum healthcare information necessary to properly care for a resident, but the omission of EBP from the resident’s baseline care plan did not meet this standard.
Failure to Implement and Communicate Droplet Precautions for an Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to fully implement droplet transmission-based precautions for a cognitively impaired male resident who was readmitted from the hospital with rhino virus/possible flu and pneumonia and required droplet precautions. The resident had multiple diagnoses including TIA, hypertension, dementia, and dysphagia, and was dependent on staff for all self-care. His care plan reflected Enhanced Barrier Precautions (EBP) for prior conditions, including use of gown and gloves for high-contact care and optional mask/eye protection as indicated. Upon readmission, baseline/readmission documentation and hospital paperwork indicated that he required droplet precautions, and a nursing progress note documented that he was on single-room isolation. Orders were entered for droplet precautions due to influenza. Despite this, surveyor observation on the morning after readmission showed that there was no droplet/isolation sign posted at the resident’s door and no PPE set up outside the room until after 8:40 a.m., when staff were seen placing the sign and hanging PPE. Multiple CNAs and nurses reported that, although some staff verbally knew the resident was on droplet precautions and individually obtained PPE from carts or the nurses’ station, the standardized visual cues and room setup (signage and PPE station) were not in place during the night and early morning. One CNA reported providing incontinence care around 6:30 a.m. wearing only gown and gloves based on the resident’s prior EBP status and stated she was not informed of droplet isolation until later that morning; she also reported having entered multiple rooms and assisted with breakfast before learning of the droplet status. Another CNA assigned to the hallway overnight stated there were no isolation signs or PPE set up at the door while she worked, although she personally used mask, shield, gown, and gloves based on verbal report. Interviews with nursing staff and leadership revealed inconsistent understanding and execution of responsibilities for initiating and posting droplet precautions. One LVN who assisted with admission stated she knew from hospital report that the resident was on droplet precautions and used full PPE for the skin assessment but did not place signs or PPE at the door and could not recall if they were present. Another LVN on night shift stated she was aware of the droplet order, wore appropriate PPE, and verbally informed CNAs and a lab technician, but confirmed that signs and PPE were not posted at the door and cited limited access to certain supplies at night. A day-shift RN acknowledged that when he arrived, there were no precautions posted and that the admitting nurse was responsible for setting them up. The DON and Administrator both stated that when a resident is admitted or readmitted on droplet precautions, appropriate signage and PPE should be in place immediately based on hospital report and that nurses are responsible for clarifying isolation type and informing staff. The facility’s infection prevention and control policy requires that residents with communicable diseases be placed on transmission-based precautions per CDC guidelines and that staff use PPE according to policy, but in this case, the facility did not ensure that all staff were informed of the resident’s droplet status and did not ensure that droplet precaution signage was posted at the room entrance during the period the resident was on droplet precautions.
Failure to Document Physician-Ordered 1:1 Observation in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who had physician orders for 1:1 constant observation every hour due to aggressive behaviors associated with vascular dementia and psychosis. The resident's care plan and physician orders specified that hourly monitoring was required, including during all activities, toileting, and sleeping, for a period of 72 hours. However, review of the Medication Administration Record (MAR) revealed that documentation of this monitoring was missing for a six-hour period on a specific date. Interviews with staff indicated that the assigned nurse was responsible for both performing and documenting the 1:1 observation during the time in question. The nurse confirmed that the monitoring was completed but acknowledged that she did not sign the MAR as required by facility policy, which states that documentation should be completed at the time of service. The nurse also stated that she believed another nurse might sign off, but clarified that the person performing the monitoring should be the one to document it. The Director of Nursing (DON) confirmed the omission on the MAR and stated that the facility's policy requires timely and accurate documentation of care. The DON also noted that monitoring was performed during the unsigned period, but the lack of documentation meant there was no official record of compliance with the physician's order. Facility records showed that the nurse responsible had received recent training on documentation, but the required entries were still not made in this instance.
Unqualified Activity Director Leads to Deficiency in Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by regulations. Record review showed that the current Activity Director (AD) was not certified and did not meet the state requirements for the position, which include being licensed or registered, eligible for certification as a therapeutic recreation specialist or activities professional, having two years of relevant experience, or being a qualified occupational therapist or occupational therapy assistant. The AD had no previous experience in the role and had not yet enrolled in an approved AD program, despite being hired several months prior. The AD stated she had submitted paperwork and fees to enroll in an online program but was not officially enrolled as of the date of the survey. Interviews with the HR Coordinator and Administrator confirmed that the AD was not certified and had not met the qualifications outlined in the facility's job description or state requirements. The Administrator acknowledged responsibility for ensuring the AD enrolled in a program within six months of hire, as stipulated in a written agreement, but this had not occurred by the time of the survey. The facility did not have a policy on the requirements for an AD, only a job description, and all 61 residents were affected by the lack of a qualified professional directing the activities program.
Failure to Include Essential Medications in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included essential medication instructions for a resident within 48 hours of admission, as required by facility policy. Specifically, the baseline care plan for a female resident with multiple diagnoses, including Type 2 Diabetes Mellitus and Peripheral Arterial Disease, did not include her prescribed insulin and anticoagulant medications, despite physician orders and administration records confirming their use. The omission was confirmed through record review and interviews with staff, including the MDS nurse, LVN, and DON, all of whom acknowledged that such medications should be included in the baseline care plan to ensure proper care. The resident's admission records indicated she was cognitively intact and had significant medical needs requiring careful medication management. The facility's own policy and staff interviews confirmed that baseline care plans must include all necessary medications and be completed within 48 hours of admission. However, the review of the resident's baseline care plan showed that insulin and anticoagulant medications were not documented, and this was acknowledged by the DON during the survey. The failure to include these medications in the baseline care plan constituted a deficiency in meeting professional standards of quality care.
Failure to Provide Required Two-Person Assistance During Bed Bath
Penalty
Summary
A deficiency occurred when a resident with paraplegia, severe cognitive impairment, and total dependence for bathing was given a bed bath by only one CNA, despite her care plan and MDS assessment specifying the need for assistance from two staff members. The resident was observed receiving a bed bath from a single CNA, with the resident uncovered and the bath water present, confirming that the care was being provided by only one staff member at that time. Interviews with the CNA involved and other staff confirmed that the resident was known to require two-person assistance due to her physical and behavioral needs, including a history of hitting and kicking during care. Staff interviews revealed inconsistent understanding and practices regarding when two-person assistance was required. Some CNAs relied on the Kardex, care plan, or verbal instructions from nurses to determine the level of assistance needed, while others mentioned that the need for two-person assistance could depend on the resident's behavior at the time. There was also uncertainty about the frequency and content of in-service training related to one- or two-person assists, with some staff recalling recent training and others unsure about when it last occurred. The facility's leadership, including the DON and Administrator, confirmed that the care plan and Kardex should be checked to determine the required level of assistance, and that nurses are responsible for monitoring and communicating changes to CNAs. However, it was noted that there was no specific policy on supervision, use of the Kardex, or CNA responsibilities regarding one- or two-person assists. This lack of clear policy and inconsistent staff practices led to the resident not receiving the required level of supervision and assistance during a bed bath.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours on one day during the review period. Record review of RN timesheets showed that on a Saturday, the facility only had RN coverage for 3.91 hours instead of the required 8 consecutive hours. The Director of Nursing (DON) acknowledged responsibility for ensuring RN coverage and stated that if the scheduled RN was unavailable, it was her or the Assistant Director of Nursing's (ADON) responsibility to find coverage or cover the shift themselves. However, the DON could not recall the specific circumstances that led to the shortfall on the identified day and noted that if she or the ADON had covered the remainder of the shift, it would not have been documented since they are salaried and not required to clock in. The facility's policies require RN coverage for at least 8 consecutive hours per day, 7 days a week, and include the DON's hours toward this requirement. Both the DON and the Administrator confirmed their understanding of the policy and acknowledged the potential for certain RN-specific tasks to go unperformed when coverage is lacking. The Administrator also stated that it was ultimately her responsibility to ensure compliance with RN staffing requirements and that the facility had sufficient RNs to meet the coverage requirement, despite the documented lapse.
Failure to Ensure Drug Regimen Free from Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of risperidone (Risperdal), an antipsychotic medication. The resident in question was an elderly female with diagnoses including paraplegia, mood disorder, and schizoaffective disorder. Her medical records, including the face sheet and MDS assessment, reflected severe cognitive impairment and the use of antipsychotic and antidepressant medications. The care plan documented the use of Risperdal for symptoms related to schizophrenia, such as mood changes and yelling, and included monitoring for adverse reactions and pharmacy review per facility policy. Upon review, it was found that the medical diagnosis supporting the use of Risperdal was inconsistently documented. While the care plan and some physician notes referenced schizophrenia or schizoaffective disorder, the official medical diagnosis in the resident’s records did not consistently reflect this until the day of the survey. The nurse practitioner and DON confirmed that the diagnosis of schizophrenia was only present in certain notes and the order entered into the electronic charting system, but not in other official paperwork. The diagnosis was added to the medical record on the day of the survey, and the nurse practitioner clarified that the correct diagnosis should be schizoaffective disorder, as originally given by the primary care provider. Interviews with facility staff, including the DON and LVN, revealed that medication orders are entered and double-checked by nursing staff, but if the wrong diagnosis is entered, it could result in an inappropriate medication regimen. The lack of a consistent and adequate indication for the use of Risperdal in the resident’s official medical record led to the finding that the facility failed to ensure the resident’s drug regimen was free from unnecessary drugs.
Inaccurate Documentation of Psychiatric Diagnosis in Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident diagnosed with schizoaffective disorder. Documentation inconsistencies were found in the resident's medical record, with some parts inaccurately listing schizophrenia as the diagnosis instead of schizoaffective disorder. The resident's face sheet and several clinical assessments correctly identified schizoaffective disorder, but the care plan, physician orders, and some nurse practitioner notes referenced schizophrenia. The discrepancy was confirmed during interviews with the DON and NP, who acknowledged that the original diagnosis was schizoaffective disorder, but schizophrenia had been documented in various parts of the record, including the care plan and medication orders. This documentation error resulted in the resident's clinical records not being maintained in accordance with accepted professional standards and practices. The resident, who had a history of paraplegia, mood disorder, and schizoaffective disorder, was receiving antipsychotic medication (Risperdal) for her condition. The inaccurate documentation could affect the appropriateness of care provided, as the care plan and medication orders were not aligned with the resident's actual diagnosis as established by the primary care provider.
Failure to Provide Prescribed Pain Medication Due to Lapses in Pharmaceutical Services
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident with a history of left below-knee amputation, peripheral vascular disease, type 2 diabetes with hyperglycemia, and cellulitis. The resident had an active order for Acetaminophen-Codeine Tablet 300-30 mg to be administered every six hours for pain, but missed three doses due to the medication not being available. Nursing staff did not ensure the prescription was filled in a timely manner, and the resident was instead given Tylenol 500 mg without a corresponding order being entered into the electronic medical record. The resident reported being in pain and questioned the nurse about the medication provided, noting that the pill given did not match the usual appearance of his prescribed pain medication. Despite the resident's repeated inquiries, the nurse assured him it was the correct medication. The nurse later admitted to giving Tylenol 500 mg instead of the prescribed Acetaminophen-Codeine and signing off on the medication administration record for the wrong medication. The nurse also failed to notify supervisors or access the emergency medication supply system (cubex) when the prescribed medication was unavailable. Interviews with facility staff revealed that the process for reordering controlled medications required a new prescription from the prescriber, and that staff were trained to access emergency supplies or notify supervisors if medications were not available. However, in this instance, the nurse did not follow these procedures, resulting in the resident missing prescribed doses and receiving an unprescribed substitute medication. The incident was only brought to the attention of facility leadership after the resident filed a grievance.
Failure to Accurately Document and Administer Ordered Pain Medication
Penalty
Summary
A deficiency occurred when a resident with a history of left below-knee amputation, peripheral vascular disease, type 2 diabetes with hyperglycemia, and cellulitis of the right lower limb did not have complete and accurate documentation of medication administration. The resident had a physician's order for Acetaminophen-Codeine Tablet 300-30 mg to be given every six hours as needed for pain, but missed three doses over two days. The Medication Administration Record (MAR) did not accurately reflect the administration of the ordered medication, and the resident reported receiving a different medication than what was prescribed. The resident reported experiencing significant pain and requested his usual pain medication, but was given Tylenol 500 mg instead of the ordered Acetaminophen-Codeine. The nurse administering the medication confirmed she provided Tylenol 500 mg because the prescribed medication was not available, and she did not inform anyone about the shortage or document the administration of Tylenol 500 mg in the MAR. The nurse also mistakenly signed off in the MAR as if the resident had received the Acetaminophen-Codeine, and failed to add the Tylenol 500 mg order to the electronic medical record. Interviews with facility staff revealed that the nurse did not access the emergency medication supply system or notify supervisors about the unavailability of the prescribed medication. The Director of Nursing and the administrator were not aware of the incident until the resident filed a grievance. The facility's policy required medications to be administered as ordered and documented accurately, but this was not followed in this case, resulting in incomplete and inaccurate medical records for the resident.
Failure to Obtain Proper Medication Consents
Penalty
Summary
The facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for three residents who were reviewed for resident rights. Specifically, Resident #36 did not have signed and dated consents for psychotropic medications such as Risperdal, clonazepam, buspirone, fluvoxamine, or Wellbutrin XL ER. The consent for Risperdal was signed by the resident instead of the responsible party (RP) and was not dated. This oversight was noted despite the resident having a diagnosis of Alzheimer's Disease, dementia, and other conditions that impair cognition, as indicated by a BIMS score of 09, showing moderately impaired cognition. Similarly, Resident #7 did not have signed and dated consents for psychotropic medications including clonazepam, buspirone, Seroquel, Paxil, and Trazadone. The consents were signed by the resident instead of the RP and were undated. Additionally, there was no consent form for clonazepam. Resident #7 had a diagnosis of chronic obstructive pulmonary disease (COPD), respiratory failure, hypertension, chronic kidney disease, schizophrenia, type 2 diabetes mellitus, and epilepsy, with a BIMS score of 09, indicating moderately impaired cognition. Resident #38 also did not have properly completed consent forms for antipsychotic and antidepressant medications. The consent form for Olanzapine did not have the medication name, was not dated, and was signed by the resident who had a responsible party and was cognitively unable to sign the consent form. There was no consent form for Zoloft. Resident #38 had diagnoses including bipolar disorder and major depressive disorder, with a BIMS score of 00, indicating severe cognitive impairment. Interviews with the DON and LVN B revealed that the process for obtaining and documenting consents was not consistently followed, leading to these deficiencies.
Failure to Maintain Proper Consent Forms for Medications
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for three residents reviewed for pharmacy services. Specifically, the facility did not ensure that consent forms were properly completed or signed by a responsible party prior to the administration of antipsychotic and antidepressant medications. This deficiency was identified for three residents, each with significant cognitive impairments and complex medical histories, including bipolar disorder, major depressive disorder, Alzheimer's disease, and schizophrenia. For Resident #38, the facility did not have a consent form for the medication Zoloft, and the consent form for Olanzapine was incomplete, lacking the medication name, date, and proper signature from the responsible party. Resident #38 had severe cognitive impairment and was unable to provide informed consent, yet the consent form was signed by the resident instead of the responsible party. The responsible party for Resident #38 confirmed that they were not aware of signing any consent forms for the medications. Resident #36's records revealed that consent forms for multiple medications, including Fluvoxamine, Bupropion, Clonazepam, and Wellbutrin, were either missing or improperly signed by the resident instead of the responsible party. Similarly, Resident #7's consent forms for several medications, including Buspirone, Clonazepam, Seroquel, Paxil, and Trazadone, were signed by the resident and not the responsible party, with some forms undated. The Director of Nursing acknowledged the oversight and indicated that consent form audits were conducted monthly but would now be performed weekly. However, there was no policy in place for consent forms at the time of the survey.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies. One incident involved an LVN who did not change gloves after touching a resident's remote before performing a glucose check and administering insulin. This failure to follow proper hand hygiene and glove-changing protocols was acknowledged by the LVN and the DON, who both recognized the risk of cross-contamination and infection spread due to these actions. Another deficiency was observed with a resident who was supposed to be on contact isolation due to an ESBL urinary tract infection. The facility did not place the required contact precautions signage outside the resident's room, and housekeeping staff entered the room without donning PPE. The housekeeping staff member admitted to forgetting to wear PPE and was unaware of the potential consequences. Additionally, there were no biohazard or soiled laundry bins in the resident's room to dispose of PPE and soiled linens, which was confirmed by the Housekeeping Manager and the DON. The facility's infection prevention and control program, as outlined in their policy, mandates the use of PPE, adherence to safe injection practices, and proper isolation protocols. However, the observed deficiencies indicate a failure to implement these policies effectively. Staff interviews revealed a lack of awareness and adherence to these protocols, contributing to the risk of infection spread within the facility.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided with professional standards of practice. Specifically, Resident #7's oxygen was administered at 4.0 Lpm instead of the physician-ordered 2 Lpm via nasal cannula. This discrepancy was observed on 03/26/24 when the resident's oxygen concentrator was set at 4 Lpm, despite the order for 2 Lpm. Interviews with the nursing staff revealed that Resident #7 sometimes adjusted the oxygen settings herself, and the nurses were continually monitoring it. However, the incorrect setting was still found during the surveyor's observation. Resident #7, a [AGE] year old female with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure, was admitted to the facility on 12/22/22. Her care plan included interventions for respiratory distress and oxygen use as ordered. Despite these measures, the facility's failure to maintain the correct oxygen setting as per the physician's order was evident. The Director of Nursing (DON) confirmed that oxygen settings are checked by nurses every shift, but the discrepancy in oxygen administration was still noted, indicating a lapse in adherence to the prescribed care plan.
Deficiency in Pharmaceutical Services and Monitoring
Penalty
Summary
The report identifies a deficiency in the pharmaceutical services provided to a resident who is receiving antidepressant medication (Zoloft) for major depressive disorder and antipsychotic medication (olanzapine) for bipolar disorder. The care plan includes administering these medications as ordered by the physician and monitoring for side effects and effectiveness every shift. However, the report highlights the presence of black box warnings for both medications, indicating serious risks such as increased suicidality in young adults for Zoloft and increased mortality in elderly patients with dementia-related psychosis for olanzapine. The care plan also includes detailed instructions for monitoring and documenting adverse reactions, but it is unclear if these protocols were adequately followed or if the necessary monitoring was consistently performed, leading to the deficiency noted by the surveyors. The resident's care plan specifies the need to monitor and report any adverse reactions to the medications, including changes in behavior, mood, cognition, and physical symptoms such as unsteady gait, muscle cramps, and gastrointestinal issues. The report does not provide specific instances of adverse reactions or failures in monitoring but emphasizes the critical nature of these monitoring activities due to the severe risks associated with the medications. The deficiency appears to stem from potential lapses in adhering to the care plan's requirements for vigilant monitoring and documentation of the resident's response to the medications, which is essential for ensuring their safety and well-being.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, specifically for one resident who was administered Risperdal, an antipsychotic medication, twice daily for vascular dementia. The resident, a male with a diagnosis of Alzheimer's Disease and dementia, was admitted to the facility and had a BIMS score indicating moderately impaired cognition. Despite the facility's policy against using psychotropic drugs unless necessary to treat a specific condition, the resident's care plan included Risperdal for vascular dementia, which is not an appropriate indication for antipsychotic use according to the facility's policy and standard medical guidelines. Interviews with facility staff, including an LVN and the DON, confirmed that antipsychotics should not be prescribed for residents with Alzheimer's or dementia due to the associated risks and black box warnings. The facility's records showed that the resident received Risperdal consistently from February through March, and attempts to contact the prescribing NP and MD for clarification were unsuccessful. The facility's policy on psychotropic medication, implemented in August 2022, was not adhered to in this case, leading to the administration of an unnecessary drug to the resident.
Environmental Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to provide a safe and functional environment for residents, staff, and the public in one of the resident rooms and the designated smoking area. Specifically, the cold water in a resident's bathroom was not functioning due to the Maintenance Director forgetting to turn the valve back on after repairs. The ADON, who was responsible for checking the functionality of the water, verbally informed the Maintenance Director but did not input a work order into the system. The resident affected did not notice the lack of cold water and stated it did not affect him. The Administrator confirmed there was no policy on the environment. Additionally, the designated smoking area was found to be littered with cigarette butts in a trash can and a planter pot, which were not the designated disposal areas. The trash can was rusted and lacked a functioning lid. The Maintenance Director and Housekeeping Manager acknowledged the issue, with the Housekeeping Manager stating that the area is cleaned every other day but without a tracking log. The Administrator confirmed that housekeeping is responsible for cleaning the area twice a week and acknowledged the absence of a check-off list for documentation.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who eloped from the facility undetected on multiple occasions. Resident #44, who had a history of moderate cognitive impairment and various medical conditions, was able to remove her wander guard bracelet and exit the facility on two separate occasions. The first elopement occurred on 05/05/23, when the resident was found walking outside the facility by a dietary aide and was subsequently redirected back inside by an LVN. Despite being placed on 1:1 supervision for 72 hours and having a wander guard bracelet applied, the resident managed to elope again on 06/24/23 and 06/26/23 by removing the bracelet undetected each time. On 06/24/23, Resident #44 was found outside the building in the front patio without her wander guard bracelet, which she had placed in a drawer. A new wander guard was applied, but the resident eloped again on 06/26/23 and was found approximately 0.2 miles away from the facility by a busy intersection. The facility staff, including the DON and LVNs, conducted interviews and reviewed records, but were unable to determine how the resident managed to remove the wander guard bracelet. The resident was placed on 1:1 supervision for another 72 hours following the second elopement. The facility conducted in-services with staff on elopement prevention and monitoring residents with exit-seeking behaviors. Despite these measures, the facility's failure to provide adequate supervision and ensure the effectiveness of the wander guard bracelet led to multiple elopements by Resident #44, posing a significant risk to her safety. The resident was eventually discharged home with family on 06/27/23 after the second elopement incident.
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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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