Alfredo Gonzalez Texas State Veterans Home

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to the State Survey Agency (HHSC) and appropriate officials within the required two-hour timeframe. A male resident with Alzheimer’s disease, schizoaffective disorder, anxiety, depression, and muscle weakness, and with a BIMS score of 02 indicating severe cognitive impairment and a history of physical behaviors toward others, hit another male resident’s hand with an empty water bottle. The second resident had unspecified dementia, anxiety, restlessness/agitation, muscle wasting and atrophy, and a BIMS score of 00 indicating severe cognitive impairment, and did not have a history of physical or verbal behavioral symptoms toward others. The incident occurred in the morning, and the administrator, who served as the abuse coordinator, was notified of the event at approximately 10:45 AM. The facility’s policy, revised in January 2024, required that all alleged or suspected abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property be reported immediately, but not later than two hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The administrator acknowledged that the incident between the two residents met criteria for reporting within two hours, but she did not report it to HHSC until 2:26 PM, exceeding the required timeframe. She stated that the delay occurred because she was conducting interviews and gathering information. Progress notes for both residents on the date of the incident documented head-to-toe assessments with no new skin abnormalities, no signs or symptoms of emotional distress or pain, and subsequent observations showed no visible injuries and that both residents were not in distress; however, the reporting requirement was still not met as specified by facility policy and regulatory expectations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a resident from abuse and to implement adequate protective interventions after a reported resident‑to‑resident physical altercation. One male resident with dementia, severe cognitive impairment (BIMS score 04), generalized anxiety disorder, major depressive disorder, and a history of verbal aggression toward staff and other residents was sharing a room with another male resident with Alzheimer’s disease and moderate cognitive impairment (BIMS score 11). The cognitively impaired aggressive resident had documented episodes of verbal aggression toward staff and residents in the months prior to the incidents, including multiple resident‑to‑resident verbal aggression events. The roommate had a history of some anger issues at home per family, but non‑physical. On the morning of 02/07/26, staff reported a resident‑to‑resident altercation at the doorway of the shared room. CNA A stated she saw the aggressive resident holding the roommate’s shirt and striking him with a closed fist once to the jaw and once to the chest while the roommate was in his wheelchair trying to exit the room. CNA A reported this to LVN B, including her concern that the two residents could not safely remain together and that the aggressive resident could attack or even kill the roommate. LVN B assessed the roommate, documented that he denied being hit and had no injuries or emotional distress, and documented that the aggressive resident did not recall the incident and had no injuries. The DON and Administrator were notified, but no abuse investigation was initiated because the roommate denied being hit, and the facility relied on his denial despite CNA A’s eyewitness account. The facility did not separate the residents or change rooms; instead, they intermittently monitored and alternated the residents’ presence in the room, with only brief or inconsistent staff presence outside the door and no formal, continuous monitoring documentation during the night shift. In the early morning hours of 02/08/26, a second, more serious altercation occurred between the same two residents. At approximately 4:00 a.m., staff responded to calls for help and found the roommate on the floor with the aggressive resident standing nearby; another CNA reported seeing the aggressive resident holding a bedside table at his waist and later heard him say he would hit the roommate again. Nursing staff assessments documented skin tears to both antecubital areas and the right knee, as well as redness on the bridge of the nose. The roommate stated that the aggressive resident had grabbed him by the arms and pushed him to the floor, and another nurse documented that the roommate reported being pulled from his wheelchair to the floor. Both residents were sent to the hospital for evaluation. The facility’s DON later acknowledged that, in response to the first incident, they had only implemented limited monitoring as reflected in the chart, did not conduct an abuse investigation because the roommate denied being hit, did not perform a room change, and that the second incident could have been prevented had monitoring and protective measures been continued and fully implemented. The surveyors determined that the facility failed to ensure residents were free from abuse and failed to protect the roommate after the initial reported physical altercation, resulting in a second incident with documented injuries and constituting past noncompliance at the Immediate Jeopardy level from 02/07/26 to 02/08/26. The noncompliance was identified as past noncompliance with Immediate Jeopardy beginning on 02/07/26 and ending on 02/08/26. The facility’s failure to protect residents from abuse and to follow its abuse policy for protection during an investigation could place residents at risk of physical harm, mental anguish, and emotional distress. The DON stated that not implementing the abuse policy for protection of residents could negatively impact residents because it could cause injury, and in this case, the only negative impact identified for the roommate was superficial skin tears. The Administrator and DON both confirmed that, at the time of the first incident, they did not identify the event as abuse due to the roommate’s denial of being hit, did not initiate a formal abuse investigation, and relied on limited monitoring rather than separation or one‑to‑one supervision, which did not prevent the second altercation and resulting injuries.

Removal Plan

• Changed Resident #1’s room
• Implemented 15-minute observation checks for Resident #1
• Sent Resident #1 out of the facility
• Implemented a resident-to-resident behavior monitoring tool to identify residents with incidents/behaviors and document corrective actions taken
• Held an ADHOC QAPI meeting addressing the resident-to-resident incident
• Updated Resident #1 care plan to address resident-to-resident aggression
• Updated Resident #2 care plan to address resident-to-resident altercations
• Reviewed care plans for additional identified residents with behaviors to ensure behaviors and interventions were addressed
• Coordinated psychiatric nurse practitioner involvement via email communications identifying residents with behaviors and follow-up
• Ensured psychiatry evaluations occurred for residents with behaviors
• Conducted facility-wide in-service training for all team members on immediate reporting of abuse/injury/neglect/exploitation to the Administrator, reporting resident-to-resident aggression/inappropriate touching, redirecting and keeping residents safe, and placing residents on one-to-one monitoring and keeping them separated
• Provided additional staff training and awareness on immediately reporting abuse to the Administrator and separating residents and implementing one-to-one monitoring after resident-to-resident altercations
• Provided abuse guidance training to the DON and Administrator

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, specifically in relation to resident-to-resident aggression. Resident #1, an elderly male with dementia, severe cognitive impairment (BIMS score of 4), generalized anxiety disorder, major depressive disorder, and insomnia, had a documented history of verbal aggression toward staff and other residents. His care plan reflected multiple episodes of resident-to-resident and resident-to-staff verbal aggression prior to the incidents in question. Resident #2, an elderly male with Alzheimer’s disease and moderate cognitive impairment (BIMS score of 11), also had documented behavioral symptoms, including physical and verbal behaviors directed toward others. On 02/07/26, a resident-to-resident altercation occurred between Resident #1 and Resident #2 at the entrance to their shared room. CNA A reported seeing Resident #1 holding Resident #2’s shirt and striking him with a closed fist once in the jaw and once in the chest while Resident #2 was in his wheelchair attempting to exit the room. CNA A stated she yelled for them to stop and called for help, after which LVN B assisted in separating the residents and took Resident #2 to the common area. CNA A reported to LVN B that she had witnessed the punches and warned that the two residents could not safely remain together because Resident #1 was aggressive and could attack Resident #2. LVN B assessed Resident #2, documented no injuries or pain, and recorded that Resident #2 denied being hit and stated only his wheelchair was struck. The DON and Administrator were notified of the incident and of CNA A’s report that Resident #1 had hit Resident #2, but no abuse investigation was initiated because Resident #2 denied being hit. Following the first incident, the facility’s response consisted of limited and inconsistently implemented monitoring. CNA A reported she was posted outside the room for about 10 minutes and did not see anyone else sit outside the room afterward. The DON and RN F stated that monitoring and having an aide posted outside the door were used, but the DON acknowledged there was no documentation of monitoring during the night shift and that the only monitoring was what appeared in the chart. No room change or one-to-one supervision was implemented at that time, and the residents continued to share a room. On 02/08/26 at approximately 4:00 a.m., a second incident occurred in which Resident #2 was found on the floor with bilateral arm and right knee skin tears and redness to the bridge of his nose. Staff interviews and documentation indicated that Resident #2 stated his roommate had grabbed him by the arms and pushed him to the floor, and another aide reported seeing Resident #1 standing over Resident #2 holding a bedside table and saying he would hit him again. Both residents were sent to the hospital for evaluation. The DON later stated that because Resident #2 denied being hit after the first incident, the facility did not initiate an abuse investigation and only implemented limited monitoring, and further acknowledged that the second incident could have been prevented had monitoring been continued. This sequence of events demonstrated the facility’s failure to fully implement its abuse policy requiring protection of residents from harm during abuse investigations and prevention of occurrences of abuse.

Removal Plan

• Completed a room change for Resident #1.
• Implemented 15-minute observation checks for Resident #1.
• Sent Resident #1 out of the facility and cancelled the bed hold.
• Implemented a monitoring tool to identify residents with resident-to-resident behaviors and document actions taken to correct behaviors.
• Held an ADHOC QAPI meeting addressing the resident-to-resident incident.
• Updated Resident #1’s care plan to address resident-to-resident aggression.
• Updated Resident #2’s care plan to address resident-to-resident altercations.
• Reviewed and updated care plans for additional identified residents with behaviors with interventions to address behaviors.
• Coordinated psychiatric nurse practitioner involvement to identify residents with behaviors and follow up.
• Ensured psychiatric evaluations occurred for residents with behaviors.
• Conducted facility-wide in-service training for all team members on immediate reporting of abuse, injury, neglect, and exploitation to the Administrator; reporting resident-to-resident aggression and inappropriate touching; redirecting and keeping residents safe; placing residents on one-to-one monitoring; and keeping residents separated.
• Trained staff to report abuse immediately to the Administrator and to separate residents and implement one-to-one monitoring with any resident-to-resident altercation.
• Trained the DON and Administrator on the abuse guidance policy for preventing, identifying, and reporting.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices by not completing and documenting weekly skin assessments as required by facility policy and physician orders. The resident was an elderly female with epilepsy, dysphagia following a nontraumatic intracerebral hemorrhage, age-related physical debility, and a cognitive communication deficit, with a BIMS score indicating moderate cognitive impairment. Her care plan identified her as having actual or at risk for skin impairment related to incontinence and dependence on staff for toileting and mobility, and included an intervention to follow the facility’s practice for assessing skin and following the skin protocol. Her MDS indicated no current pressure ulcers, venous or arterial ulcers, or other wounds, and a prior skin and wound evaluation documented a healed surgical incision. The resident had an order for weekly skin checks that was discontinued on 09/11/25 and not reordered until 02/24/26, leaving a gap during which no weekly skin assessment orders were in place. Record review showed that her last documented skin and wound evaluation form was completed on 09/30/25, and the DON confirmed that staff had not been doing skin assessments on this resident since sometime in September 2025. The facility’s Skin and Wound Prevention and Management policy required a licensed nurse to conduct and document a routine weekly skin assessment to identify new pressure injuries or other skin concerns, but this was not done for the resident during the identified period. The DON acknowledged that it was not identified that the resident lacked skin assessment orders and that the RN supervisor and DON were responsible for ensuring orders and documentation were in place, and stated that this failure could negatively impact residents by leaving issues untreated in a timely manner.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary antipsychotic medication. A male resident with severe dementia, generalized anxiety disorder, major depressive disorder without psychotic features, and insomnia was admitted and later discharged from the facility. His Quarterly MDS showed severe cognitive impairment with a BIMS score of 4, no indicators of psychosis, and only limited behavioral symptoms. Despite this, the MDS reflected that he was taking an antipsychotic with an indication noted. The care plan initiated in early September documented a focus on antipsychotic medication related to major depressive disorder and insomnia due to another mental disorder. A consent form for Seroquel 200 mg at bedtime was signed by the responsible party and completed by a physician, listing diagnoses including severe dementia with agitation, major depressive disorder without psychotic features, late-onset Alzheimer’s disease, and unspecified anxiety disorder. The resident’s order summary showed Seroquel 200 mg by mouth at bedtime for dementia with severe agitation and unspecified anxiety disorder, with administration documented on the MAR from early to late January. An order for antipsychotic side effect monitoring every shift was also in place. During interviews, the DON stated that antipsychotics such as Seroquel were not indicated for dementia and was unable to explain why or what negative impact they could have. She reported that the diagnosis associated with Seroquel was later changed to insomnia and that the resident was receiving Seroquel for insomnia, anxiety, and major depressive disorder. A PA stated that the resident was also followed by a mental health provider and that antipsychotics should be used carefully in the elderly, noting both potential benefits and negative impacts. The facility’s policy on psychotropic medication and gradual dose reduction stated that physicians and mid-level providers would use psychotropic medications appropriately with interdisciplinary team involvement, but the survey findings concluded there was not an adequate indication for the use of Seroquel before its administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident abuse incident to the state agency and appropriate officials within the required 2-hour timeframe. On the date in question, Resident #2 was found on the floor of his room at approximately 4:00 a.m., calling for help. A CNA entered the room and found Resident #2 on the floor with skin tears on both arms and the right knee. Resident #2 stated that his roommate, Resident #1, had pushed or pulled him down. Nursing documentation by LVN D and RN J identified bilateral antecubital skin tears, a right knee skin tear, and a red discoloration on the bridge of the nose, with Resident #2 reporting arm pain but denying emotional distress. Resident #2 was assessed, transferred to the hospital, and later returned with no fractures or critical findings noted in the hospital records. Resident #1’s records showed a history of dementia with severe cognitive impairment (BIMS score of 4), generalized anxiety disorder, major depressive disorder, and insomnia, with documented episodes of verbal aggression toward staff and other residents, and prior resident-to-resident verbal aggression. The care plan and IDT documentation reflected multiple prior behavioral incidents, including resident-to-resident verbal aggression on several dates and an entry on the date of the incident indicating resident-to-resident physical and verbal aggression. An IDT ABC tool completed by LVN D on the date of the incident documented that at 4:00 a.m. Resident #1 was standing over his roommate with a table and was upset, stating he would hit the roommate again. Resident #2’s records reflected Alzheimer’s disease with moderate cognitive impairment (BIMS score of 11) and a history of behavioral symptoms, including physical and verbal behaviors directed toward others. His care plan noted prior resident-to-resident physical altercations on the day before and the day of the incident. The Administrator, who served as the abuse coordinator, stated she was notified by LVN D at approximately 5:00 a.m. of the altercation and injuries but did not report the allegation to HHSC until 5:00 p.m., well beyond the 2-hour requirement. She acknowledged that the altercation should have been reported within 2 hours and that facility policy, consistent with HHSC PL 19-17, required alleged or suspected abuse to be reported immediately, but not later than 2 hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The Administrator stated she reported late because she was busy conducting interviews.

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Resident #42 had the call light within reach while in bed in his room. Resident #42 was admitted on 1/07/2025 with diagnoses including Parkinson's Disease, Diabetes Mellitus Type 2, and Alzheimer's Disease. His quarterly MDS reflected a BIMS score of 3, indicating severe cognitive impairment, and Section GG showed he was dependent for eating, oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. On 1/05/2026, observation showed the resident's call light device hanging low on the bedside rail and he was unable to reach it. During interview, a CNA stated the resident could not reach the call light, used it when he needed assistance, and that it was supposed to be within reach because he required total assistance with care. An LVN stated that if the resident needed something, he would not be able to notify staff, and said she checked that call lights were within reach during rounds. Later, the resident stated that if the call light was not within reach, he would just have to do without and said it would work better if clipped to his gown. The DON stated on 1/07/2026 that there was no policy in place for call lights.

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for Resident #96’s contact precautions. Resident #96 was an 83-year-old male admitted with a diagnosis of ESBL to an arterial ulcer. His quarterly MDS assessment reflected a BIMS score of 4, indicating severe cognitive impairment. Record review showed that his most recent care plan did not include contact precautions or any related interventions, and his physician order summary reflected Meropenem IV for Escherichia coli ESBL to the arterial ulcer until 01/06/2026. There was no contact precaution order documented. During interview, the MDS nurse stated she was responsible for developing the care plan and said contact precautions should have been care planned, but she did not know why it was not completed. She stated that orders were checked daily in morning meetings except on weekends. The MDS nurse identified the lack of communication between staff and resident as a negative outcome, along with the spread of infection to others. The ADON stated that the nurses, herself, and MDS nurses were responsible for developing the care plan and that contact precautions should have been care planned as soon as possible, but she did not know how it was missed. The DON stated that the nurse who received the order was responsible for completing the care plan for Resident #96 and that contact precautions should have been care planned as soon as the order was received. The facility’s care plan policy stated that the community develops a comprehensive care plan for each resident with measurable objectives and appropriate interventions based on the comprehensive assessment, and that the care plan is updated and reviewed at least quarterly, annually, and with significant changes in condition.

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medical records were complete and accurately documented for one resident reviewed. Resident #96, an 83-year-old male admitted on an original admission date of 06/10/2021, had diagnoses including ESBL to an arterial ulcer. His record showed a Quarterly MDS dated 10/10/2026 indicating a BIMS score of 4 and severe cognitive impairment, and the care plan reflected ESBL to the wound with antibiotics for 14 days, with interventions to report changes in condition, administer medication and/or antibiotics as ordered, and monitor vital signs as indicated. However, the care plan did not include isolation precautions for the resident. The Physician's Order Summary dated 01/05/2026 reflected Meropenem IV for Escherichia coli ESBL to the arterial ulcer until 01/06/2026, but there was no physician order for isolation precautions. Staff interviews reflected differing understanding of who was responsible for entering isolation orders, with the ADON, DON, LVN staff, and wound care nurse each describing that nurses or the person receiving the order should enter it. The DON stated the order should be entered as soon as it is received so staff know how to care for residents in isolation and what PPE is required. The facility policy titled Professional Standard of Care stated that when a licensed nurse takes a verbal or telephone order, the nurse should sign the order and obtain the provider's signature in a timely manner.

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional principles when expired medications were found in the 400-hall medication nurse cart for a resident. During observation of the cart, two expired blister packs were identified for the resident: Metoprolol Tartrate 100 mg with an expiration date of 12/31/2025 and Amlodipine Besylate 10 mg with an expiration date of 12/31/2025. The resident’s record showed diagnoses including essential hypertension, cerebral infarction, chronic kidney disease, Parkinson’s disease, unspecified dementia, and anxiety, and the resident had a BIMS score of 12 indicating moderate cognitive impairment. Interviews confirmed that the expired medications should not have been in the cart. An LVN stated the Metoprolol Tartrate was administered from that cart at night and the Amlodipine Besylate was given as needed when the resident’s SBP was above 130. The LVN stated nurses were responsible for checking medication carts, while the pharmacy nurse audited carts monthly. The pharmacy nurse stated nurses and med aides were expected to check expiration dates at every medication pass and that he had not checked the carts that month because it was early in the month. The DON stated nurses, the pharmacy nurse, and med aides were responsible for checking expiration dates each time medications were pulled for administration, and that there should be no expired medications in the carts.

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its Infection Prevention and Control Program for Resident #96, an 83-year-old male with diagnoses including ESBL to an arterial ulcer, dementia, muscle weakness, type 2 diabetes mellitus, and acute kidney failure. His quarterly MDS reflected severe cognitive impairment. Record review showed he was receiving Meropenem IV for Escherichia coli ESBL to the arterial ulcer, but there was no isolation precaution order and the care plan did not include isolation precautions; it only addressed ESBL to the wound, antibiotics for 14 days, reporting changes in condition, administering medication as ordered, and monitoring vital signs. During observation, there was no contact precaution sign posted on the resident’s door and no PPE near the door. In interviews, the LVN stated the resident should have been on contact precautions and that the sign probably fell off when the privacy curtains were changed, while the PPE was across the hall. The RN who served as the IP stated nurses were responsible for placing isolation signage and PPE, and the ADON and DON stated the nurse who received the order or the ADON was responsible for placing the sign and that the PPE bin and sign alerted staff and visitors. The facility policy stated contact precautions may be implemented for a resident known or suspected to be infected with microorganisms transmitted by direct or indirect contact.

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #105 had a functional call light in his room. During observation, the resident demonstrated that pressing the call button did not activate the light inside the room or the outside light. When a CNA arrived and tested the call light, it still did not work until the roommate’s light was turned on, at which point both the inside and outside lights activated. The resident stated the call light had been working earlier in the day but was not working at the time of the observation. Resident #105 was a 77-year-old male with diagnoses including cerebral infarction, hemiplegia and hemiparesis, speech and language deficits, and hypertension. His quarterly MDS indicated a BIMS score of 5, showing severe cognitive impairment. He was dependent for personal hygiene, upper and lower body dressing, showering, and toileting, and he was frequently incontinent of urine and always incontinent of bowel. His care plan included risk for seizure activity, chronic health conditions affecting physical function, and bowel and bladder incontinence related to cerebral infarction and hemiplegia/hemiparesis. Staff interviews showed the CNA checked call lights in other rooms and said a nonfunctional call light could lead to falls or delays in changing a brief. The LVN stated she performed rounds and checked call lights during her shift and that Resident #105 used his call light. The Maintenance Supervisor said he was notified that the call light was not working and replaced the cord, and the Administrator stated the facility had a call light system with monitors at nurse’s stations. Record review showed routine nurse call checks and a work order for checking call lights throughout the facility, but the resident’s room was found with a call light that did not function during the observation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective infection prevention and control program for one resident who was under Enhanced Barrier Precautions (EBP). Specifically, staff members did not consistently don the required personal protective equipment (PPE) before entering the resident's room and providing care. Video footage confirmed that on two separate occasions, a licensed vocational nurse (LVN) and a certified nursing assistant (CNA) entered the resident's room without wearing the appropriate gown and gloves, despite clear signage and available PPE supplies outside the room. The resident involved was an older male with multiple complex medical conditions, including Parkinson's disease with dyskinesia, type 2 diabetes mellitus, and a feeding tube due to dysphagia. His care plan and medical records indicated the need for EBP, which required staff to wear gowns and gloves during high-contact care activities, such as medication administration and incontinent care. Observations showed that PPE and hand hygiene supplies were accessible, and signage was posted to instruct staff on the required precautions. Interviews with various staff members, including CNAs, LVNs, and nursing leadership, revealed that they were aware of the EBP requirements and the importance of PPE use to prevent infection and cross-contamination. Despite this knowledge and ongoing in-service training, the observed failures by the LVN and CNA to don PPE before providing care to the resident constituted a breach of the facility's infection control policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN A, who did not adhere to the required Enhanced Barrier Precautions (EBP) when providing care to a resident with a PEG tube. On multiple occasions, LVN A entered the resident's room without donning the appropriate personal protective equipment (PPE), specifically a gown and gloves, while performing high-contact activities such as applying gauze to the PEG tube. This non-compliance with EBP was observed on specific dates and times, as captured by video footage from the resident's electronic monitoring device. The resident involved was an elderly male with severe cognitive impairment, requiring a feeding tube due to conditions such as Parkinson's disease and dysphagia. The resident's care plan and order summary explicitly required the use of EBP, which mandates the use of gown and gloves during high-contact activities to prevent the transmission of infections. Despite the presence of signage and available PPE supplies, LVN A failed to follow these guidelines, as confirmed by video evidence and interviews with facility staff. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that LVN A had been trained on infection control and EBP guidelines. Both the ADON and DON acknowledged the failure of LVN A to adhere to the facility's infection control policy, which could potentially place residents at risk of infection. The facility's policy and training records indicated that LVN A had completed the necessary competencies and in-service training related to infection control and PPE usage.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a sanitary and comfortable environment in room [ROOM NUMBER], as evidenced by the presence of a white dirty towel with brown colorations in the private shower area. This issue was observed on two separate occasions, a week apart, indicating a lack of effective cleaning and oversight. Housekeeping staff, including HK J and HK S, reported that rooms were cleaned daily, including the shower areas, but no concerns had been raised about room [ROOM NUMBER]. Despite the cleaning routine, the dirty towel remained in the shower, suggesting a lapse in the cleaning process or communication among staff. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that neither was aware of the issue until it was brought to their attention. Both acknowledged that the towel should not have been left in the shower for an extended period. The DON confirmed that there was no negative outcome to the residents from the dirty towel, but emphasized the importance of maintaining a clean environment. The facility's Physical Environment policy, revised in January 2023, mandates a safe, functional, sanitary, and comfortable environment, which was not upheld in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate medical records for a resident, as staff continued to log temperatures on the Medication Administration Record (MAR) for the resident's personal refrigerator even after it had been taken home by the resident's family. The resident, a male with severe cognitive impairment and multiple diagnoses including Parkinson's disease and type 2 diabetes, had a care plan that did not include the personal refrigerator after it was removed from the facility. Despite this, the MAR continued to reflect recorded temperatures for the refrigerator from the time it was taken home until a later date, indicating a lapse in accurate documentation. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed a lack of awareness regarding the continued documentation of refrigerator temperatures after its removal. The DON acknowledged that the order for temperature checks should have been discontinued once the refrigerator was no longer present, but was unable to explain why the documentation persisted. The facility's administrator also confirmed that the order should have been discontinued and expressed uncertainty about how temperatures were recorded without the refrigerator. The facility's policy on personal refrigerators did not provide specific guidance on accurate record-keeping, contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two licensed vocational nurses (LVNs) who did not adhere to enhanced barrier precautions (EBP) when providing care to residents. Specifically, LVN A did not don a gown while caring for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, despite the resident being on EBP. This resident had severe cognitive impairment and required a feeding tube due to dysphagia. The facility had signage indicating the need for gowns and gloves during high-contact activities, but LVN A only wore gloves, citing a lack of recent training and misunderstanding of the requirements. Similarly, LVN B failed to wear a gown while providing care to another resident with a midline catheter, who was also on EBP. This resident had intact cognition and was being treated for Parkinson's disease and type 2 diabetes. Despite the presence of signage and available PPE, LVN B only wore gloves during the procedure. LVN B initially claimed unawareness of the EBP status and later admitted to forgetting to wear the gown, indicating a lapse in adherence to the facility's infection control policy. The facility's infection prevention and control program required the use of gowns and gloves during high-contact activities with residents on EBP, as outlined in their policy. However, both LVNs failed to comply with these guidelines, potentially placing residents at risk for cross-contamination and infection. The facility had provided training on EBP, but the incidents suggest a need for reinforcement and consistent adherence to infection control protocols.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to have physician orders for enhanced barrier precautions (EBP) in place at the time of admission for two residents, both of whom had invasive devices that necessitated such precautions. Resident #4, a male with a history of dysphagia and a feeding tube, was admitted without EBP orders despite the presence of signage and personal protective equipment (PPE) indicating the need for such precautions. Similarly, Resident #5, who also had a feeding tube and severe cognitive impairment, was admitted without EBP orders, although PPE and signage were present. The absence of EBP orders was identified during a survey, and the Assistant Director of Nursing (ADON) confirmed that the orders were missing from the residents' charts. The ADON acknowledged that the admitting nurse was responsible for inputting these orders, and the oversight was attributed to a lack of formal training and reliance on on-the-job training. The Director of Nursing (DON) also confirmed the deficiency, noting that the facility's policy required EBP orders to be in place, but this was not followed. Both the ADON and DON recognized the importance of having EBP orders to ensure staff compliance with infection control measures. The deficiency was noted to potentially place residents with indwelling devices at risk of developing infections, as the absence of formal orders could lead to lapses in precautionary measures. The facility's failure to input EBP orders was attributed to a lack of adherence to policy and insufficient training for staff responsible for order entry.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its policy regarding the storage of foods brought to residents by family and other visitors, specifically for a resident with a personal refrigerator. The deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not maintain complete documentation of temperature checks for the resident's personal refrigerator throughout October. This oversight could potentially expose residents with personal refrigerators to the risk of foodborne illness. The resident in question was a male with Parkinson's disease, type 2 diabetes, and dysphagia, who had a feeding tube and was cognitively intact. The resident's care plan indicated that the personal refrigerator was for family use, and the temperature log was to be updated daily. However, the temperature log for October showed entries only for a few days, and the Director of Nursing (DON) confirmed that the staff did not follow the facility's policy. The DON acknowledged that the night nurses were responsible for checking and logging the refrigerator's temperature but admitted there were gaps in the log. Interviews with the resident's family member revealed that the refrigerator was used for the resident's pleasure feeding items, contradicting the DON's statement that it was for family use. The facility had previously conducted in-service training on refrigerator monitoring, but the deficiency persisted.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate respiratory care for a resident, specifically by not ensuring the resident received oxygen at the prescribed rate. Resident #49, a 76-year-old male with severe cognitive impairment and diagnoses including congestive heart failure and pleural effusion, was prescribed continuous oxygen therapy at 2 liters per minute (Lpm) via nasal cannula. However, during an observation, the resident was found to be receiving oxygen at 3 Lpm, which was not in accordance with the prescribed rate. Interviews with the nursing staff revealed inconsistencies in monitoring and maintaining the correct oxygen flow rate. LVN B, who was responsible for Resident #49, stated that she checked the oxygen rate at the beginning of her shift and found it set at 2 Lpm, but later it was observed at 3 Lpm. She was unsure how the rate changed and mentioned that the resident was not known to adjust the oxygen settings himself. Another nurse, LVN C, confirmed that it was the responsibility of the floor nurses to ensure the accuracy of oxygen rates, and she had not known the resident to adjust the rate independently. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both emphasized that nurses were responsible for checking oxygen settings during rounds and whenever they entered the resident's room. The facility's policy on oxygen administration required physician orders for oxygen therapy, including the flow rate, to be documented in the Treatment Administration Record (TAR) and/or Medication Administration Record (MAR). Despite this policy, the discrepancy in the oxygen flow rate for Resident #49 was not addressed, indicating a lapse in adherence to the facility's procedures and professional standards of practice. This failure to maintain the prescribed oxygen rate could potentially place residents at risk for respiratory distress.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nurse staffing data was posted and readily accessible to residents and visitors with all required information for two of the four days reviewed. Specifically, on 10/2/24 and 10/3/24, the daily staffing information was not updated and posted in a prominent location as required. During a walkthrough on 10/3/24, the State Surveyor observed that the Direct Care Staff sign had not been updated since 10/1/24. This oversight could potentially place residents, families, and visitors at risk of not being informed about the census and the number of staff working each day to provide care on all shifts. Interviews conducted during the investigation revealed that CNA A, who was responsible for updating the staffing information, prioritized resident care and other duties over updating the staffing information. She acknowledged that she was aware of the requirement to update the staffing information daily but did not do so on 10/2/24 due to other work commitments. The Director of Nursing (DON) confirmed that CNA A was informed of her responsibilities and that the RN supervisors were responsible for updating the information on weekends. However, the DON admitted that there was no one currently ensuring the staff information was being posted. The Administrator also acknowledged the regulatory requirement for daily posting but assumed the information was being updated without verifying it.