Crestway Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 7181 Crestway Dr, San Antonio, Texas 78239
- CMS Provider Number
- 675171
- Inspections on file
- 52
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Crestway Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that a kitchen employee was working without a clearly current and verified food handler certificate, in violation of facility policy requiring dietary staff to hold valid food handler permits within 30 days of hire. Records showed the employee’s prior certificate had expired, and the Dietary Manager acknowledged not noticing the expiration. When a new certificate was produced, its completion date conflicted with the date shown in the online verification system, and the Administrator could not explain the discrepancy, demonstrating a failure to ensure sufficient qualified food and nutrition service staff.
A resident with severe cognitive impairment died in the facility, and staff did not notify the family of the death as required by policy, following instructions from law enforcement who were investigating the incident as a potential crime scene. The family was only informed after they contacted the facility, at which point they were referred to the police for further information.
Multiple residents with severe cognitive and physical impairments had their use of side rails as restraints unreported in the MDS, despite staff and DON confirming restraint use. Additionally, a resident receiving hospice care and another with a surgical wound were inaccurately documented in their MDS assessments, with the DON attributing errors to the absence of an MDS nurse. These documentation failures were identified through record review, staff interviews, and observation.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables or specific actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risks, reviewing risks and benefits with the resident or representative, obtaining informed consent, or ensuring proper installation and maintenance.
Several residents were prescribed psychotropic and psychoactive medications without appropriate diagnoses or monitoring. One resident received an antipsychotic for agitation without documented behavioral issues, another was given antidepressant and antianxiety medications without monitoring for side effects or behaviors, and a third was administered multiple psychoactive drugs without supporting diagnoses. Facility policies requiring clinical indications and monitoring for such medications were not followed.
Surveyors found that the kitchen dry storage area had two containers of sugar with unsecured lids, a box of juice cups with spillage and gnats, and two boxes of funnel cake mix lacking manufacturer expiration dates. The Dietary Manager and Registered Dietitian confirmed the importance of proper food storage and handling, and facility policy requires safe food handling practices.
Staff failed to follow infection control protocols by not performing hand hygiene between glove changes and after touching potentially contaminated surfaces during care for two residents, including colostomy and tracheostomy procedures. The DON confirmed these actions were not in line with facility policy and could lead to infection transmission.
A resident with newly diagnosed Major Depressive Disorder and Schizophrenia was not referred for a PASARR Level II evaluation, despite severe cognitive impairment and ongoing psychiatric care. The responsibility for PASARR referrals was unassigned due to a vacant MDS Coordinator position, and the facility could not provide a PASARR policy when requested.
A resident with multiple medical conditions was assessed as a safe, independent smoker, but the care plan was not updated to reflect this change, continuing to require storage of cigarettes and lighters in the med room. The DON confirmed the care plan should have been revised after the assessment, but this was not done due to the absence of the MDS nurse responsible for care plan updates.
A resident with impaired mobility and a history of Critical Illness Myopathy experienced prolonged foot pain and developed long, ingrown toenails after an LVN failed to assess his feet during weekly skin checks. The DON later discovered the resident's toenails were significantly overgrown and ingrown, despite facility policy requiring thorough skin and foot assessments.
A CNA failed to clean the suprapubic area of a resident with an indwelling urinary catheter and multiple medical conditions during incontinence care, despite facility policy and recent peri-care training. The omission was acknowledged by the CNA and confirmed by the DON, highlighting a lapse in required perineal care procedures.
A nurse flushed a resident's gastrostomy tube by pushing water with a syringe plunger instead of using gravity, contrary to the resident's care plan and physician orders. The resident, who had severe cognitive impairment and was dependent on enteral nutrition, was at risk for complications due to this improper technique. Both the nurse and DON acknowledged that gravity should have been used, and the facility lacked a specific policy on this procedure.
Expired bottles of Gentle Lax and Acetaminophen 500mg were found on a medication cart, with both an LVN and the DON confirming that these should not be administered due to potential ineffectiveness or adverse reactions. Facility policy requires expired medications to be returned or destroyed, but these were not removed as required.
A resident's medical record was not updated to include a new diagnosis of general anxiety after a psychiatric physician prescribed diazepam for this condition. Although the medication was ordered and administered, the diagnosis was missing from the electronic medical record and face sheet. The DON confirmed the oversight, noting the absence of an MDS nurse contributed to the incomplete documentation.
A deficiency was found when an oxygen cylinder was improperly stored in a resident's room, in violation of facility policy requiring such cylinders to be kept in a designated storage area. The resident had multiple medical conditions and required assistance with transfers. Staff interviews confirmed the cylinder should not have been in the room, and facility policy prohibits this practice.
A medication cart was left unlocked and unattended in a hallway, with its computer screen displaying a resident's personal and medical information. An LVN admitted to forgetting to lock the screen, resulting in exposed confidential data. The DON confirmed that staff are expected to lock computer screens to protect resident information, in accordance with facility policy.
A resident with cognitive impairment and swallowing difficulties had a physician-ordered change from a pureed to a mechanical soft diet, but the care plan was not updated to reflect this change. Although the correct diet was provided, staff interviews revealed confusion about who was responsible for updating the care plan, resulting in the care plan not matching the resident's current dietary needs.
A resident with multiple complex medical conditions, including an indwelling urinary catheter and a stage 4 pressure ulcer, did not have these needs reflected in their comprehensive care plan. Although medical orders and assessments documented the catheter and wound care requirements, the care plan was not updated by the interdisciplinary team to include these interventions, as confirmed by staff interviews and record review.
A resident with severe cognitive impairment and multiple medical conditions requiring enteral feeding did not receive the prescribed amount of water flushes before and after medication administration. An LVN administered only 10 ml and 15 ml water flushes instead of the ordered 30 ml, contrary to physician's orders and facility policy, resulting in a deficiency in care.
Medication carts on two separate halls were repeatedly left unlocked and unattended, with both an LVN and a respiratory technician admitting to forgetting to secure the carts. Staff interviews and facility policy confirmed that carts are required to be locked when not in use to prevent unauthorized access, especially due to residents who wander.
A resident with cognitive impairment, hemiplegia, and a mechanically altered diet was not provided with an ordered Adult Sip Cup at the start of a meal, resulting in repeated beverage spillage. Staff interviews and documentation confirmed the resident required adaptive equipment and assistance, but the appropriate device was only provided after the resident experienced difficulty.
Two residents with significant mobility impairments were injured due to improper transfer procedures: one was transferred without a mechanical lift despite being dependent on it, resulting in a femoral fracture, while another was dropped when a CNA performed a single-person mechanical lift transfer, causing a facial laceration. In both cases, staff did not follow established protocols requiring mechanical lifts and two-person assistance.
A resident with significant respiratory and mobility needs reported being sprayed with an unknown substance by an unidentified staff member. The facility failed to fully investigate the grievance, did not identify or interview all involved staff, and did not provide the required follow-up or communication to the resident or her family, as mandated by facility policy.
A resident with significant mobility impairments and a history of mechanical lift transfers did not have this requirement reflected in her care plan, despite documentation and staff knowledge of her needs. On one occasion, staff transferred her without a mechanical lift due to equipment unavailability, and the care plan remained outdated, relying instead on CNA tracking lists.
CNAs failed to wear required gowns while transferring a resident on enhanced barrier precautions (EBP) for a tracheostomy and ventilator dependence, using only gloves despite facility policy and signage. The staff were unaware of the resident's EBP status and believed the precautions were for the roommate, even though the resident required total assistance and had significant medical needs. The DON confirmed that gowns and gloves were required for such transfers according to facility policy.
A Respiratory Therapy Director worked as a Respiratory Therapist without holding a valid Texas state license for an extended period, with only national certification and a future-dated state license present in the personnel file. The HR department relied solely on national licensure, and a remedial plan from the state board confirmed the individual practiced without proper state credentials, contrary to facility policy.
A resident with significant disabilities was subjected to rough handling by a CNA, resulting in bruising and emotional distress. Despite being cognitively intact and social, the resident was dependent on staff for care. Video evidence showed the CNA's abusive actions, which were inconsistent with the resident's care plan and facility's abuse prevention policy.
A resident in an LTC facility did not receive prescribed doses of Lamictal and Phenobarbital, and Ativan was improperly administered for agitation instead of seizures. The facility's staff failed to document the omissions and did not follow procedures for verifying unclear orders or addressing medication unavailability, leading to deficiencies in pharmaceutical services.
A facility failed to ensure privacy for two residents during personal care, leading to a deficiency. One resident, who requires assistance due to cerebral cysts, was exposed during incontinence care as the privacy curtain was not fully closed, and the camera in the room was not obstructed. The other resident, with mild cognitive impairment, was captured on camera without consent. The facility did not adhere to privacy protocols, resulting in a breach of privacy and dignity.
A resident with a history of stroke and physical debility did not receive necessary therapy services due to insurance approval issues, despite having an active order for evaluation and treatment. The facility failed to implement a comprehensive care plan, leading to dissatisfaction from the resident and their responsible party. The lack of therapy services and unclear processes for handling therapy referrals contributed to the deficiency.
A resident with a history of stroke and physical debility did not receive required PT, OT, and ST services due to insurance issues, despite having physician orders. The facility's process for therapy orders involved insurance review first, and therapy screening depended on the resident's insurance type. The lack of documentation and clear policy for therapy referrals contributed to the deficiency.
A resident with complex medical needs was mistakenly given another resident's medications, including atorvastatin, labetalol, and hydralazine, by an LPN during an evening medication pass. The error was realized partway through the administration, and the resident was monitored for adverse reactions, with none observed. The facility's medication administration policies were not followed, as the LPN failed to verify the resident's identity and medication labels properly.
A resident on Enhanced Barrier Precautions did not receive proper infection control measures during care. LVN A and CNA B failed to wear gowns, and LVN A did not change gloves or perform hand hygiene while providing wound care. The resident had multiple indwelling devices and required EBP, but staff were unaware or did not adhere to protocols, leading to potential cross-contamination risks.
The facility failed to ensure resident privacy during personal care for four residents, as staff did not adequately close privacy curtains, doors, or blinds. This deficiency was observed during incontinence care for residents with various medical conditions, including cognitive impairments. Staff interviews confirmed the importance of maintaining privacy to prevent residents from feeling embarrassed or ashamed, as outlined in the facility's policies on resident rights and dignity.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended. The Respiratory Treatment Cart #1 and Wound Treatment Cart #2 were both found unlocked, with the latter containing treatments that could be ingested by residents, posing a risk of adverse reactions. The DON confirmed the expectation for carts to be locked when not in use.
The facility failed to maintain proper infection control practices during perineal and incontinent care for several residents. Staff did not change gloves or perform hand hygiene at critical points, such as after removing soiled briefs or before handling clean items. Observations revealed systemic failures in adhering to infection control guidelines, affecting residents with various medical conditions.
A facility failed to develop a comprehensive person-centered care plan for a resident, neglecting critical areas such as cognitive loss, urinary incontinence, and nutritional status. The resident had multiple diagnoses, including diabetes and hypertension, and was dependent on assistance for daily activities. Despite these needs, the care plan only addressed a fall incident, and staff interviews revealed that the care plan was not completed in a timely manner following the MDS assessment.
The facility failed to maintain sanitary conditions for two residents requiring tracheostomy care. Aerosol tubing for both residents was found on the floor and reconnected without being replaced, as the LVN was not informed of the contamination. This oversight was acknowledged by the CNA involved, and the DON emphasized the importance of reporting such incidents to prevent infection.
A facility failed to document the insertion and care of a suprapubic catheter for a resident, leading to incomplete medical records. An LVN changed the catheter but did not record the procedure or urine output, despite the resident's report and the LVN's acknowledgment. The DON confirmed that such events should be documented, but due to a busy night, the LVN neglected this duty, potentially affecting the resident's continuity of care.
A resident's catheter bag was found on the floor instead of being anchored to the bed rail, posing an infection control issue. The resident, with a history of diabetes and UTIs, reported that morning staff did not empty the bag, although other shifts did. Staff interviews confirmed the improper placement, and the facility's policy required catheter bags to be kept off the floor.
The facility did not comply with professional standards for food storage, as observed in the kitchen where two open gallon jugs of ranch dressing were found unlabeled in the reach-in refrigerator. The Dietary Manager confirmed that all food should be labeled with the date opened and use-by date, as per the facility's policy. This oversight placed residents at risk for foodborne illness.
The facility failed to accurately document blood pressure readings for residents on hypertension medication, leading to repeated entries in the EMAR. Nursing staff admitted to using a system feature that duplicated previous readings, which did not reflect the true effectiveness of the medication. This affected residents with varying cognitive abilities, potentially impacting their care.
A resident with a history of cerebral infarction, tracheostomy status, anxiety disorder, and schizophrenia had a care plan that failed to include necessary interventions for mitten restraints. The care plan only required visual checks every two hours, despite physician orders to remove the restraints for skin checks and exercises. Nursing staff followed the physician's orders, but the care plan documentation was incorrect.
The facility failed to provide adequate supervision and security for residents at risk of elopement, leading to an incident where a resident with dementia left the facility unsupervised and was found miles away. The front door was left unlocked and unmonitored during specific hours, and staff were unaware of which residents required supervision. This lack of oversight and security measures resulted in an Immediate Jeopardy situation.
A facility failed to maintain accurate medical records for a resident, specifically regarding meal consumption on two consecutive days. The resident, who required total assistance for eating, did not have documented records of meals provided on those days. Interviews revealed that the meals were given but not documented due to agency staff not being fully oriented to the facility's documentation methods.
Expired and Unverified Food Handler Certification for Kitchen Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a kitchen employee, Cook A, maintained a current food handler certificate as required for food and nutrition service staff. Record review showed Cook A had completed a Learn2Serve Food Handler Training Course with a certificate valid from 04/15/2023 through 04/14/2026. A staff list dated 04/29/26 indicated Cook A was hired on 01/14/26 and worked in the kitchen. During an interview, the Administrator stated she believed Cook A’s current food handler certificate was expired and would check for another certificate. The Dietary Manager reported that Cook A was scheduled to work that afternoon and had been instructed to complete his food handler training before returning to duty, and acknowledged he had not noticed that Cook A’s existing certificate had expired. Subsequent observation and record review showed the Administrator produced a food handler certificate for Cook A from The Always Food Safe Company that reflected a completion date of 04/22/2026 and validity through 04/22/2029, while online database verification for the same program showed a completion date of 04/29/2026 with validity through 04/29/2029. In a follow-up interview, the Administrator stated she was unsure why the dates on the physical certificate and the online verification were different. The facility’s policy, “Nutrition Services Personnel Guidelines,” revised 01/01/2026, stated that dietary employees should have food handler permits in accordance with local, state, and federal regulations within 30 days of hire. The survey findings concluded the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out food and nutrition service functions because Cook A did not have a current, clearly verified food handler certificate at the time of review.
Failure to Notify Family of Resident Death Due to Police Directive
Penalty
Summary
Facility staff failed to notify the resident's representative or family of a significant change in condition, specifically the death of a resident, as required by facility policy and regulatory standards. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including a healing cervical fracture, hypertension, and anxiety disorder, died in the facility. Documentation showed that staff performed CPR until EMS arrived, and the time of death was recorded. The incident was complicated by another resident's report of a possible altercation, leading to a police investigation. During the police investigation, facility staff, including the DON, ADON, and Administrator, were instructed by law enforcement not to notify the family of the resident's death, as the scene was considered a crime scene and the police stated it was their responsibility to notify next of kin. Staff complied with this directive and did not inform the family until the family called the facility themselves. At that point, the ADON confirmed the death but could not provide further details, instead directing the family to contact the police investigator for more information. Interviews with facility leadership confirmed that they did not inform the police of their regulatory requirement to notify the family, nor did they seek guidance from the Ombudsman, state program management, or the Medical Director regarding the conflict between law enforcement instructions and facility policy. The facility's own policy required timely notification of family or legal representatives in the event of significant changes in a resident's condition, but this was not followed due to the police directive.
Inaccurate Resident Assessments and MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of multiple residents, as evidenced by discrepancies found in the Minimum Data Set (MDS) documentation and care plans. For several residents with severe cognitive impairment and significant physical limitations, the use of side rails as restraints was not properly identified in their MDS assessments, despite staff and the Director of Nursing (DON) confirming that the side rails were used for safety and restraint purposes. Observations and interviews revealed that these residents were totally dependent on staff for activities of daily living (ADLs), had contractures or wore mittens, and could not use the side rails for mobility, yet the MDS did not reflect restraint use as required. In addition, the facility failed to accurately document other critical aspects of resident care. One resident's quarterly MDS inaccurately indicated that the resident was not receiving hospice care, despite documentation and physician certification confirming hospice enrollment and a prognosis of less than six months to live. Another resident's MDS failed to identify the presence of a current surgical wound, even though care plans, physician orders, and weekly skin assessments documented ongoing wound care for a post-surgical wound. In both cases, the DON acknowledged the inaccuracies and attributed them to the absence of a dedicated MDS nurse, with responsibilities temporarily handled by a company nurse who was unavailable at the time. The facility's own policy requires that all individuals completing any portion of the MDS assessment attest to the accuracy of the information provided. However, the lack of accurate and timely updates to the MDS assessments resulted in documentation that did not reflect the residents' true conditions or care needs. This deficiency was identified through a combination of record reviews, staff interviews, and direct observations, affecting multiple residents and potentially impacting the quality of care provided.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on the surveyor's observation that the care plan did not comprehensively cover the resident's needs, and there was an absence of clear, measurable objectives and interventions to guide staff in providing appropriate care.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report excerpt.
Failure to Follow Bed Rail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow required procedures before the use of a bed rail. Specifically, the facility did not attempt alternative approaches prior to bed rail use, did not assess the resident for safety risks, and did not review the risks and benefits of bed rail use with the resident or their representative. Additionally, informed consent was not obtained, and there was a failure to ensure the bed rail was correctly installed and maintained.
Failure to Ensure Drug Regimens Are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications, as evidenced by the lack of appropriate diagnoses and monitoring for several residents receiving psychotropic and psychoactive drugs. For one resident, Zyprexa was prescribed for agitation without a documented diagnosis of agitation or any behavioral disturbances, and the care plan did not address agitation or anxiety. The resident's medical records and interviews with the responsible party confirmed the absence of aggressive behaviors or a history of agitation, yet the medication continued to be administered without proper justification or review. Another resident was prescribed Remeron for depression and Buspirone for anxiety, but there was no evidence in the medical record of monitoring for behaviors or side effects associated with these medications. The care plan indicated a risk for side effects and called for monitoring, but this was not carried out. The DON acknowledged that the required monitoring was not performed, which was contrary to facility policy and expectations for medication management. A third resident received multiple psychoactive medications, including Olanzapine for agitation and Divalproex Sodium for mood, without documented diagnoses to support their use. The care plan referenced the use of these medications for agitation and mood, but the clinical record did not contain corresponding diagnoses. Facility policy required that antipsychotic medications only be used for specific, documented conditions, and that all medications be clinically indicated, but this was not followed in these cases.
Improper Food Storage and Handling in Kitchen Dry Storage Area
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen dry storage area. Two containers of sugar were found with unsecured lids, and a box containing nine individual juice cups had spillage and approximately four gnats present when the box was moved. Additionally, two boxes of funnel cake mix were present without manufacturer expiration dates, only a handwritten date was visible. These conditions were directly observed by surveyors during their inspection of the dry storage area. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) confirmed the importance of proper food storage and the risks associated with improper practices. The DM acknowledged the need to ensure foods are not expired and are properly stored to prevent contamination or cross-contamination. The RD emphasized that food should be kept in airtight containers to maintain integrity and prevent contamination from bugs or debris. Facility policy reviewed by surveyors stated that foods must be received and stored in compliance with safe food handling practices, and that dry foods should be handled and stored to maintain packaging integrity until use.
Failure to Follow Hand Hygiene and Glove Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents during direct care activities. In one instance, a CNA changed gloves without sanitizing or washing hands while emptying a resident's colostomy bag, and again after cleaning the bag, only sanitizing hands after all tasks were completed. The CNA acknowledged receiving hand hygiene training and recognized the need to sanitize or wash hands between glove changes, especially after contact with body fluids. The Director of Nursing confirmed that the CNA should have sanitized or washed hands between glove changes according to facility policy. In another case, a respiratory therapist changed gloves without performing hand hygiene while providing tracheostomy care for a resident who was totally dependent on staff, had a tracheostomy, and required oxygen therapy. Additionally, an LVN donned gloves and a gown, then touched the privacy curtain and bed controls before administering medication through a PEG tube without changing gloves. The Director of Nursing stated that both the respiratory therapist and LVN failed to follow infection control policy, which could result in the transfer of bacteria and infection to residents. Facility policies reviewed emphasized the importance of hand hygiene and changing gloves when contamination occurs.
Failure to Refer Resident for PASARR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a PASARR (Preadmission Screening and Resident Review) Level II comprehensive evaluation after the resident was diagnosed with Major Depressive Disorder and undifferentiated Schizophrenia following admission. The resident's records showed no diagnosis of dementia, but did indicate severe cognitive impairment, ongoing use of psychotropic medications, and receipt of psychological and psychiatric services. Despite these factors and the new diagnoses, the resident's PASARR Level I screening from a previous date indicated no mental illness, and no subsequent referral for a Level II evaluation was made after the new diagnoses were established. Interviews and record reviews revealed that the responsibility for PASARR referrals typically fell to the MDS Coordinator, a position that was vacant at the time. The DON confirmed that the resident should have been referred for PASARR services following the new diagnoses but was not. Additionally, the facility was unable to provide a PASARR policy when requested during the survey.
Failure to Update Care Plan After Change in Smoking Status
Penalty
Summary
The facility failed to review and revise the care plan for a resident following a change in smoking status, as identified through interviews and record review. The resident, an adult male with diagnoses including paraplegia, hypertension, and other conditions, was assessed as a safe and independent smoker according to a smoking assessment. Despite this assessment, the resident's care plan continued to state that all cigarettes and lighters must be stored in the medication room and that smoking was only permitted in designated areas under supervision. The care plan was not updated to reflect the resident's new status, which allowed him to keep his cigarettes and lighter per facility policy. The Director of Nursing confirmed that the care plan should have been updated after the smoking assessment, but this was not done due to the absence of the MDS nurse, who was responsible for care plan updates. The facility's policy allows residents with independent smoking privileges to keep smoking materials in their possession, but the resident's care plan did not reflect this change. This oversight was attributed to staffing issues, specifically the unavailability of the MDS nurse at the time.
Failure to Provide Proper Foot Care and Assessment
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) responsible for weekly skin assessments failed to assess a resident's feet, resulting in significantly long toenails and two ingrown toenails going unnoticed. The resident, who had a diagnosis of Critical Illness Myopathy and was at risk for skin breakdown due to impaired mobility, reported foot pain related to ingrown toenails and stated he had informed nursing staff about the issue since admission. Despite weekly skin assessments being part of the care plan, the LVN did not recall assessing the resident's feet, and the charge nurse was unaware of any foot problems. Upon assessment by the Director of Nursing (DON), the resident was found to have scaly, dry feet, all toenails were long, and both great toenails appeared ingrown, with one toenail extending approximately one inch past the nail bed and showing red spots. The DON confirmed that the treatment nurse should have identified these issues during routine assessments, and that certified nursing assistants (CNAs) should also report any skin problems. Facility policy required comprehensive physical exams, including skin and foot assessments, but these were not properly completed for this resident.
Failure to Provide Complete Incontinence and Catheter Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate incontinence care to a female resident with multiple complex medical conditions, including type 2 diabetes mellitus, necrotizing fasciitis, chronic kidney disease, hypertension, and heart failure. The resident was cognitively intact, had an indwelling urinary catheter, and was dependent on staff for transfers and toileting due to her medical status. Facility records indicated that the resident required catheter care every shift and incontinence care every two hours or as needed. During an observed care episode, the CNA cleaned the resident's catheter, genital area, and groin, but neglected to clean the suprapubic area, which was folded with skin and required attention to prevent infection. The CNA admitted during an interview that she forgot to clean the suprapubic area due to nervousness, despite having received peri-care training two months prior. The Director of Nursing (DON) confirmed that the suprapubic area should have been cleaned during peri-care, especially given the skin folds present. Facility policy on perineal care emphasized the importance of cleanliness to prevent infections and skin irritation, specifically instructing staff to wash the perineal area. The failure to clean the suprapubic area as required constituted a lapse in proper incontinence and catheter care for the resident.
Improper Flushing Technique Used for Gastrostomy Tube
Penalty
Summary
A deficiency occurred when a nurse flushed a resident's gastrostomy tube by pushing 30 ml of water into the tube using a syringe plunger, rather than allowing the water to flow by gravity. The resident involved was an older male with severe cognitive impairment, dependent on a feeding tube for nutrition, and at risk for aspiration. The resident's care plan specified that tube feedings and flushes should be administered as ordered, with checks for placement and appropriate flushing to maintain hydration and tube patency. The physician's order required flushing the gastrostomy tube with specific amounts of water before and after medications. During observation, the nurse was seen using the plunger method to flush the tube, which was confirmed in an interview with the nurse, who acknowledged the error and stated that gravity should have been used. The Director of Nursing also confirmed that gravity should be used for flushing unless there is a blockage, in which case gentle plunger use may be considered. The facility did not have a policy regarding the use of gravity for tube feeding flushes.
Expired Medications Found on Medication Cart
Penalty
Summary
Surveyors observed that medication cart #1 on the 400 hall contained one bottle of Gentle Lax with an expiration date of 03/2025 and one bottle of Acetaminophen 500mg with an expiration date of 04/2025. These expired medications were not removed from the cart as required. During an interview, an LVN acknowledged missing the expiration dates and stated that administering expired medications would not be safe, as they could cause adverse reactions or be less effective. The Director of Nursing also confirmed that expired medications may not provide the intended therapeutic results or could potentially cause adverse reactions. A review of the facility's policy on "Medication Labeling and Storage" indicated that discontinued, outdated, or deteriorated medications should be returned or destroyed according to instructions from the dispensing pharmacy. The presence of expired medications on the medication cart demonstrates a failure to follow this policy and to provide pharmaceutical services that meet the needs of each resident.
Failure to Accurately Update Resident Medical Record with New Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as required by accepted professional standards. Specifically, a psychiatric physician added a diagnosis of general anxiety and prescribed diazepam 2 mg three times daily for anxiety, but this new diagnosis was not added to the resident's medical record. The resident's face sheet and electronic medical record did not reflect the updated diagnosis, despite the medication being ordered and administered for anxiety. The resident's medication administration record and physician orders confirmed the ongoing use of diazepam for anxiety, and the psychiatric physician's note documented the addition of the diagnosis. The Director of Nursing confirmed that the resident was receiving diazepam for anxiety and that the psychiatric doctor had added the diagnosis of general anxiety, but acknowledged that the facility did not update the medical record accordingly. It was noted that updating the medical record was the responsibility of the MDS nurse, but the facility did not have an MDS nurse at the time, which contributed to the inaccuracy. The facility's policy allowed for the use of electronic medical records, but the failure to update the diagnosis resulted in an incomplete and inaccurate medical record for the resident.
Improper Storage of Oxygen Cylinder in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen cylinder was found stored in a resident's room, contrary to the facility's policy which prohibits storing oxygen cylinders in any resident room or living area. The resident involved was an elderly female with a history of dysphagia, chronic pain, encephalopathy, hyponatremia, and a personal history of COVID-19. Her medical records indicated moderate cognitive impairment and a need for assistance with transfers. She had orders for oxygen therapy and nebulizer treatments due to respiratory failure. During an observation, a full oxygen cylinder was found in the resident's room. Interviews with the LVN and DON confirmed that the oxygen cylinder should have been stored in the designated oxygen storage room for safety reasons. The LVN was unaware of how long the cylinder had been in the room or why it was there, as the resident did not use it. Facility policy, as reviewed, clearly states that oxygen cylinders must be stored in racks, carts, or approved stands and never in resident rooms.
Resident Information Exposed Due to Unlocked Medication Cart Computer
Penalty
Summary
A medication cart was observed left unlocked and unattended in a hallway, with the computer screen on top of the cart displaying a resident's personal and medical information. The cart and exposed screen were visible and accessible to unauthorized individuals passing by. This incident involved a staff member, LVN A, who left the computer screen open and unattended, resulting in the exposure of confidential resident information. Upon returning to the cart, LVN A acknowledged forgetting to lock the computer screen and recognized that leaving it open constituted a HIPAA violation, as it could allow unauthorized access to resident information. The Director of Nursing (DON) confirmed that it was facility policy and expectation for staff to lock computer screens to prevent unauthorized disclosure of resident information, as outlined in the facility's Resident Rights policy.
Failure to Update Care Plan for Diet Order Change
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's current dietary needs. Specifically, the care plan for a male resident with a history of brain cancer, hemiplegia, and aphasia did not reflect a physician-ordered change from a pureed diet to a mechanical soft diet, despite the order being in place and the resident receiving the correct diet during meal service. The resident was moderately cognitively impaired, dependent on staff for eating, and required a mechanically altered diet, as documented in his assessments and physician orders. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for updating care plans. The Dietary Manager updated the meal ticket but was unaware of the need to update the care plan, while the LVN who received the diet order acknowledged she should have updated the care plan. The MDS Coordinator, responsible for auditing care plans, was not aware of the Dietary Manager's role in care plan updates. The facility's policy required care plans to be updated as resident conditions changed, but this was not followed in this instance.
Failure to Update Comprehensive Care Plan for Resident with Catheter and Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, to reflect the resident's current condition. Specifically, the care plan did not include the resident's use of an indwelling urinary catheter or the presence of a stage 4 pressure ulcer to the sacrum, despite these conditions being documented in the resident's medical records and orders. The resident had diagnoses including severe protein-calorie malnutrition, heart failure, respiratory failure, dysphasia, kidney failure, and urinary retention, and was cognitively intact. Orders for catheter care and wound care were present and active, but these interventions were not reflected in the care plan. Interviews with facility staff revealed that the MDS Coordinator was responsible for auditing and updating care plans, and the DON acknowledged that the care plan should have included the resident's wound and catheter. The omission was attributed to the care plan not being updated after the admission MDS assessment, which had triggered the need for these interventions. Facility policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan within seven days of the comprehensive assessment, but this was not followed for the resident in question.
Failure to Follow Physician's Orders for Enteral Tube Flushing
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician's orders regarding the flushing of an enteral feeding tube for a resident with significant medical needs. The resident, a male with diagnoses including pneumonitis due to inhalation of food and vomit, acute respiratory failure with hypoxia, gastroparesis, and gastrostomy status, was severely cognitively impaired and dependent on an enteral feeding tube for nutrition and medication administration. According to the physician's orders, the feeding tube was to be flushed with 30 ml of water before and after medication administration, and 10 ml between medications. During a medication pass, the LVN only flushed the tube with 10 ml of water prior to administering medications and 15 ml after, instead of the prescribed 30 ml. The LVN acknowledged forgetting to follow the correct flush amounts as ordered. The facility's policy and the Director of Nursing both confirmed the importance of adhering to the prescribed flush volumes to prevent tube clogging and ensure proper medication administration. The failure to follow the physician's orders constituted a deficiency in providing appropriate care for a resident with an enteral feeding tube.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on both the 200 and 300 halls were left unlocked and unattended on multiple occasions. On the 200 hall, a medication cart was found unlocked and unattended in the hallway, and the assigned LVN admitted to forgetting to lock it. The LVN acknowledged that leaving the cart unsecured could allow unauthorized persons to access medications, potentially leading to consumption of drugs not prescribed to them. On the 300 hall, the medication cart was also observed unlocked and unattended twice, and the assigned respiratory technician later locked it after being observed. The technician admitted to forgetting to lock the cart and recognized the risk of unauthorized access to respiratory and oxygen treatment medications. Interviews with staff, including the DON and unit manager, confirmed that facility policy requires medication carts to be locked when not in use to prevent unauthorized access, especially given the presence of residents who wander. Review of facility policy documents corroborated this expectation, stating that medication carts must be securely locked at all times when out of the nurse's view. The repeated failure to secure medication carts as required constituted a deficiency in the facility's medication storage practices.
Failure to Provide Required Adaptive Eating Equipment and Assistance
Penalty
Summary
The facility failed to provide special eating equipment, specifically an Adult Sip Cup, and appropriate assistance to a resident who required such adaptive devices for safe and effective meal consumption. The resident, a male with a history of malignant brain neoplasm, left-sided hemiplegia, and aphasia, was documented as being moderately cognitively impaired, dependent on staff for eating, and requiring a mechanically altered diet. Physician orders and the care plan specified the use of an Adult Sip Cup to assist with beverages and prevent spillage or choking. However, during observation, the resident was initially given regular cups by staff, resulting in repeated spillage while attempting to drink. The appropriate adaptive equipment was only provided later during the meal service after the resident had already experienced difficulty. Interviews with staff, including the ADON, dietary manager, CNA, and DON, confirmed that the resident was supposed to receive beverages in an Adult Sip Cup due to issues with dexterity and to prevent aspiration and dehydration. The facility's own policy required that adaptive devices be provided to residents who need them and that assistance be given to ensure residents can use and benefit from such equipment. Despite these documented needs and policies, the resident was not consistently provided with the required adaptive equipment at the start of the meal, leading to observed difficulties and spillage.
Failure to Ensure Safe Resident Transfers and Adequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, a female with hemiplegia, hemiparesis, age-related debility, lack of coordination, and an amputation below the left knee, was dependent on staff for transfers and had a history of being transferred via mechanical lift. On one occasion, she was transferred by two staff members without the use of a mechanical lift, despite her request and her usual transfer method. During this transfer, she was unable to bear weight, was lowered to the ground, and subsequently experienced pain and a distal femoral fracture, as confirmed by later imaging. Interviews revealed that the mechanical lift was not used because all lifts were occupied at the time, and staff deviated from the established transfer protocol. Another resident, a female with diabetes, dementia, and quadriplegia, required total assistance for transfers using a mechanical lift with two staff members. However, she was transferred by a single CNA using a mechanical lift, which resulted in the lift tipping over and the resident being dropped. The resident sustained a laceration and abrasion to her nose and was transported to the emergency room for evaluation. The facility's policy explicitly required two-person assistance for all mechanical lift transfers, and the CNA's action was unauthorized and against policy. Both incidents were confirmed through record reviews, staff and resident interviews, and facility documentation. The deficiencies were related to staff not following established protocols for safe resident transfers, either by not using the required mechanical lift or by not ensuring the mandated number of staff were present during a mechanical lift transfer. These failures resulted in injuries to both residents and demonstrated a lack of adequate supervision and hazard prevention in the resident environment.
Failure to Properly Investigate and Communicate Grievance Regarding Suspected Aerosol Use
Penalty
Summary
A resident with multiple complex medical conditions, including chronic respiratory failure requiring ventilator support, morbid obesity, myotonic muscular dystrophy, asthma, and spina bifida, reported a grievance after suspecting that an unknown staff member sprayed an unknown substance in her room. The resident, who was dependent on staff for all mobility and had intact cognition, stated she felt a mist on her arm but could not see who entered her room due to her physical limitations. She became upset when staff would not provide the name of the person who entered, leading her to call 911. The grievance was filed by a weekend supervisor on behalf of the resident and her family member, who also sought follow-up on the incident. The facility's documentation and investigation into the grievance were incomplete. The grievance form lacked signatures from the department head and did not include a response from the concerned party or indicate whether follow-up was required. The assigned social worker was unaware of the incident and had not spoken to the resident about it. The weekend supervisor interviewed one CNA who was present in the room but did not document the identity of the second, unknown staff member or her attempts to interview that person. The administrator and DON acknowledged the incident but could not identify the unknown staff member, and there was no evidence that the resident or her family received a written or verbal summary of the investigation or its findings, as required by facility policy. Interviews with staff revealed inconsistencies regarding who was present during the incident and whether any aerosol was used, despite facility policy prohibiting aerosols in resident rooms. The resident and her family reported that no one from the facility followed up with them about the outcome of the grievance. The facility's grievance policy requires prompt investigation, written and verbal communication of findings to the complainant, and documentation of actions taken, none of which were fully completed in this case.
Failure to Update Care Plan for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised by the interdisciplinary team after each assessment, specifically omitting the need for a mechanical lift for transfers. The resident, a female with hemiplegia, hemiparesis, age-related debility, lack of coordination, and an amputation below the left knee, was documented as dependent for transfers and cognitively intact. Despite multiple records indicating the use of a mechanical lift for transfers, the care plan only reflected supervision or limited to extensive assistance with one-person physical help, without specifying the mechanical lift requirement. Additional documentation and CNA assignment sheets did indicate the use of a mechanical lift, especially after dialysis when the resident was weaker. On a specific occasion, staff transferred the resident without a mechanical lift, despite her request and her history of being transferred this way for three years. The staff cited unavailability of mechanical lifts as the reason for not using one. Interviews revealed that the care plan was not updated to reflect the mechanical lift requirement, and the facility relied on CNA tracking lists due to the absence of an MDS nurse. The facility's policy required care plans to be updated after significant changes in condition, but this was not followed in this case.
Failure to Use Required PPE During Transfer of Resident on Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistants (CNAs) O and P failed to wear proper personal protective equipment (PPE) while transferring a resident who was on enhanced barrier precautions (EBP) due to a tracheostomy and dependence on a ventilator. During the transfer using a mechanical lift, both CNAs wore gloves but did not wear gowns, despite facility policy and signage indicating the need for gown and glove use for residents on EBP. The CNAs stated they were unaware that the resident was on EBP and believed the precautions and PPE were intended for the roommate. Both CNAs acknowledged receiving frequent infection control training but did not follow the required protocols during the observed transfer. The resident involved had significant medical needs, including quadriplegia, tracheostomy status, ventilator dependence, diabetes, and dementia, and required total assistance for activities of daily living. Facility policy specified that gown and glove use is required for high-contact care activities, such as transferring residents with indwelling medical devices under EBP. The Director of Nursing (DON) confirmed that the resident was on EBP due to the tracheostomy and acknowledged that staff should have worn gowns and gloves during the transfer, as outlined in the facility's infection prevention and control policy.
Respiratory Therapy Director Practiced Without Valid State License
Penalty
Summary
The facility failed to ensure that the Respiratory Therapy Director, who was working as a Respiratory Therapist, held a valid state license to practice in Texas during the period from August 2021 to August 2024. Review of the personnel file showed only a national certification and a state license effective beginning January 2025, with no evidence of a valid Texas license during the time the individual was employed in the role. The HR department head confirmed that only the national licensure was on file and did not see the need for state licensure. Additionally, a remedial plan from the Texas Board of Respiratory Care documented that the individual practiced without a state license during the specified period. Facility policy requires that personnel not perform duties requiring licensure until a current, unencumbered license is verified, which was not followed in this case.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse by a Certified Nursing Assistant (CNA), identified as CNA A, who provided rough bed mobility assistance and incontinent care. The incidents occurred on two separate occasions, during which CNA A was observed in video footage to handle the resident roughly, causing visible bruising. The resident, who was cognitively intact with a BIMS score of 15, reported feeling unsafe with CNA A and identified her as the source of his injuries. The resident's responsible party submitted videos and pictures showing the bruising, which were consistent with the rough handling observed in the videos. The resident, a male with significant physical and intellectual disabilities due to genetic conditions, was dependent on staff for toileting hygiene and lower body dressing. He was always incontinent and used a wheelchair. Despite his impairments, he was social and engaged in activities like bingo. The resident's care plan indicated he required assistance with activities of daily living and was known to become upset easily. However, the facility failed to ensure that staff approached him in a calm and reassuring manner, as outlined in his care plan. Interviews with staff revealed that CNA A had been assigned to the resident during the week of the incidents and had documented providing care on the days in question. Despite being trained on resident rights and abuse prevention, CNA A's actions were deemed abusive by the facility's Director of Nursing (DON) after reviewing the video footage. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the failure to protect the resident from rough handling and the subsequent emotional distress reported by the resident.
Failure in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, resulting in missed doses of critical seizure medications and improper administration of a PRN medication. Specifically, the resident did not receive five doses of Lamictal and two doses of Phenobarbital over a two-day period. Additionally, Ativan, which was prescribed for seizures, was administered for agitation and anxiety instead, contrary to the physician's orders. The resident, a male with a history of tracheostomy, unspecified dementia, schizophrenia, anxiety disorder, and seizures, was admitted to the facility shortly before the deficiencies occurred. The facility's Medication Administration Record (MAR) indicated that the resident missed several doses of his prescribed medications, and there was no documentation explaining these omissions. Furthermore, the MAR showed that Ativan was given for agitation, despite the order specifying its use for seizures, and there was no documentation of seizure activity to justify its administration. Interviews with facility staff, including LPNs and the DON, revealed confusion and lack of clarity regarding the administration of medications. The DON acknowledged that medications might not have been available due to specialty or insurance issues, but was unsure of the exact reasons. The facility's policies required staff to verify unclear orders with prescribers and to contact them if medications were unavailable, but these procedures were not followed, contributing to the deficiencies observed.
Privacy Breach During Personal Care
Penalty
Summary
The facility failed to ensure the privacy of two residents during personal care activities, leading to a deficiency in maintaining resident privacy and dignity. Resident #2, who is cognitively intact and requires assistance with activities of daily living due to cerebral cysts, was observed on video having his incontinence brief changed without the privacy curtain being fully closed. This exposed his lower body to his roommate, Resident #3, and potentially to the camera installed in the room. The camera, authorized by Resident #2's responsible party, was not obstructed during perineal care as required, leading to a breach of privacy. Resident #3, who has mild cognitive impairment and is highly hearing impaired, was also affected by the privacy breach. The facility did not have a signed consent for electronic monitoring for Resident #3, and his image was captured on the camera without proper authorization. The facility's social worker and administration were aware of the camera's presence but failed to ensure that Resident #3's privacy was protected, as his responsible party was not informed about the need for consent. Interviews with facility staff, including the CNA involved and the Director of Nursing, revealed that there was a lack of adherence to privacy protocols during personal care. The CNA did not close the privacy curtain, and the facility's policies on dignity and videotaping were not followed, resulting in the exposure of residents' private areas and the unauthorized capture of images. The facility's failure to maintain privacy during care and to obtain necessary consents for electronic monitoring contributed to the deficiency.
Failure to Implement Comprehensive Care Plan Due to Insurance Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs. The resident, a 61-year-old male with a history of cerebral infarction and age-related physical debility, was admitted to the facility and required assistance with activities of daily living due to cognitive and physical impairments. Despite having an active order for physical, occupational, and speech therapy evaluation and treatment, the resident did not receive these services due to issues related to insurance approval. The resident's care plan indicated a need for rehabilitation therapy screening, but the facility did not ensure that the resident was assessed for physical and occupational therapy as planned. The resident's interdisciplinary screen recommended referrals to therapy services, but these were not acted upon due to the resident's Medicaid pending status and lack of insurance coverage. The facility's Director of Rehabilitation (DOR) and Director of Nursing (DON) acknowledged that the resident had not received therapy services and cited insurance approval as a barrier, with no documentation of therapy assessments by physical and occupational therapy staff. Interviews with the resident and their responsible party (RP) revealed dissatisfaction with the lack of therapy services, and the RP expressed concerns about the resident's declining physical condition. The facility's policy on therapy services required physician orders, but there was no clear process for handling therapy referrals when insurance approval was delayed. The facility's failure to provide necessary therapy services and implement a comprehensive care plan placed the resident at risk of not receiving the care needed to address their specific needs.
Failure to Provide Required Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services to a resident as required by their comprehensive plan of care. The resident, a 61-year-old male with a history of cerebral infarction and age-related physical debility, was admitted to the facility and had an active physician order for evaluations and treatments by physical therapy (PT), occupational therapy (OT), and speech therapy (ST) dated several months prior. Despite these orders, the resident did not receive the necessary evaluations and treatments, which could place him at risk of a decline in his physical capabilities. Interviews and record reviews revealed that the resident had not received PT, OT, or ST services due to issues related to insurance approval. The Director of Rehabilitation (DOR) stated that the resident was not referred to PT or OT initially because he was Medicaid pending and did not have insurance coverage. The resident's responsible party (RP) expressed concerns about the lack of rehabilitation services and noted that the resident had become weaker since admission. The facility's process for therapy orders involved insurance review first, and therapy screening depended on the resident's insurance type. The facility's policy on therapy services required orders to be obtained from the resident's attending physician, but there was no clear process for handling therapy referrals or treatment orders. The DOR admitted that PT and OT staff did not document or complete screens or assessments for the resident, and the DON was unsure if a policy existed for therapy orders. The facility's failure to provide the necessary rehabilitative services as ordered by the physician highlights a deficiency in their process for ensuring residents receive appropriate care.
Medication Error Involving Incorrect Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an LPN administered medications intended for another resident. The medications included atorvastatin, labetalol, and hydralazine, which were not prescribed for the resident. This incident occurred during the evening medication pass, and the error was realized by the LPN partway through the administration process. The resident involved was a female with a complex medical history, including anoxic brain damage, chronic respiratory failure with hypoxia, and secondary hypertension. She was not assessed for mental status due to communication difficulties and was receiving nutrition through a feeding tube, along with oxygen therapy and tracheostomy care. Her prescribed medications included anticoagulants, antiplatelets, and anticonvulsants, none of which were the medications mistakenly administered. The error was documented in the resident's progress notes, and the facility's policies on medication administration were not followed, as the LPN did not verify the resident's identity or check the medication label three times as required. The incident was reported to the physician and the resident's family, and the resident was monitored for any adverse reactions, although none were noted. The facility's policy on adverse consequences and medication errors defines such errors as the administration of drugs not in accordance with physician orders or professional standards.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN A and CNA B during the care of a resident on Enhanced Barrier Precautions (EBP). On the specified date, LVN A and CNA B did not wear gowns while providing wound care and peri-care to the resident, despite the resident's status requiring such precautions. The resident, who was admitted with multiple diagnoses including anoxic brain damage and dependence on a ventilator, had orders for EBP due to the presence of indwelling devices and a skin integrity issue. During the observed care, LVN A did not adhere to proper infection control practices. She failed to change gloves or perform hand hygiene throughout the procedure, even after touching potentially contaminated surfaces and the resident's wound. LVN A used the same piece of gauze multiple times to clean the wound and did not change gloves after handling soiled dressings. Additionally, she touched various medical devices and the resident's body without changing gloves, increasing the risk of cross-contamination. Interviews with the staff revealed a lack of awareness and understanding of EBP requirements. CNA B was unaware that the resident was on EBP and believed that the use of gowns was optional. LVN A admitted to deviating from her training due to being in a hurry and acknowledged her failure to follow proper procedures. The Director of Nursing (DON) confirmed the infection control issues upon reviewing the video footage, highlighting the need for staff to wear gowns and adhere to hand hygiene protocols during high-contact care activities.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the right to personal privacy during personal care for four residents. Observations revealed that staff did not adequately close privacy curtains, doors, or blinds while providing incontinence care. This lack of privacy was noted during care for residents with various medical conditions, including hypertension, diabetes, tracheostomy status, and cognitive impairments. The failure to provide privacy was observed during specific instances of care, such as checking for incontinence and providing incontinent care. Resident #5, who has severe cognitive impairment and is incontinent of bowel and bladder, was checked for incontinence by a CNA who did not pull the privacy curtain or close the blinds. Similarly, Resident #6, who has intact cognition and requires bowel and bladder incontinence care, was provided care by a CNA who did not completely close the privacy curtain. Resident #7, with severe cognitive impairment and a catheter, was checked for incontinence by an RN who left the door and blinds open and did not fully close the privacy curtain. Resident #8, with severe cognitive impairment and a catheter, received incontinent care from two CNAs who did not fully close the privacy curtain. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the facility's policy requires privacy curtains, doors, and blinds to be closed during resident care to protect residents' privacy. Staff acknowledged the importance of maintaining privacy to prevent residents from feeling embarrassed or ashamed. The facility's policies on resident rights, perineal care, and dignity emphasize the importance of treating residents with respect and ensuring their privacy during personal care.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by state and federal laws. During an observation and interview, it was found that the Respiratory Treatment Cart #1 on the 300 hall was left unlocked and unattended. The Director of Nursing (DON) confirmed that the cart was not supposed to be left unlocked, even though it contained only respiratory supplies such as tracheostomy equipment. This oversight occurred in an environment where mobile residents were present, increasing the risk of unauthorized access. Additionally, the Wound Treatment Cart #2 was observed to be left unlocked on two separate occasions by an LVN. The cart contained various treatments, including creams and ointments, which could potentially be ingested by residents, leading to adverse reactions. The LVN acknowledged that the cart should not have been left unlocked, especially with mobile residents in the facility. The DON reiterated the expectation that all medication and treatment carts should be locked when unattended to prevent unauthorized access and potential harm.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal and incontinent care for seven residents. Observations revealed that staff members did not change gloves or perform hand hygiene at critical points during care, such as after removing soiled briefs or before handling clean items. For instance, a CNA was observed dropping a clean brief on the floor, picking it up without changing gloves, and placing it in a resident's drawer. Another staff member washed hands for only 8 seconds after checking a resident for incontinence, contrary to the recommended 20 seconds. Several residents with various medical conditions, including diabetes, respiratory failure, and cognitive impairments, were affected by these practices. The care plans for these residents indicated the need for assistance with activities of daily living and incontinence care. However, staff members were observed not adhering to infection control guidelines, such as failing to perform hand hygiene between glove changes and using the same surface of wipes repeatedly during perineal care. Interviews with staff and the Director of Nursing (DON) revealed a lack of adherence to infection control policies. Staff members expressed confusion about proper glove use, with some believing double gloving was acceptable. The DON admitted to not knowing the facility's hand hygiene policy and acknowledged that double gloving was not acceptable. The Administrator emphasized the importance of following infection control policies to reduce exposure to infections, yet the observations indicated a systemic failure in implementing these practices.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a requirement to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment. The deficiency was identified for one of the eight residents reviewed for care plans. The care plan did not address several critical areas, including cognitive loss/dementia, visual function, communication, urinary incontinence and indwelling catheter, psychosocial well-being, activities, nutritional status, feeding tube, dehydration/fluid maintenance, pressure ulcer, physical restraints, and functional abilities related to self-care and mobility. The resident in question was admitted with multiple diagnoses, including type 2 diabetes, hypertension, nontraumatic intracerebral hemorrhage, and acute/chronic respiratory failure, among others. The comprehensive MDS assessment revealed that the resident had severely impaired cognitive skills for daily decision-making and was dependent on assistance for various activities of daily living. The resident also had an indwelling catheter, was always incontinent of bowel, required a feeding tube, and was at risk of developing pressure ulcers. Despite these needs, the care plan only focused on an actual fall incident, neglecting other significant care areas. Interviews with facility staff, including an RN and the DON, revealed that the care plan was not completed in a timely manner following the MDS assessment. The RN acknowledged the importance of completing care plans to ensure that all staff are aware of the plan of care and can appropriately care for the residents. The facility's policy requires that a comprehensive, person-centered care plan be developed within seven days of completing the MDS assessment, but this was not adhered to in this case.
Failure to Maintain Sanitary Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents requiring tracheostomy care, as observed during a survey. For both residents, the aerosol tubing connected to their tracheostomies was found on the floor. In the case of the first resident, the tubing was picked up by a CNA and placed on a side table, after which an LVN reconnected it to the resident's tracheostomy without being informed that it had been on the floor. Similarly, for the second resident, the tubing was also found on the floor, picked up, and placed on a side table by a CNA, and subsequently reconnected by the same LVN without knowledge of its prior location. Interviews with the staff revealed a lack of communication regarding the tubing's contamination, which is crucial for preventing infection. The CNA involved admitted to not informing the LVN about the tubing being on the floor, acknowledging the importance of replacing it to maintain sanitary conditions. The LVN stated that had she been aware of the tubing's contamination, she would have ensured it was replaced. The facility's Director of Nursing expressed an expectation for staff to report such incidents due to the risk of infection. The facility's policy on tracheostomy care emphasizes maintaining cleanliness to prevent infection, which was not adhered to in these instances.
Failure to Document Suprapubic Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had a suprapubic catheter. On 9/29/24, a Licensed Vocational Nurse (LVN A) inserted a suprapubic catheter for the resident but did not document the procedure or the urine output in the medical records. The resident, a 22-year-old male with a history of neuromuscular dysfunction of the bladder and quadriplegia, was admitted to the hospital with gross hematuria and a malfunctioning suprapubic catheter. Despite the resident's report and the LVN's acknowledgment of the catheter change, the documentation was missing, which is against the facility's policy requiring all services and changes in a resident's condition to be recorded. Interviews revealed that LVN A had the competencies for suprapubic catheter insertion but failed to document the procedure due to a busy night. The Director of Nursing (DON) confirmed that major events like catheter insertions should be documented, and if another nurse was present, they should have recorded the procedure in the progress notes. Another nurse, LVN D, checked on the resident throughout the shift and confirmed urine output, but this was also not documented. The lack of documentation could lead to a lack of continuity in care and diminished quality of life for the resident.
Improper Catheter Bag Handling Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the improper handling of a catheter bag for a resident. The resident, a cognitively intact female with a history of type 2 diabetes, urinary tract infections, and end-stage renal disease, was observed with her catheter bag lying on the floor instead of being anchored to the bed rail. This observation was made during a survey, and it was noted that the catheter bag contained no urine, although there was urine present in the tubing. The resident reported that the morning staff did not consider it their responsibility to empty the catheter bag, although the evening and night shifts did not have this issue. Interviews with the facility's staff, including an LVN and the DON, confirmed the improper placement of the catheter bag on the floor, which was acknowledged as a potential infection control issue. The LVN, who was the charge nurse for the day shift, admitted that the nursing staff was responsible for ensuring the catheter bag was properly anchored, but could not explain why the bag was on the floor. The DON also confirmed that the bag was anchored during her check but could not explain the discrepancy. The facility's policy on catheter care, revised in September 2024, clearly stated that catheter tubing and drainage bags should be kept off the floor.
Failure to Label Open Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service in their kitchen. During an observation of the reach-in refrigerator, two open gallon jugs of ranch dressing were found unlabeled. The Dietary Manager confirmed that all food items should be labeled with the date opened and the use-by date after being opened, as per the facility's policy. This policy, named Food Receiving and Storage, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. The Dietary Manager stated that staff are trained to follow this procedure, and it is their responsibility to ensure compliance. The failure to label the food items placed residents at risk for foodborne illness, as it did not comply with the Food Code standards set by the U.S. Public Health Service and the FDA.
Inaccurate Blood Pressure Documentation in EMAR
Penalty
Summary
The facility failed to maintain accurate medical records for five residents, specifically in documenting blood pressure readings when administering hypertension medication. The discrepancies were found in the electronic medical administration records (EMAR) where the same blood pressure readings were recorded for different shifts on the same day. This inconsistency was noted for residents who were on metoprolol tartrate, a medication used to treat hypertension, with specific instructions to hold the medication if systolic blood pressure (SBP) was less than 110 or pulse was less than 60. The residents involved had various levels of cognitive impairment, with some being cognitively intact and others moderately impaired. Each resident had a care plan that included monitoring blood pressure and notifying the physician if readings were high or low. However, the documentation in the EMAR did not reflect accurate blood pressure readings, which could potentially lead to medication errors and affect the continuity of care. Interviews with the nursing staff revealed that they took their own vital signs and recorded them on paper before entering them into the computer system. Some staff admitted to using the 'use last documented' button in the electronic system, which led to repeated blood pressure readings being recorded. The Director of Nursing (DON) and the Administrator acknowledged the issue and noted that the repeated use of the same blood pressure readings did not accurately reflect the effectiveness of the medications administered.
Inadequate Care Plan for Resident with Restraints
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which was inconsistent with the resident's rights and did not describe the services necessary to attain or maintain the resident's highest practicable well-being. The resident, a male with a history of cerebral infarction, tracheostomy status, anxiety disorder, and schizophrenia, had an order to remove his mitten restraints every two hours for ten minutes for skin checks and exercises. However, the care plan only documented a requirement to visually observe the mitten restraints every two hours, without including the necessary intervention to release the restraints for skin checks or exercises. Observations and interviews revealed that the nursing staff were following the physician's order to remove the restraints every two hours, despite the care plan's incorrect documentation. The LVN confirmed that she removed the restraints one at a time to check the resident's skin and perform finger exercises, while the DON acknowledged the discrepancy between the care plan and the actual practice. The facility's policy on comprehensive assessments indicated that significant errors in assessments could result in inappropriate care plans, which was evident in this case.
Inadequate Supervision and Security Measures for Residents at Risk of Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for several residents identified as at risk for elopement. Resident #5, who was admitted with dementia and assessed as a high wander risk, managed to leave the facility unsupervised and was found 13 miles away. The facility's front door was left unlocked and unmonitored during specific hours, and the receptionist was unaware of which residents were at risk for wandering or elopement. Residents #7, #10, #11, and #12 were also assessed as at risk for wandering, yet the facility did not have adequate measures in place to monitor them. The front door was unlocked and unmonitored during certain hours, and the receptionist did not have a list of residents who required supervision when going outdoors. Observations revealed that residents were able to leave the facility unsupervised, posing a risk of harm. Interviews with staff indicated a lack of awareness and training regarding the supervision of residents at risk for elopement. The facility's policy on elopement was not effectively implemented, as evidenced by the unlocked doors and the absence of a system to monitor residents at risk. This lack of supervision and security measures led to the identification of an Immediate Jeopardy situation, highlighting the potential for severe injury or death.
Failure to Document Meal Consumption
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of meal consumption on two consecutive days. The resident, who was cognitively intact and totally dependent on assistance for eating, did not have records indicating that meals were provided on 3/9/24 and 3/10/24. Interviews with staff revealed that the meals were given but not documented due to the involvement of agency staff who were not fully oriented to the facility's documentation methods. The resident's care plan and physician's orders specified a no-added-salt diet with regular texture and consistency, and the resident required total assistance for feeding. Despite these clear instructions, the lack of documentation created confusion about whether the resident was fed. The weekend supervisor and agency staff failed to document the meals, and there were no notes indicating that the resident refused to eat on those dates. Interviews with the Director of Nursing (DON) and other staff confirmed that the resident was fed but the documentation was missing. The DON acknowledged that the agency staff and weekend supervisor did not document the feeding in the Point of Care (POC) system. This lapse in documentation was attributed to the agency staff not being fully trained in the facility's documentation procedures, leading to potential misinformation about the resident's care.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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