Focused Care Of Gilmer
Inspection history, citations, penalties and survey trends for this long-term care facility in Gilmer, Texas.
- Location
- 623 Hwy 155n, Gilmer, Texas 75644
- CMS Provider Number
- 675602
- Inspections on file
- 41
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 19 (2 serious)
Citation history
Health deficiencies cited at Focused Care Of Gilmer during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for ADLs, who was receiving Eliquis, slid from bed onto a floor mat and remained on the floor for several hours before being found. Nursing staff manually lifted the resident from the floor back into bed without a mechanical lift or gait belt and did not obtain vital signs, perform neuro checks, or immediately notify the physician, despite an unwitnessed fall and anticoagulant use. Routine rounding every two hours did not occur, and the resident was later sent to the ED at family request. When the resident returned, the receiving LVN did not obtain or secure hospital records, and the facility did not review the ED imaging that documented possible bilateral massive rotator cuff tears and a right humeral head fracture until surveyor intervention. These actions and omissions violated the facility’s own fall and risk management policies and resulted in an Immediate Jeopardy finding for failure to provide care according to professional standards and the care plan.
A resident with advanced dementia, severe functional limitations, and on Eliquis fell from bed onto a floor mat and remained on the floor for over two hours before being discovered by staff. The assigned CNA and RN acknowledged they had not rounded on the resident during that period, despite expectations for 2‑hour checks. When the RN, an LVN, and a CNA returned the resident to bed, they manually lifted him from the floor without a mechanical lift, lift sheet, or gait belt, contrary to facility policy requiring mechanical devices for heavy lifting. The RN did not obtain post‑fall VS or neuro checks, did not notify the physician at the time of the unwitnessed fall, and documentation confirmed these assessments were not completed. Family reported delayed notification and were initially told the resident had not hit his head, while later hospital imaging showed bilateral shoulder abnormalities and a possible fracture. On return from the ED, the receiving LVN did not obtain hospital records, and significant imaging findings were not communicated to or reviewed by facility clinicians at that time, contributing to the cited deficiency under F689.
A resident with paraplegia and a history of bowel issues missed a scheduled surgical consultation because the facility failed to provide transportation, despite being aware of the appointment in advance. The regular van driver called in sick, and no backup driver was available in time. Attempts to arrange alternative transportation were unsuccessful, resulting in the cancellation of the appointment.
A resident with significant mobility and toileting needs was found in an unclean room with strong urine odors, sticky floors, and flies present. Staff interviews revealed urinals were not emptied as frequently as required, leading the resident to empty them into a trashcan, causing spills and persistent odors. Housekeeping staff cleaned daily but lacked specialized products to address urine smells, and leadership acknowledged the ongoing issue and the need for more frequent checks.
Two residents with indwelling catheters and a history of incontinence did not receive proper infection control during catheter and incontinent care, as CNAs failed to change gloves and perform hand hygiene when moving between dirty and clean tasks, and handled clean items after contact with soiled materials, despite documented training and care plans addressing their needs.
Two CNAs provided incontinent care to a resident with a Foley catheter, gastrostomy tube, and wound without wearing required PPE, despite having completed EBP training and PPE being available. The resident was medically complex and dependent on staff for care. Staff interviews revealed inconsistent understanding and application of EBP protocols, and facility policy required PPE use for such care activities.
A medication aide failed to administer physician-ordered medications to three residents due to unavailability during a medication pass. The residents, with conditions such as quadriplegia, dementia, and depression, did not receive their prescribed Pepcid and paroxetine (Paxil). The aide did not report the shortage to management, highlighting a communication breakdown in maintaining medication supplies.
A medication aide in an LTC facility failed to administer medications as ordered, resulting in a 15.22% error rate. Errors included not administering Pepcid and Paxil due to unavailability and incorrect dosing of Vitamin C. The aide mixed medications contrary to training, affecting four residents with various conditions such as quadriplegia, dementia, and leukemia.
The facility failed to ensure proper labeling and disposal of expired foods in the kitchen, as observed during a survey. Unlabeled and expired items were found in the refrigerator and dry storage, and staff interviews revealed inconsistencies in checking and discarding expired foods. The Dietary Manager and Administrator acknowledged the lapses, which could risk foodborne illness to residents.
The facility failed to maintain safe and sanitary conditions in the personal refrigerators of three residents, leading to the presence of expired and improperly stored food items. A resident's refrigerator was found dirty with unlabeled food, another contained expired soup, and a third had expired fruits. Housekeeping staff were responsible for checking refrigerators but did not consistently check for expired foods, despite facility policy requiring proper food storage and disposal. This deficiency could potentially place residents at risk for foodborne illness.
The facility failed to maintain an effective infection prevention and control program, as evidenced by lapses in hand hygiene and equipment sanitation. Two CNAs did not change gloves or sanitize hands during incontinent care, and a medication aide failed to sanitize hands and clean a blood pressure cuff between residents. These actions were against the facility's infection control protocols, potentially putting residents at risk of infection.
A resident with atherosclerotic heart disease, requiring extensive assistance with activities of daily living, was found with long, jagged fingernails and a thick black substance under them, indicating a lack of proper nail care. Staff interviews revealed confusion over responsibilities, with a CNA assuming hospice or the treatment nurse handled nail care. The treatment nurse confirmed weekly checks but had not done so until late on the day of observation. The DON and Administrator acknowledged the lack of a specific policy on nail care.
A resident in a facility experienced delays in care due to insufficient staffing, with only one nurse often on duty, particularly overnight. Staff reported being sent home early, leaving inadequate coverage for resident needs. Despite concerns raised by staff, the administration maintained current staffing levels, citing corporate directives, even though the facility's assessment indicated a need for more staff.
Two residents' bathrooms were found without call light pull cords, posing a risk in case of falls. Both residents, one with hemiplegia and the other with COPD, were at risk for falls and required assistance with toileting. Staff interviews revealed a lack of awareness and communication regarding the missing cords, with the Maintenance Director unaware of the issue due to no work orders being submitted.
The facility failed to provide mandatory QAPI training to two CNAs, hired in 2017 and 2024, respectively. The ADON, responsible for training oversight, was unaware of the deficiency, using a manual system to track training. The Administrator, also unaware, acknowledged the potential impact on resident care due to untrained staff.
Two residents in a long-term care facility experienced verbal and physical abuse by a CNA during incontinent care. Despite being trained on abuse policies, the CNA was rough and spoke inappropriately to the residents, causing emotional distress. The facility confirmed the abuse through an investigation and terminated the CNA after a week of employment.
Failure to Assess, Monitor, and Follow Up After Anticoagulated Resident’s Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, the resident’s care plan, and the resident’s clinical status following a fall. An elderly male resident with dementia, severe cognitive impairment, functional limitations in all extremities, and total dependence for ADLs was on Eliquis, an anticoagulant. His care plan identified a history of falls and required post-fall monitoring for 72 hours, including neurological checks and observation for changes in mental status, pain, bruising, and other signs of injury. On the evening in question, video evidence showed the resident slowly sliding from his bed onto a floor mat, ultimately lying on his left side with his head and face on the mat. The resident remained on the floor for approximately two to three hours before being discovered by staff. A housekeeper found him on the floor next to the bed, and RN A and LVN B responded. Video recordings showed that RN A, LVN B, and a CNA manually lifted the resident from the floor mat back into bed by holding under his arms and legs, without using a mechanical lift or gait belt. Interviews with RN A, LVN B, and the CNA confirmed that no vital signs or neurological checks were performed at the time of the fall, despite the fall being unwitnessed and the resident being on a blood thinner. RN A acknowledged he did not obtain vital signs or neuro checks, did not contact the physician after the fall or when the resident was sent to the hospital, and did not check on the resident prior to the fall during that shift. The CNA reported she had not rounded on the resident between the start of her shift and the time he was found on the floor, and that routine rounding every two hours did not occur. The facility also failed to obtain, review, and follow up on the resident’s hospital records after he was sent to the emergency department at the family’s request the following morning. Progress notes documented that the resident returned from the ED without any paperwork from the hospital. LVN E, who received the resident back from the hospital, stated that no records accompanied him, that she was told by the hospital that records had been given to the family, and that she requested a fax but did not receive it. The DON and Administrator stated that the receiving nurse was responsible for ensuring hospital records were obtained and for following up if they were not. Hospital documentation, later obtained during the survey, showed imaging findings of elevation of both humeral heads suggesting massive rotator cuff tears and a possible fracture of the right humeral head. The facility’s nurse practitioner reported she was only notified of these significant diagnostic findings during the survey and had not been able to order timely follow-up because the hospital records had not been obtained or reviewed by facility staff. Family interviews corroborated that the resident lay on the floor for an extended period, that they were notified late at night, and that they were told he had not hit his head, despite the hospital HPI describing a fall in which he struck his head on the floor. Family members also reported bruising on the resident’s head and shoulder and a scratch on his back, and expressed concern that vital signs and neurological checks were not done and that the transfer from the floor back to bed was improper. The DON and Director of Rehabilitation, after viewing the video, stated that the transfer technique used by staff was inappropriate and that a mechanical lift or gait belt should have been used. The facility’s own fall and risk management policy required a head-to-toe assessment, vital signs, pain assessment, environmental assessment, physician and responsible party notification, and neurological checks for any unwitnessed fall or fall involving the head, which were not carried out in this case. These combined failures led to the identification of an Immediate Jeopardy related to quality of care for this resident.
Failure to Supervise, Assess, and Safely Transfer a Resident After an Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment as free of accident hazards as possible and to provide adequate supervision and post‑fall assessment. An elderly male resident with dementia, severe cognitive impairment, functional limitations in all four extremities, and total dependence for bed mobility and transfers was care planned as at risk for falls, with interventions including fall mats, anticipating needs, prompt assistance, and staff assistance for all mobility. He was on Eliquis, an anticoagulant. Video provided by family showed the resident in bed with his head, shoulder, and arm off the side of the bed, reaching toward the bedside dresser, then gradually sliding off the bed and onto the floor mat, coming to rest on his left side with his head and face on the mat. The time stamp on this video was approximately 8:05 p.m. A second video, time stamped around 10:25 p.m., showed the resident still lying on the floor mat on his side next to the bed when an LVN and an RN entered the room. The LVN stated they would need a mechanical lift, and the RN briefly left the room. A third video, beginning around 10:28 p.m., showed the RN, LVN, and a CNA manually moving the resident from lying on the mat to a seated position and then lifting him back into bed by placing their hands under his arms and legs and lifting him together, without use of a mechanical lift, lift sheet, or gait belt. This manual lift occurred despite a facility policy stating that manual lifting of residents shall be eliminated when feasible and that mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. The Director of Rehabilitation later characterized the transfer as inappropriate, and the DON stated she did not think the transfer was proper and believed a mechanical lift or lift sheet should have been used. Progress notes documented that the resident was found on the floor next to his bed by a housekeeper, with fall mats in place, and that no injuries were initially noted. Interviews with the CNA assigned to the hall and the RN revealed that neither had checked on the resident between the start of the shift and the time he was found on the floor; the CNA stated she usually rounded every two hours but had not checked on him before he was found, and the RN stated he first saw the resident only when notified he was on the floor. The CNA acknowledged that if she had checked on him earlier, she might have found him sooner. The RN admitted he did not obtain vital signs or perform neurological checks after the unwitnessed fall, despite recognizing that such assessments are important, especially for unwitnessed falls, and acknowledged he did not contact the physician at the time of the fall or when the resident was sent to the hospital. The LVN who assisted with the transfer stated she did not see the RN obtain vital signs, perform an assessment, or complete neurological checks while she was in the room and believed the resident should have been sent out at the time of the fall. Family members reported they were not notified of the fall until several hours after it occurred and were initially told the resident did not hit his head. They later described observing bruising on his head and shoulder and a scratch on his back. Hospital records from the subsequent ED visit documented that the resident had fallen from bed, primarily onto his left side, with video reviewed at the hospital indicating he had been on the floor for about two hours, and that he was on Eliquis. Imaging of both shoulders showed elevation of both humeral heads suggesting massive rotator cuff tears and possible fracture of the right humeral head. The facility’s own documentation showed that neurological checks and vital signs were not completed after the fall, and the DON confirmed that post‑fall vital signs and neurological checks were not done. The facility also failed to ensure that hospital records, including the abnormal imaging findings, were obtained and reviewed when the resident returned from the hospital; the receiving LVN reported that no paperwork accompanied the resident, that she requested records and a fax but did not receive them, and that she was told by hospital staff that everything was clear. The nurse practitioner later stated she was only notified of the imaging findings on a later date and would have ordered follow‑up imaging and an orthopedic consult had she been informed when the resident returned. The CNA and RN both acknowledged staffing limitations on the night of the fall, including the absence of a medication aide and only two CNAs on duty, and the RN stated he was busy passing medications and did not check on the resident prior to the fall. The CNA confirmed that she was assigned to the resident’s hall, usually rounded every two hours, but did not check on the resident until around the time he was found on the floor. The DON and Administrator both stated they expected nurses and CNAs to check on residents every two hours and that vital signs and neurological checks should be completed after a fall, particularly for a resident on a blood thinner. The combination of delayed discovery of the resident on the floor, failure to monitor him at least every two hours, failure to perform timely and complete post‑fall assessments (including vital signs, neurological checks, and physician notification), failure to use appropriate lifting equipment or techniques to return him to bed, and failure to obtain and review hospital records with significant diagnostic findings constituted the deficient practice that led to the Immediate Jeopardy determination.
Failure to Provide Transportation for Medical Appointment
Penalty
Summary
The facility failed to provide transportation for a resident to a scheduled medical appointment, despite being aware of the appointment two weeks in advance. The resident, who had paraplegia and required dependent assistance with all activities of daily living, was scheduled for a consultation with a colon surgeon regarding a colostomy due to a swollen colon. Documentation showed that the appointment was known to staff, and reminders were given by a family friend on the day of the appointment. However, the facility did not arrange for transportation, citing the absence of the regular van driver, who called in sick that morning, and the unavailability of a backup driver in time for the appointment. Interviews with staff and family members confirmed that the facility had only one designated driver at the time, and the backup driver was not available early enough to transport the resident. The maintenance staff member, who also served as the van driver, notified the facility early in the morning that he would not be able to work. Attempts to secure alternative transportation, including contacting local emergency medical and transportation services, were unsuccessful. As a result, the appointment was canceled to avoid a fee for a missed appointment, and the resident did not receive the scheduled medical evaluation. The facility's policies indicated that they were responsible for assisting residents in arranging transportation to medical appointments. Despite this, the lack of a backup driver and the failure to secure alternative transportation led to the resident missing an important medical consultation. The incident was corroborated by interviews with the resident, family members, and facility staff, all of whom acknowledged the missed appointment and the facility's inability to provide transportation as required.
Failure to Maintain Clean, Odor-Free, and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was found to be unclean and had a persistent strong urine odor. The resident, a male with hypertensive heart disease, paraplegia, and spinal stenosis, required total assistance with toileting hygiene and was occasionally incontinent of urine. Observations revealed that the resident kept two urinals hanging on a trashcan beside his bed, both containing urine, and the floor near the bed and trashcan was wet, sticky, and had flies present. The resident reported that staff did not empty his urinals frequently enough, leading him to sometimes empty them into the trashcan himself, which contributed to the odor and uncleanliness in the room. Interviews with staff confirmed that urinals should be emptied at least every two hours, but this was not consistently done. A CNA noted that the urinal was overflowing and urine had spilled onto the floor, which she attempted to clean. Housekeeping staff reported ongoing issues with urine odor in the room, attributed to the resident's use of urinals and occasional incontinence, and stated that while the room was cleaned daily, there were no special cleaners available to address urine odors. The housekeeping supervisor and other staff acknowledged the persistent odor and the challenges in maintaining cleanliness, despite daily cleaning and attempts at deep cleaning. Facility leadership, including the Assistant Director of Clinical Operations and the Administrator, recognized that staff should have been checking and emptying the urinals more frequently. They also noted that the resident did not like staff entering his room at night, which may have contributed to the issue. The facility's policy emphasized the importance of a clean, sanitary, and homelike environment, but the ongoing presence of urine odor and unclean conditions in the resident's room demonstrated a failure to meet these standards.
Failure to Follow Infection Control Practices During Incontinent and Catheter Care
Penalty
Summary
The facility failed to ensure that two residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore continence to the extent possible. For one resident with a history of frontotemporal neurocognitive disorder, Down syndrome, paraplegia, and neuromuscular dysfunction of the bladder, a CNA did not follow proper infection control practices during catheter and incontinent care. The CNA did not clean or place a barrier on the bedside table before placing supplies, failed to change gloves and perform hand hygiene when moving from dirty to clean tasks, and handled clean items after touching soiled materials without changing gloves. The CNA acknowledged these lapses during an interview, stating he should have changed gloves and performed hand hygiene at multiple points during care. For another resident with multiple sclerosis, neurogenic bladder, and a history of recurrent UTIs, a different CNA also failed to follow infection control protocols during incontinent care. The CNA washed her hands and donned gloves initially but did not perform hand hygiene when changing gloves between dirty and clean tasks. She also handled clean linens without changing gloves after providing care to soiled areas. The CNA admitted she should have used hand sanitizer and changed gloves at appropriate times but did not have sanitizer available and became distracted during care. Both residents had care plans and physician orders addressing their incontinence, catheter use, and risk for UTIs, including specific medications and interventions. Despite documented competency evaluations for the CNAs, direct observation revealed that infection control practices were not consistently followed during care. Facility leadership confirmed their expectations for proper hand hygiene and glove use during such care, and acknowledged the importance of these practices in preventing infection.
Failure to Ensure Staff Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff consistently followed infection prevention and control protocols, specifically Enhanced Barrier Precautions (EBP), when providing care to a resident with multiple risk factors for infection. On the date in question, two CNAs provided incontinent care to a resident who had a Foley catheter, gastrostomy tube, and a wound, without wearing the required personal protective equipment (PPE). This was confirmed through photo evidence submitted by a responsible party, which showed the staff members not wearing PPE during the care activity. Both CNAs had completed EBP training prior to the incident, and facility records indicated that PPE was available and that signage and supplies were in place to support compliance with EBP protocols. The resident involved was an older male with significant medical complexity, including end stage renal disease, osteomyelitis, heart failure, neuromuscular bladder dysfunction, a gastrostomy, peripheral vascular disease, and a below-the-knee amputation. He was dependent on staff for most activities of daily living, including toileting and mobility, and was unable to complete a BIMS assessment. The care plan and physician orders specified that the resident was to be on EBP due to his Foley catheter, gastrostomy tube, and chronic wounds, with interventions including staff and family education, signage, and ready access to PPE. Interviews with staff revealed inconsistent understanding and application of EBP protocols. One CNA could not recall if PPE was worn during the incident and admitted to not always using PPE, while the other CNA demonstrated a lack of understanding regarding when gowns were required. Other staff, including the ADON, DON, and additional CNAs, acknowledged the importance of EBP and the availability of PPE, but also noted ongoing challenges with staff compliance despite repeated in-servicing. Facility policy required PPE use for high-contact care activities for residents on EBP, but the observed failure to follow these protocols led to the identified deficiency.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents, as observed during a medication pass. The medication aide, MA E, did not administer Pepcid to three residents as ordered by their physicians. Additionally, one resident did not receive their prescribed paroxetine (Paxil). These medications were not available during the medication pass, despite being ordered by the physicians. Resident #1, a male with quadriplegia, osteoarthritis, and dysphagia, did not receive his Pepcid medication as ordered. Resident #41, a male with hemiplegia, dementia, and type 2 diabetes mellitus, also did not receive his Pepcid medication. Resident #206, a female with dementia, depression, and gastroesophageal reflux, did not receive her Pepcid or paroxetine (Paxil) medications. The failure to administer these medications as ordered could potentially impact the residents' health and quality of life. The medication aide, MA E, acknowledged not administering the medications due to a lack of available stock and did not report the shortage to the Director of Nursing (DON) or Assistant Director of Nursing (ADON). The facility's policy requires maintaining a seven-day supply of medications, but there was a breakdown in communication between the medication aide and management, leading to the unavailability of the medications. The DON, ADON, and Administrator were unaware of the medication shortages and emphasized the importance of communication to ensure medications are available as needed.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 15.22% due to 7 errors out of 46 opportunities. These errors involved four residents and one medication aide (MA E) and one LVN. The errors included the failure to administer medications as ordered by the physician, such as Pepcid and Paxil, due to unavailability, and incorrect dosing of Vitamin C. Resident #1, a male with quadriplegia, osteoarthritis, and dysphagia, did not receive his prescribed Pepcid due to the medication not being available. Similarly, Resident #41, with hemiplegia, dementia, and type 2 diabetes, also did not receive his Pepcid for the same reason. Resident #206, a female with dementia, depression, and gastro-esophageal reflux, did not receive her prescribed Pepcid or Paxil because the medications were not available. Resident #17, a male with lymphocytic leukemia, depression, and atrial fibrillation, received an incorrect dose of Vitamin C and had his medications mixed together, contrary to training instructions. The medication aide, MA E, confirmed these errors and admitted to not reporting the unavailability of medications to the charge nurse. The Assistant Director of Nurses and the Director of Nursing were unaware of the medication shortages and emphasized the importance of following the five rights of medication administration.
Failure to Properly Label and Discard Expired Foods
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not ensure that food stored in the kitchen refrigerator and dry storage area was properly labeled, dated, and free from expiration. During an observation, it was noted that the refrigerator contained a bag of black olives and a tray of lettuce that were not labeled or dated. Additionally, the dry storage area contained cracker crumbs, flour tortillas, and coffee packages that were past their expiration dates. Interviews with staff revealed inconsistencies in the process of checking and discarding expired foods. A staff member mentioned that the kitchen staff were supposed to check expiration dates upon delivery and regularly inspect all products, but this process was not consistently followed. The Dietary Manager (DM), who had been at the facility for about two weeks, acknowledged the responsibility of checking expiration dates and was in the process of orienting staff on proper food storage procedures. The Administrator expected daily and weekly checks for expired foods, emphasizing the DM's responsibility in ensuring compliance. The facility's policy required all food to be labeled with receive and open dates and discarded before expiration, but these procedures were not consistently implemented, posing a risk of foodborne illness to residents.
Failure to Maintain Safe and Sanitary Conditions in Resident Refrigerators
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors, which led to unsafe and unsanitary conditions in the personal refrigerators of three residents. Resident #21's refrigerator was observed to be dirty, with an orange sticky substance spilled at the bottom, and contained unlabeled and undated food items, including leftover desserts from the kitchen. Resident #42's refrigerator contained expired broccoli cheddar soup, and Resident #23's refrigerator had expired peaches and pears. These conditions were identified during observations and interviews with the residents, who indicated that they or their family members sometimes cleaned the refrigerators, but staff assistance was also involved. The facility's housekeeping staff were responsible for checking the residents' personal refrigerators daily for temperature and cleanliness, but they did not check for expired foods. The Maintenance Director, who supervised housekeeping, stated that staff were trained to check for expired foods, but this was not being done consistently. The Director of Nursing (DON) acknowledged that personal refrigerators needed to be cleaned weekly, with expired foods discarded, but this had not been consistently implemented. The Administrator and Assistant Director of Nursing (ADON) also recognized the responsibility of housekeeping to maintain the cleanliness and safety of personal refrigerators. The facility's policy titled "Food from Outside Sources" required community personnel to manage appropriate temperatures and food storage in resident refrigerators, with cold items discarded based on labeled dates or three days after opening. However, the policy was not effectively enforced, as evidenced by the presence of expired and improperly stored food items in the residents' refrigerators. This lack of adherence to policy and procedure could potentially place residents at risk for foodborne illness.
Infection Control Lapses in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several lapses in hand hygiene and equipment sanitation. During an observation, two CNAs did not change gloves or perform hand hygiene while providing incontinent care to a resident. They moved from handling soiled items to clean items without sanitizing their hands, which is against infection control protocols. Both CNAs acknowledged their failure to follow proper procedures, attributing it to nervousness. Additionally, a medication aide did not sanitize her hands during medication administration for multiple residents. She handled medication bottles and equipment without performing hand hygiene before, between, or after resident interactions. Furthermore, she used a blood pressure cuff on two residents without cleaning it between uses. The aide admitted to being aware of the proper procedures but failed to follow them due to nervousness. Interviews with the ADON and DON confirmed that staff are trained on infection control protocols, including hand hygiene and equipment sanitation, during hire and annually. However, the observed failures indicate a lapse in adherence to these protocols, potentially putting residents at risk of infection. The facility's policies on hand hygiene and equipment cleaning were not followed, as evidenced by the staff's actions during the survey.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living, specifically in maintaining personal hygiene, including nail care. The resident, an elderly female with a diagnosis of atherosclerotic heart disease, required extensive assistance with most activities of daily living and had moderately impaired cognitive skills. Observations revealed that the resident's fingernails were long, jagged, and had a thick black substance under them, indicating a lack of proper nail care. Interviews with staff revealed a lack of clarity and responsibility regarding nail care. A CNA, who had been assigned to the resident, admitted to not noticing or cleaning the resident's fingernails, assuming that hospice staff or the treatment nurse had done so. The treatment nurse confirmed that she checked nails weekly but had not done so until late in the afternoon on the day of observation. The Director of Nursing and the Administrator acknowledged that aides were responsible for daily nail checks and cleaning, while the treatment nurse was responsible for weekly checks and trimming. However, there was no specific policy on nail care or activities of daily living care in place at the facility.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff with the appropriate competencies and skills to meet the needs of residents, specifically impacting a resident who experienced delays in having her call light answered and receiving basic care such as ice and water. The resident, who had diagnoses including hemiplegia, epilepsy, and cognitive communication deficit, reported that the facility was often short-staffed, leading to extended wait times for care. Interviews with staff confirmed that CNAs were sent home early to cut down on hours, leaving insufficient staff to adequately care for all residents. Interviews with various staff members, including CNAs and LVNs, revealed that the facility often operated with only one nurse on duty, particularly during overnight shifts. This staffing level was deemed insufficient by the staff, who expressed concerns about their ability to perform necessary care and interventions in emergency situations. Despite these concerns being communicated to the facility's administration, the staffing levels remained unchanged due to directives from corporate management. The Director of Nursing (DON) and the Administrator both acknowledged the staffing issues but believed the current staffing was adequate, citing the lack of daytime activity during night shifts. However, the facility's own assessment indicated a need for more staff than was being provided. The Administrator admitted to following a corporate template for staffing assessments without fully understanding the requirements, leading to discrepancies between the facility's staffing plan and actual staffing levels. This misalignment posed risks to resident safety and care quality.
Missing Call Light Cords in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the bathrooms of two residents, identified as Resident #107 and Resident #110, were equipped with a functioning call light pull cord. This deficiency was observed on two separate occasions, where it was noted that the call light pull cords were missing from the bathrooms of these residents. Resident #107, a male with a history of hemiplegia and hemiparesis following a stroke, was at high risk for falls and required moderate assistance with toileting. Resident #110, a female with chronic obstructive pulmonary disease, was also at risk for falls and was dependent on assistance for toileting. Both residents had intact cognition and were continent of bowel and bladder. Interviews with the residents revealed that they were unaware of the missing call light cords and expressed concern about their ability to call for help in the event of a fall. A CNA with several years of experience at the facility acknowledged the absence of the cords and indicated that call lights should be checked during rounds. The Maintenance Director, responsible for ensuring the functionality of call lights, was unaware of the missing cords and stated that no work orders had been submitted for their replacement. The Administrator confirmed that the Maintenance Director was responsible for call light maintenance and emphasized the importance of daily checks by staff to ensure all call lights were operational.
Failure to Provide Mandatory QAPI Training to CNAs
Penalty
Summary
The facility failed to ensure that mandatory Quality Assurance and Performance Improvement (QAPI) training was provided to two Certified Nursing Assistants (CNAs), identified as CNA G and CNA L, as part of its QAPI program. CNA G, hired on July 13, 2017, had not completed the required annual QAPI training, and CNA L, hired on February 6, 2024, had not completed any QAPI training. During interviews, the Assistant Director of Nursing (ADON) acknowledged her responsibility for overseeing training and admitted to being unaware of the incomplete QAPI training for these CNAs. The ADON used a manual binder system to track training, which may have contributed to the oversight. The facility's Administrator, who is ultimately responsible for training oversight, also stated she was unaware of the training deficiencies but recognized the potential impact on resident care if staff were not properly trained.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from verbal and physical abuse by a certified nursing assistant (CNA) identified as CNA G. Resident #1, a female with a history of cognitive impairment, fractures, and other medical conditions, reported that CNA G was rough during incontinent care, causing emotional distress. Multiple interviews confirmed that CNA G spoke rudely to Resident #1 and handled her roughly, although no physical injuries were reported. The investigation revealed that CNA G's behavior was confirmed as abusive, leading to her suspension and eventual termination. Resident #2, who had mild dementia and required assistance with activities of daily living, also reported rough treatment by CNA G during care. Interviews with staff and the resident indicated that CNA G was rough and spoke inappropriately during care. Although Resident #2 did not suffer physical harm, the incident was distressing, and the resident expressed relief at CNA G's termination. The facility's investigation confirmed the abuse, and CNA G was terminated after only a week of employment. The facility's records showed that CNA G had been trained on abuse policies and resident rights upon hiring. Despite this training, her conduct during care was found to be abusive towards the residents. The facility's administration and nursing staff were involved in the investigation, and the abuse was reported to the necessary authorities. The facility took immediate action by suspending and then terminating CNA G, but the incidents highlighted a failure to protect residents from abuse during her brief tenure.
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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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