Citations in Texas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Texas.
Statistics for Texas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
Some of the Latest Corrective Actions taken by Facilities in Texas
- Revised and reinforced timely pressure-injury risk identification on admission and with condition change using the 24-hour report, with DON/MDS reviewing every admission and condition change to ensure issues were identified and addressed (K - F0686 - TX)
- Implemented weekly skin assessments with leadership validation by having charge nurses complete weekly skin assessments and ADON audit after completion (K - F0686 - TX)
- Implemented a physician-notification audit process for skin issues by requiring charge nurses to notify the physician for identified skin issues and having the DON audit physician notification through progress notes (K - F0686 - TX)
- Implemented a wound-consultant follow-up process by having the ADON round with the wound physician and implement orders and new treatments (K - F0686 - TX)
- Implemented a care-plan revision validation process by requiring charge nurse/ADON/MDS to revise care plans following required change and having the DON audit care plan changes (K - F0686 - TX)
- Implemented a heel offloading monitoring system by assigning charge nurses/CNAs to offload heels in bed, using an ADON/DON monitoring sheet for validation, and maintaining a DON list of residents requiring heel offloading (K - F0686 - TX)
- Re-educated licensed nurses and CNAs with a post-test on pressure-injury prevention covering risk recognition, repositioning/offloading techniques, immediate reporting of skin changes, and documentation of skin checks on skin observation sheets (with administrator tracking attendance and post-tests) (K - F0686 - TX)
- Implemented ongoing DON/ADON monitoring and audits for pressure-injury prevention and wound care compliance including audits of residents with pressure injuries/at risk for breakdown, repositioning documentation, weekly skin assessments, wound treatment compliance, and care plan updates, with immediate correction of negative findings and reporting of trends to QAPI (K - F0686 - TX)
- Implemented DON/designee daily spot checks of wound treatments to verify ordered wound care was completed and documented (K - F0686 - TX)
- Implemented a daily wound care assignment sheet to ensure accountability for completing ordered wound treatments (K - F0686 - TX)
- Re-educated licensed nurses on the wound care policy including treatment frequency, dressing type, documentation requirements, and expectations for notifying the physician of wound-condition changes (K - F0686 - TX)
- Reviewed audit results in QAPI meetings to support ongoing oversight of wound-treatment compliance (K - F0686 - TX)
- Amended wound-treatment orders to require pain evaluation prior to treatments and medication if indicated to prevent unmanaged pain during wound care (J - F0697 - TX)
- Re-educated licensed nurses on pain assessment and management including change in condition, administering pain medications, and the pain-clinical protocol (including anticipating increased pain with wound care, ambulation, repositioning, and using the critical element pathway for pain recognition/management) (J - F0697 - TX)
- Re-educated non-licensed nursing staff on recognizing and reporting pain changes using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse (J - F0697 - TX)
- Validated staff education via quiz and acknowledgement covering recognition of changes in condition, notification procedures, and pain assessment/management (J - F0697 - TX)
- Implemented ongoing change-in-condition/pain assessment audits by reviewing the 24-hour summary report and nurse progress notes to ensure changes were reported to the provider and documented and that pain assessments were completed prior to treatments, with audit results reviewed in IDT/QAPI meetings and issues addressed immediately (J - F0697 - TX)
- Re-educated licensed nurses, MDS staff, and IDT members on comprehensive person-centered care planning requirements including timely care plan revision after new wounds/condition changes, measurable objectives and individualized interventions, and communication of updated interventions to direct care staff via Kardex/POC system and documentation of care plan review/implementation (J - F0656 - TX)
- Implemented an expectation for immediate care-plan revision when issues were identified by requiring the ADON responsible for wound care to revise care plans as soon as an issue was identified and having the DON validate care plan revisions during morning meeting (J - F0656 - TX)
- Established ongoing monitoring/audits for timely care-plan updates by having DON/ADON/MDS Coordinator audit residents with new wounds, current pressure injuries, significant changes in condition, and identified skin risk factors to verify care plans were revised timely and interventions were individualized and implemented, with results brought to QAPI for trend analysis and additional corrective action (J - F0656 - TX)
Failure to Implement Heel Offloading, Repositioning, and Skin Assessment Leading to Stage 4 Heel Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer prevention and treatment services, consistent with professional standards, for a severely cognitively impaired, bedbound resident who was always incontinent and fully dependent on staff for mobility and transfers. On admission from the hospital, the resident had no heel wounds but did have a history of skin issues on the buttocks and peri-area, and the hospital’s wound care documentation included a prevention plan directing that the heels be offloaded using heel protector boots or pillows. The resident’s care plan identified her as at risk for pressure ulcers, with goals to prevent breakdown and interventions such as frequent incontinence care, bathing per schedule, weekly skin checks, and nutritional support, but it did not include specific interventions for heel offloading or repositioning every two hours. The record shows that the facility did not consistently assess and monitor the resident’s skin condition as ordered. A Braden Scale assessment was completed once, rating the resident as low risk, and no further Braden assessments were found. Physician orders dated 12/31/2025 required head-to-toe skin assessments and documentation of any changes in skin integrity on specified days, with physician notification of changes, yet there was no evidence these assessments were performed on multiple ordered dates. The EHR contained no documented Skilled Observation Notes used as skin assessments for a prolonged period, and later Skilled Observation Notes uniformly described the skin as intact with no notable changes, despite the subsequent development of heel blisters and pressure injuries. The DON later acknowledged that skin assessments were not documented in the EHR and that only changes in skin integrity were recorded in progress notes. When blisters on both heels were identified on 02/09/2026, the nurse practitioner ordered daily skin prep to the bilateral heel blisters and offloading of both heels with heel protectors while in bed. However, the MAR/TAR showed multiple shifts where heel offloading was not documented as provided, and there were several days when the ordered skin prep was not documented as applied. CNAs reported that heel protectors were sometimes removed by nurses, that the resident sometimes refused them, and that bandages were often not changed over weekends. The wound care physician, who began seeing the resident after the heel wounds developed, noted that the resident was sometimes not wearing heel protectors and attributed the wound development to immobility and general decline. By 03/10/2026, the resident’s right heel remained an unstageable deep tissue injury and the left heel had progressed to a Stage 4 pressure wound. The facility’s own skin integrity policy required repositioning at-risk residents at least every two hours and use of pillows or wedges to keep bony prominences from direct contact, but the DON later confirmed that the resident’s care plan lacked interventions for heel offloading or repositioning, and there were no orders for an air pressure mattress.
Removal Plan
- DON/ADON conducted an audit of all current residents to identify those at risk for pressure injuries (limited mobility, dependence for repositioning, malnutrition, existing wounds, recent decline); screened all residents and identified at-risk residents.
- Completed updated skin assessments on all residents and filed them in the medical record under the document tab.
- Verified pressure-relieving devices for identified at-risk residents (physician order as required, care planned, and device in place).
- Reviewed treatment orders for all at-risk residents to ensure treatment orders exist for all identified skin issues; notify MD to obtain orders when missing.
- Reviewed nutritional status for all at-risk residents to ensure nutrition assessment completed; obtain MD orders as needed; update care plan; RD review.
- Reviewed and updated care plans for all at-risk residents to address skin concerns including wounds, treatment, pressure-relieving devices, repositioning, and nutrition.
- Revised and reinforced the process for timely risk identification on admission and with condition change using the 24-hour report; DON/MDS to review every admission and condition change to ensure conditions are identified and addressed.
- Implemented weekly skin assessments completed by charge nurse with ADON auditing after completion.
- Implemented physician notification process: charge nurse to notify physician of identified skin issues; DON to audit physician notification through progress notes.
- Implemented wound consultant follow-up process: ADON to round with wound physician; ADON to implement orders and new treatments.
- Implemented care plan revision process: charge nurse/ADON/MDS to revise care plan following required change; DON to audit care plan changes.
- Implemented heel offloading process for applicable residents: charge nurse/CNAs responsible for offloading heels while residents are in bed; ADON/DON to validate using a monitoring sheet; DON to develop and maintain a list of residents requiring heel offloading.
- Re-educated licensed nurses and CNAs with post-test on pressure injury risk recognition, repositioning and offloading techniques, immediate reporting of skin changes, and documentation of skin checks on skin observation sheets; administrator to track attendance and post-tests.
- Implemented ongoing monitoring and audits by DON/ADON of residents with current pressure injuries, residents at risk for skin breakdown, repositioning documentation, weekly skin assessments, wound treatment compliance, and care plan updates.
- Correct negative audit findings immediately, including staff counseling and re-education, resident reassessment, physician notification, and care plan revision as indicated.
- Report audit findings and trends to the QAPI Committee for ongoing review and additional action if needed.
- Notified the Medical Director of the IJ and discussed and obtained approval of the plan of removal.
Failure to Implement Abuse Reporting and Protection Policies for Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse prohibition policies and procedures to identify, report, and protect residents from abuse, specifically in relation to two cognitively intact residents who were in a relationship and shared a room. The facility’s Abuse Prohibition Policy defined abuse to include physical, mental, and verbal abuse, and required that any allegation of abuse made by residents, staff, or visitors be reported immediately to the Abuse Coordinator and investigated. The policy also required immediate protection of residents, monitoring of staff and resident behaviors to identify potential abuse, and specific steps for resident‑to‑resident incidents, including separating residents, assessing for injury, notifying the physician and family, completing incident reports, and contacting the Abuse Coordinator. One resident, an adult male with paraplegia, major depressive disorder, and anxiety disorder, and another resident, an adult female with cerebral infarction, severe visual impairment, bipolar disorder, and anxiety disorder, both had intact cognition with BIMS scores of 15/15 and had requested to room together. The male resident had care plan entries documenting a history and potential for verbally aggressive and accusatory behavior toward staff and residents, and episodes of verbal aggression/irritability when care for his girlfriend/roommate was not provided immediately. On one occasion, nursing notes documented that the female resident reported crying and being upset because her boyfriend yelled at and belittled her in front of others, and she expressed a desire to move out of the shared room. The LVN reported this to the social worker, who spoke with the resident; the resident later recanted and stated she loved him, and the male resident stated he had only told her to tell the nurse about her stomach pain. The Administrator was aware of this incident but, based on the recantation, did not consider it reportable and did not treat it as an abuse allegation under the policy. On a subsequent date, a CNA completed a written witness statement indicating she had observed the male resident yell at the female resident and call her a derogatory term, specifically “[f‑ing retard].” The CNA believed the Abuse Coordinator would see this in the statement, but the Administrator later stated she had not seen that portion of the statement. The Administrator acknowledged that such language would constitute verbal abuse and would be reportable to the state agency, yet the incident was not reported to the Abuse Coordinator or to the state agency as required by policy. Later, both a CNA and a medication aide witnessed the male resident pushing the female resident in her wheelchair and shoving her into trash and dirty linen barrels in the hallway. Both staff members stated they did not consider this to be abuse and therefore did not report it to the Administrator or Abuse Coordinator. The Administrator reported she was unaware of this physical incident until informed by the CNA shortly before the surveyor interview and acknowledged that it could be considered physical abuse and would be reportable. These failures to recognize, report, and respond to resident‑to‑resident verbal and physical abuse incidents, despite clear policy requirements and prior knowledge of the male resident’s behavioral history, led to the cited deficiency and the identification of an Immediate Jeopardy situation.
Removal Plan
- Attempted to separate Residents #14 and #55; both residents refused a room change.
- Initiated 1:1 monitoring for Resident #14 due to refusal to change rooms; monitoring to continue until risk is fully mitigated and IDT determines supervision can be safely reduced.
- Reviewed and updated care plans for Residents #14 and #55 to reflect supervision needs and behavioral concerns.
- Provided education to Residents #14 and #55 regarding personal safety and boundaries, risks associated with unsupervised interactions, and the facility’s responsibility to intervene when safety concerns arise; ongoing reinforcement planned.
- Completed a trauma-informed psychosocial assessment for Resident #55 to evaluate for emotional distress, coercion, or unmet needs; continued monitoring initiated.
- Assessed both residents for physical and psychosocial harm; no additional injury identified.
- Completed life satisfaction rounds to ensure no other residents were negatively affected; no negative findings.
- Notified the Medical Director regarding the alleged failure to follow abuse policies and procedures.
- In-serviced Administrator and DON on abuse policy and reporting procedures; competency validated via quiz.
- In-serviced facility staff on abuse policy and reporting procedures; competency validated via quiz; staff not allowed to work next scheduled shift until training completed.
- Incorporated the abuse training material into new hire orientation and ongoing.
- Audited incident reports for the last 3 months to ensure no other reportable incidents were missed; no negative findings.
- Audited grievances for the last 3 months to ensure no other reportable issues were missed; no negative findings.
- Implemented a protocol for resident-to-resident abuse when both residents refuse room change: immediate enhanced supervision, revise care plans, complete IDT review, assess capacity and risks, involve physician and responsible parties, and consider alternative interventions; ongoing reassessment until risk is fully mitigated.
- Established monitoring/QA process: Administrator/DON daily review of all incidents, grievances, and behavior notes, then weekly, then monthly; random staff interviews to validate understanding of abuse reporting; QAPI Committee review; immediate re-education and disciplinary action as indicated.
Failure to Implement Antibiotic and Diabetes Management Orders Resulting in Significant Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to antibiotic therapy and blood glucose management. An [AGE]-year-old female resident with diagnoses including vesicointestinal fistula, hypertension, type 2 diabetes mellitus with hyperglycemia, and early-onset Alzheimer’s disease was admitted following hospitalization and surgery for colostomy placement. Her physician orders included long-acting insulin (Semglee), sliding-scale insulin (NovoLOG), blood glucose monitoring before meals and at bedtime with provider notification for values <60 or >400 mg/dL, a continuous glucose monitoring (CGM) sensor (FreeStyle Libre 2), and prophylactic antibiotics (Ciprofloxacin and Metronidazole) along with other medications. Record review showed that from admission through several days, the antibiotic orders were not transcribed onto the MAR and no doses were administered, and the CGM sensor was not implemented. During the same period, the resident’s blood glucose readings were repeatedly and significantly elevated, with documented values of 512 mg/dL, 482 mg/dL, 459 mg/dL, and 492 mg/dL. Despite an order to notify the provider if blood glucose was <60 or >400 mg/dL, there was no evidence in the record that the physician was notified of these out-of-parameter results. Additionally, there was no documentation of nighttime blood glucose checks, even though orders required blood glucose monitoring before meals and at bedtime. Staff interviews revealed that some medications, including long-acting insulin, were not immediately available or did not appear on the MAR, and that staff relied on sliding-scale insulin without obtaining new physician orders or consistently documenting provider notifications. Nursing staff also reported communication delays with on-call providers and PACE, and acknowledged that no new orders were obtained despite persistently elevated blood glucose levels. Multiple interviews with PACE clinicians and facility leadership confirmed that the ordered prophylactic antibiotics and CGM device were not implemented as prescribed, and that providers were not notified of missed medications or abnormal blood glucose values. PACE staff stated that antibiotics (Ciprofloxacin and Metronidazole), probiotics, insulin, and other routine medications had been ordered upon discharge from the hospital, but the facility failed to administer the antibiotics and did not apply the ordered glucose monitoring sensor. The DON and ADON acknowledged that medication reconciliation was not completed upon admission for this resident, that there was no standardized process to ensure baseline blood glucose assessment or consistent review of hospital records, and that oversight of admission orders and blood glucose monitoring was inconsistent. The resident ultimately required transfer to the hospital, where she was admitted to the ICU with DKA and septic shock, and hospital staff documented hyperglycemia, UTI, markedly elevated WBC, and the need for sepsis protocol, IV antibiotics, and insulin drip. Facility policies in place at the time required that blood glucose monitoring be completed per provider orders, that physicians be notified when glucose results were outside ordered parameters, and that insulin be administered only upon a physician’s order. The physician orders policy required that all physician orders be valid, safe, and clarified if unclear prior to implementation. Interviews with the DON, ADON, and other staff indicated that these policies were not consistently followed: there was no daily process to review medications for accuracy or completeness, medication pass audits were intermittent, and staff did not consistently notify physicians when medications were unavailable or when ordered treatments (such as the CGM sensor) could not be implemented. Communication gaps with external providers, particularly PACE, and lack of a standardized admission and reconciliation process contributed to the failure to transcribe and administer antibiotics, to perform ordered bedtime blood glucose checks, to notify providers of critical glucose values, and to implement the ordered continuous glucose monitoring device for this resident.
Removal Plan
- Conducted mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; obtained verbal and written confirmation of understanding; implemented ongoing competency checks; incorporated training and written competencies into new-hire orientation; made policies readily available via CNO/ACNO/Administrator.
- Reviewed the resident’s hospitalization status with the hospital and confirmed ICU admission for DKA and septic shock; confirmed the resident did not return to the facility.
- Held nurse meetings with all nursing staff who cared for the resident to review specific failures, including missing bedtime blood glucose checks, failure to notify the provider of blood glucose greater than 400, failure to implement CGM, and failure to communicate about unavailable supplies.
- Provided mandatory re-education for all licensed nursing staff on the Blood Glucose Monitoring Policy and physician notification requirements, emphasizing obtaining blood glucose exactly as ordered, immediately notifying the provider when out of parameters, notifying physician/CNO/ACNO when supplies or equipment are unavailable, and clarifying unclear or unimplementable orders prior to implementation.
- Established a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes, out-of-parameter lab or glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-serviced RNs/LVNs on the protocol.
- Implemented a redundant notification system requiring that when any blood glucose result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time/person contacted and response received; in-serviced RNs/LVNs on the system.
- Conducted a comprehensive review to identify other residents at risk for failures in physician notification, blood glucose monitoring, or implementation of physician orders.
- Reviewed all current residents to identify those with active blood glucose monitoring orders.
- Completed a chart audit of residents with blood glucose monitoring orders to verify monitoring was performed as ordered, identify out-of-parameter results, and confirm timely provider notification; reported issues to physicians and obtained clarifying or new orders; initiated continued daily monitoring by CNO/ACNO/nurse manager.
- Reviewed all current residents to identify those with orders for continuous monitoring devices or specialized medical equipment; verified implementation and identified no issues.
Failure to Notify Physician of Critically High Blood Glucose and Perform Ordered Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the physician when a resident’s blood glucose (BG) levels exceeded ordered parameters and to consistently perform ordered BG monitoring. An older female resident with type 2 DM with hyperglycemia, early-onset Alzheimer’s disease, hypertension, and a vesicointestinal fistula was admitted with physician orders for BG monitoring before meals and at bedtime, with instructions to notify the provider if BG was less than 60 mg/dL or greater than 400 mg/dL. Review of the order summary and admitting physician orders confirmed these parameters. However, record review showed multiple BG readings well above 400 mg/dL over several days without documented physician notification, and there was no evidence that bedtime BG checks were performed as ordered. Specifically, the resident’s record showed BG values of 512 mg/dL on one day, 482 mg/dL on the next day, 459 mg/dL on a later day, and 492 mg/dL on another day, all documented without any corresponding evidence that the physician was notified, despite the explicit order to notify for BG values greater than 400 mg/dL. The medication administration record and BG logs also showed no documented nighttime BG checks, even though the orders required monitoring before meals and at bedtime. The resident’s care plan identified insulin therapy and BG monitoring with goals for BG within normal limits and interventions including monitoring, documenting, and reporting adverse effects of insulin therapy and following hypo/hyperglycemia protocols, but the actual documentation did not reflect adherence to these monitoring and notification requirements. Interviews with facility staff and external PACE providers further described inconsistent communication and incomplete implementation of ordered treatments. The NP from PACE stated she was not notified that the resident’s BG had been over 400 mg/dL and that, upon later review, insulin and BG monitoring orders had been provided but were not implemented as ordered by the facility. A PACE RN reported that he was notified of elevated BG and gave instructions for additional sliding scale insulin and close monitoring, and that long-acting insulin should have continued, but there was no documentation in the facility record to support these communications or new orders. Facility nurses described elevated BG readings in the 400–500 mg/dL range, sometimes unreadable on the glucometer, ongoing use of sliding scale insulin, delays or gaps in admission order processing, and uncertainty about whether antibiotics ordered were administered. The resident was ultimately transferred to the hospital with hyperglycemia and UTI and was admitted to the ICU for DKA and septic shock. The facility’s own policy on blood glucose monitoring required following physician notification parameters when results were outside ordered ranges, but the documented practice for this resident did not meet those requirements, leading surveyors to identify an Immediate Jeopardy situation related to failure to notify the physician of out-of-parameter BG results and failure to carry out ordered BG monitoring. Additional interviews with leadership and other staff highlighted that medication reconciliation and admission review processes were inconsistent and that there was no standardized daily review of medications or BG monitoring for accuracy and completeness. The ADON and DON acknowledged that medication pass audits were not done daily, that there was no consistent daily process to review medications, and that communication with external providers such as PACE was often inconsistent. The DON and Medical Director described expectations that urgent situations be evaluated immediately and that orders be implemented without delay, but also acknowledged that residents with worsening conditions were sometimes transferred to the hospital rather than having earlier interventions. The MDS nurse stated that she did not recall seeing documentation regarding antibiotic therapy or BG monitoring for this resident and that follow-up on such treatments depended on nursing processes. The PACE NP later stated that prophylactic antibiotics and insulin management had been ordered but not administered, and that the resident’s decline, including DKA and sepsis, was attributed in part to missed medications and lack of timely intervention. These documented failures in BG monitoring, physician notification, and implementation of ordered treatments formed the basis of the cited deficiency.
Removal Plan
- Conduct mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; obtain verbal and written confirmation of understanding; implement ongoing competency checks; ensure policies are readily available from the CNO/ACNO; incorporate training and written competencies for new hires upon hire.
- Review Resident #2’s current hospitalization status with the hospital and confirm ICU admission for DKA and septic shock; confirm resident did not return to the facility.
- Hold nurse meetings with all nursing staff who cared for Resident #2 to review specific failures (missing bedtime BG checks, failure to notify provider of BG >400, failure to administer continuous glucose monitoring device, failure to communicate about unavailable supplies).
- Provide mandatory re-education for all licensed nursing staff (RNs/LPNs) emphasizing: obtaining BG readings exactly as ordered; immediate provider notification when results are outside parameters; immediate notification to physician/CNO/ACNO when ordered supplies/equipment are unavailable; and clarifying unclear or unimplementable orders prior to implementation.
- Establish a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes in condition, out-of-parameter lab/glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-service RNs/LVNs on the protocol.
- Implement a redundant notification system requiring that when any BG result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time, person contacted, and response received; in-service RNs/LVNs on the system.
- Conduct a facility-wide review to identify residents at risk for similar failures related to physician notification, BG monitoring, or implementation of orders.
- Review all current residents to identify those with active BG monitoring orders.
- Complete a comprehensive chart audit of residents with BG monitoring orders to verify monitoring was performed as ordered, identify out-of-parameter results, and confirm timely documented provider notification; report identified issues to physicians and obtain clarifying or new orders as needed; initiate continued daily monitoring by CNO/ACNO/nurse manager.
- Conduct a Root Cause Analysis (RCA) including staff interviews and fishbone analysis to identify underlying causes of the IJ event.
- Revise the Blood Glucose Monitoring Policy to require immediate physician notification for out-of-parameter BG results and to require documentation of the exact time of the out-of-parameter result, exact time of provider notification, name of person contacted, and provider response or orders received; educate staff on the revised policy.
Failure to Assess and Manage Abnormal Catheter Urine Leading to Septic Shock
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with an indwelling urinary catheter received appropriate assessment, intervention, and catheter management in response to persistent abnormal urine characteristics and signs of possible infection. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an indwelling catheter, colostomy, and feeding tube, and was dependent on staff for all ADLs. Her care plan identified her as having a catheter, being at risk for UTIs, and having frequent UTIs, with specific interventions to monitor urine for color, sediment, odor, amount, and to report abnormalities such as blood-tinged urine, cloudiness, no output, deepening of urine color, and other signs of UTI to the physician. Physician orders directed that the Foley catheter and drainage bag be changed PRN for signs of infection, obstruction, or compromise of the closed system. On one date, an LVN documented that the resident’s catheter was draining blood-tinged urine, that her blood pressure was low, and that the physician was notified, resulting in orders for a UA and IV fluids. The resident later refused IV fluids, and a UA collected showed blood, protein, mucus, and WBC clumps, with blood and protein flagged as critical, but there were no documented follow-up orders or interventions after these results. The NP documented dark orange/red urine and noted a contaminated UA with mixed microbial growth, ordering a repeat UA and labs, and recorded that the resident had refused IV fluids. The NP stated that dark orange urine could be normal if related to minor bleeding from catheter movement but that dark brown/black urine would not be normal and should be reported; she also stated that whenever a UA was ordered, staff were supposed to change the catheter. The electronic record showed the resident’s indwelling catheter was last changed several months earlier, with no documentation of catheter changes, urine color/characteristics, or change in condition from that date through the days immediately preceding the resident’s transfer to the hospital. Multiple staff interviews and video evidence showed that the resident’s urine had been dark brown to black and foul-smelling for weeks without appropriate assessment, documentation, or escalation. CNAs and LVNs reported that the urine appeared reddish, like iced tea, brown/blackish, and had a bad odor for approximately a month or a few weeks, and that they assumed it was normal after it remained that way; several nurses acknowledged they did not assess the catheter or urine every shift and did not consistently document or notify the physician about the worsening color. Video footage provided by the responsible party showed dark/black, opaque urine in the drainage bag on multiple nights, and hospital staff described the catheter on admission as draining purulent, very dark/black urine with foul odor, pus in the tubing, and mold on the catheter balloon and tip, suggesting it had not been changed for a long time. The facility’s own catheter policy required timely and appropriate assessments, ongoing monitoring for catheter-associated UTI, recognition and reporting of complications, and catheter and drainage bag changes based on clinical indications such as infection or obstruction. Despite these requirements and the resident’s known history of frequent UTIs and chronic catheter use, the facility did not assess, intervene, or change the catheter while the resident’s urine remained abnormal over an extended period, culminating in her transfer to the hospital where she was diagnosed with severe sepsis with septic shock likely from a UTI.
Removal Plan
- Performed a 100% audit (DON, ADON, Wound Care Nurse) of residents with catheters to verify catheter placement/securement, urine characteristics, signs/symptoms of UTI, EMR documentation accuracy, and catheter change dates.
- Replaced any urinary catheter immediately (by a licensed nurse) for residents with abnormal findings; notified physician immediately, implemented new orders promptly, and increased monitoring every shift.
- Provided a 1:1 in-service to the LVN who failed to document catheter change on the importance of documenting all care provided (including catheter changes), with progressive discipline up to termination for further infractions.
- Completed an in-service for all licensed nurses and CNAs on catheter care/maintenance, UTI prevention, change-in-condition notification, documentation requirements, and when to notify the physician; staff were not permitted to return to resident care until in-services were completed.
- Implemented DON/designee review of resident changes in condition via SBAR, documentation, and initiated interventions during clinical meetings; addressed issues immediately with the licensed nurse and/or IDT, resident/RP, and physician as necessary; adopted as standard IDT review process for residents with catheters.
- Implemented DON/designee verification of catheter orders and documentation of catheter care and assessments; adopted as standard IDT review process for residents with catheters.
- Conducted visual checks by DON/designee to ensure catheter care is maintained and without abnormalities until 100% compliance is achieved; communicated potential issues to the IDT, resident/RP, and physician.
- Implemented a questionnaire process to validate effectiveness of the urinary catheter care process with licensed nurses, CNAs, and nurse managers; provided immediate re-education if staff could not answer appropriately.
- Ran a physician orders report to check and verify accuracy of any new catheter orders; immediately corrected issues; adopted as standard IDT review process for residents with catheters.
- Clarified and corrected incomplete/incorrect/conflicting catheter orders/documentation immediately when identified by DON/designee; adopted as standard IDT review process for residents with catheters.
- Conducted an impromptu QAPI meeting with the Medical Director to obtain approval of the action plan.
- Reported findings to the QI process and QA committee monthly (Administrator and DON/designee) and addressed any concerns/recommendations immediately.
Failure to Notify Physician of Worsening Hematuria and Catheter-Related Changes
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a physician when a resident experienced a significant change in condition related to an indwelling urinary catheter. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an ostomy, a feeding tube, and severe cognitive impairment. Her care plan identified her as dependent for all ADLs, at risk for anemia-related complications, and at risk for UTIs due to the presence of a catheter, with specific interventions directing staff to monitor, document, and report abnormal urine characteristics and signs and symptoms of UTI to the physician. Physician orders directed that the Foley catheter be changed PRN for signs and symptoms of infection, obstruction, or compromise of the closed system. Progress notes showed that on one date an LVN documented blood-tinged urine draining from the Foley catheter, low blood pressure, and that the physician was notified, resulting in orders for a urinalysis and IV fluids. A subsequent NP note documented dark orange/red urine, a contaminated UA with mixed microbial growth, the resident’s refusal of IV fluids, and plans for repeat labs. However, from that point through several days later, there was no documentation in the electronic health record of urine color, characteristics, or other changes in condition, and the last documented catheter change had occurred weeks earlier. Despite multiple staff observing that the urine had become dark brown to black, foul-smelling, and remained that way for weeks, there was no evidence that the physician or NP was notified of this worsening change in urine appearance. Video footage provided by the family showed CNAs draining a catheter bag on multiple nights, with the urine in the drainage bag and container appearing dark/black and opaque. Hospital staff later described the catheter from the facility as having mold on the balloon, strings of pus on the tip, purulent urine, and a very dark, almost black appearance with a strong odor, and hospital records documented septic shock likely from a UTI with the indwelling catheter draining purulent urine. Facility staff interviews revealed that CNAs and LVNs had noticed the urine as dark, brown, or black and malodorous for weeks, and some believed it had become “normal” for the resident or assumed prior notification had been sufficient. Several nurses acknowledged they did not consistently assess or document urine characteristics, did not follow up on the worsening urine color, and did not notify the physician again despite recognizing that such changes could indicate infection or kidney issues. The ADON, DON, NP, and Administrator all stated that the dark or black urine color seen in the videos was not normal for the resident and that they would have expected immediate notification and follow-up, but this did not occur until the resident became lethargic and confused with low blood pressure and low oxygen saturation, at which point the physician was notified and the resident was sent to the hospital and diagnosed with severe sepsis and septic shock likely due to UTI.
Removal Plan
- Performed a 100% audit (by DON, ADON, Wound Care Nurse, RN) of residents with catheters to verify catheter placement/securement, urine characteristics, signs/symptoms of UTI, EMAR documentation accuracy, and catheter change documentation.
- Replaced urinary catheters by a licensed nurse for any resident with abnormal catheter-related findings; notified the physician, obtained and implemented new orders, notified the resident’s responsible party, and increased monitoring every shift.
- Provided a 1:1 in-service to the LVN who failed to document catheter change and notify the physician regarding change in condition/urine appearance/consistency, emphasizing reporting to physician/NP and responsible party and documenting in the EMAR; advised further infractions may result in discipline up to termination.
- Provided in-service training for all licensed nurses on catheter care/maintenance, UTI prevention, change-in-condition notification to physician/NP and responsible party, and documentation requirements; staff were not permitted to return to resident care until in-services were completed.
- Implemented DON/designee review of resident changes in condition via SBAR and documentation, and initiated interventions during clinical meetings; addressed issues immediately with physician/NP notification and review with licensed nurses and/or IDT; adopted as standard IDT review process for residents with catheters.
- Conducted a QAPI meeting with the Medical Director to notify of potential noncompliance and obtain approval of the action plan.
- Reported findings to the QI process and QA committee, with immediate follow-up on any concerns or recommendations.
Failure to Provide Ordered Daily Wound Care Resulting in Infected Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered daily wound care to a resident with multiple pressure ulcers, resulting in an infected left hip wound. The resident, a 75-year-old man, was admitted with severe protein-calorie malnutrition, metabolic encephalopathy, peripheral vascular disease, and existing pressure ulcers, including sacral and right heel ulcers and osteomyelitis of the right ankle and foot. On readmission from the hospital, he had multiple pressure injuries: unstageable pressure ulcers on both hips, a stage 4 ulcer on the left posterior shoulder, a stage 3 coccyx ulcer, an unstageable ulcer on the left medial lateral foot, and a DTPI on the left 5th toe. Physician orders dated 2/11/26 required that each wound be treated every day shift with normal saline, pat dry, and application of Santyl, calcium alginate, and border foam dressings, and that the DTPI on the 5th toe be treated with betadine and iota every day shift. Despite these orders, the treatment administration record (TAR) showed wound care documented only on 2/22/26, with all wound care documentation left blank for 2/23/26, 2/24/26, and 2/25/26. Nursing staff interviews revealed inconsistent and uncorroborated accounts of whether wound care was actually performed on those days. RN A stated she last dressed the wounds on 2/23/26 and could not explain the lack of documentation; no other staff could confirm that wound care occurred that day. LVN E claimed she performed wound care on 2/24/26 but admitted she did not document it in the TAR, stating she could not find the resident’s name and did not seek assistance from other nurses. CNA and nurse interviews about wound care performed on 2/26/26 indicated that the dressings still bore RN A’s initials from the prior treatment and appeared unchanged for 2–3 days, with staff noting a bad odor and drainage from the left hip wound. On 2/27/26, observations and interviews documented that the resident’s room had a strong foul odor, which staff attributed to his wounds. During wound care that day, the Wound Care Doctor found the right hip wound to be very dark with mostly eschar and moderate drainage, and described the left hip wound as unstageable, very smelly, and appearing infected, with purulent and serosanguinous drainage and a yellow-tinged exudate that suggested depth. The left hip wound measured larger than previously documented and was diagnosed as infected. The Wound Care Doctor stated that if the resident had received wound care on the missed days, it could have helped prevent the decline of the left hip wound, although he could not say the infection was unavoidable due to the resident’s comorbidities and poor nutrition. Hospice staff also stated that while the resident’s wounds were considered unavoidable due to his condition, having wounds that were not being treated constituted neglect and that infections were avoidable. These findings led surveyors to identify an Immediate Jeopardy situation related to failure to provide necessary pressure ulcer treatment and services as ordered.
Removal Plan
- Resident #1 was immediately assessed by the Wound Care Doctor and diagnosed with an infected unstageable pressure ulcer to the left hip.
- Physician orders were obtained for Clindamycin 450 mg three times daily for 14 days to treat the wound infection.
- Wound care resumed immediately per physician order (daily day shift treatment).
- Wound cultures were ordered and obtained.
- The DON initiated direct oversight of wound care completion and documentation.
- The facility reviewed the census and identified all residents with wounds.
- A 100% audit was completed of all wound treatment orders and TAR documentation.
- Head-to-toe skin assessments were completed for all current residents.
- Any identified documentation gaps were immediately corrected and treatments were provided.
- All licensed nurses were re-educated on the wound care policy, including treatment frequency, dressing type, and documentation requirements.
- Staff education included expectations for notifying the physician of any changes in wound condition.
- A daily wound care assignment sheet was implemented to ensure accountability.
- The DON or designee will perform daily spot checks of wound treatments.
- A daily audit of all wound treatments will be conducted for 14 days.
- Weekly audits will be conducted thereafter for 30 days.
- Audit results will be reviewed in the QAPI meeting.
- Staff failing to follow wound care procedures will receive immediate counseling and retraining.
- The facility will verify that all residents are receiving wound care as ordered, all licensed nurses have completed re-education, and monitoring systems are in place and functioning to ensure ongoing compliance.
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Failure to Integrate Heel Off-Loading and Repositioning into Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes that reflected a resident’s identified needs for pressure injury prevention. The resident was an older female with multiple complex medical conditions, including malnutrition, COPD/asthma, toxic encephalopathy, alcohol dependence, muscle wasting and atrophy of the lower leg, cognitive communication deficit, and muscle weakness. A quarterly MDS showed severe cognitive impairment with a BIMS score of 6, total dependence for transfers and mobility, and complete bowel and bladder incontinence. The resident either refused or was unable to perform basic mobility tasks such as sit-to-lying, lying-to-sitting, sit-to-stand, transfers, and walking, placing her at high risk for pressure injuries. The resident’s care plan, initiated for pressure ulcer risk, identified a focus of potential for development of a pressure ulcer with a goal that the resident would be free of preventable breakdown. Interventions listed included frequent checks for wetness and soiling, incontinence care every two hours as needed, scheduled bathing, and weekly skin checks with reporting of new skin conditions to the physician. However, the care plan did not include interventions for off-loading the heels or repositioning every two hours, despite the resident’s immobility and incontinence. The Braden Scale completed at admission rated the resident as low risk with a score of 16, and the facility’s documentation showed no skilled observation notes for skin assessments from early January through late February, and subsequent notes described the skin as intact with no notable changes. Hospital documentation in the facility’s EHR from before admission showed a prevention plan that specifically ordered heel off-loading using heel protector boots or pillows lengthwise. Later, a wound care physician’s evaluation documented that the resident developed unstageable deep tissue injuries (DTIs) on both heels, and a subsequent evaluation showed an unstageable DTI on the right heel and a Stage 4 pressure wound on the left heel. Interviews indicated that the family representative had not observed heel boots or pillows under the resident’s legs until after bandages were applied, and the NP reported that the resident had been admitted without pressure ulcers or DTIs, later developed heel blisters, and that orders for off-loading and heel boots were written. The DON and ADON acknowledged that repositioning was not reflected on the TAR/MAR, that heel riser boots had not yet been received, and that the care plan lacked interventions for off-loading heels and repositioning. These documented omissions and inconsistencies in care planning and implementation led to the identified deficiency under F656 for failure to develop and implement a comprehensive person-centered care plan.
Removal Plan
- DON/ADON conducted an audit of all current residents to determine which residents are at risk for pressure injuries (limited mobility, dependence on staff for repositioning, malnutrition, existing wounds, or recent decline).
- DON/ADON conducted an audit of residents identified as high-risk for skin breakdown (Braden scale score below 10) and reviewed residents with current wounds and significant change of condition to validate that comprehensive care plans addressed all issues with appropriate interventions and were updated as needed.
- For any resident identified with missing, incomplete, or outdated care plan interventions, the care plan was reviewed and revised immediately by the MDS Coordinator and DON.
- MDS nurse completed care plan updates for identified residents.
- DON/ADON re-educated licensed nurses, MDS staff, and interdisciplinary team members on requirements for comprehensive person-centered care planning, timely care plan revision after new wounds/condition changes, measurable objectives and individualized interventions, and communication of updated interventions to direct care staff via Kardex/POC system and documentation of care plan review/implementation.
- Implemented expectation that care plans are revised as soon as an issue is identified by the ADON responsible for wound care, with DON validating care plan revisions during morning meeting.
- Required that staff who did not attend the education will not work until education is completed; Administrator to track attendance and posttest completion.
- Established ongoing monitoring/audits by DON/ADON/MDS Coordinator for residents with new wounds, current pressure injuries, significant changes in condition, and identified skin risk factors to verify care plans are revised timely and interventions are individualized and implemented.
- Set audit schedule through QAPI as indicated.
- For any negative audit findings, correct immediately through care plan revision, staff re-education, and follow-up review.
- Bring audit results to the QAPI Committee for review, trend analysis, and additional corrective action as needed.
- Notified the Medical Director of the Immediate Jeopardy and discussed/obtained approval of the plan of removal.
Significant Insulin Reconciliation Error and Failure to Access Glucagon for Hypoglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration and emergency hypoglycemia treatment. The resident, an older male with Type II diabetes mellitus and multiple comorbidities including COPD, chronic kidney disease, atherosclerotic heart disease, atrial fibrillation, gout, and dysphagia, was originally admitted and later discharged following a hypoglycemic episode with a blood glucose level of 35. Upon readmission from the hospital, the discharge instructions included an order for Insulin Glargine 12 units once daily and regular insulin on a sliding scale before meals, with explicit instructions to stop Insulin degludec (Tresiba) 40 units once daily. The facility’s March 2026 MAR showed that these new insulin orders were not transcribed and that the prior order for Tresiba 40 units at bedtime was continued. On the readmission date, LVN A completed admission assessments but did not review the hospital discharge medication list, stating that two nurses typically split admission tasks and that the charge nurse handled the medication review. LVN B, the charge nurse on the readmission date, reported that he completed the medication reconciliation but acknowledged he failed to accurately reconcile the medications and transcribe the correct insulin orders, resulting in continuation of Tresiba instead of initiating Insulin Glargine and regular insulin per hospital instructions. The attending physician later stated he had instructed the facility to follow hospital orders and expected nurses to accurately review discharge instructions and call with accurate information when verifying orders. On the night of the incorrect insulin administration, RN C, who was aware the resident had been readmitted but relied on the prior shift’s reconciliation, followed the existing physician orders and administered 40 units of Tresiba at bedtime after a blood glucose reading of 135. At approximately 5:10 a.m. the following morning, RN C obtained a blood glucose reading of 35. The resident was alert, able to sit upright, and had no difficulty swallowing. RN C administered sugar dissolved in peach juice and water while awaiting EMS. RN C reported being unable to locate the facility emergency kit containing glucagon injection or gel at that time. The DON later confirmed that glucagon gel and an injection were present in the emergency kit in the medication room but required 45 minutes of searching to locate it. The facility’s own policies on medication reconciliation and medication errors defined the need for accurate reconciliation of pre- and post-discharge medications and identified wrong-drug administration as a medication error, which was not followed in this case.
Removal Plan
- Notified the Medical Director of the Immediate Jeopardy.
- Completed a chart audit of all residents with diabetes mellitus to ensure orders were in place for glucagon injection or gel PRN for low blood sugar and signs of hypoglycemia.
- Implemented a Glucagon Audit Sheet to be completed daily by the charge nurse to ensure glucagon is available in the emergency kit.
- Established daily monitoring of the Glucagon Audit Sheet by the DON/ADON during the clinical meeting and by the weekend supervisor/designee on weekends.
- Completed an audit to confirm emergency glucagon orders were in place for all residents with diabetes mellitus.
- Located glucagon medication in the emergency kit in the medication room and re-labeled it with a large red label to allow it to be easily located.
- Implemented a policy requiring two nurses to review medication reconciliation for all new admissions and readmissions.
- Conducted an in-service for DON/ADON regarding the diabetes protocol and medication reconciliation on all admissions.
- Conducted an in-service for all full-time and part-time nurses on accurate medication reconciliation for new admissions/readmissions, the location of the emergency kit glucagon, and hypoglycemia/diabetes protocols.
- Established that DON/ADON will educate all new nursing staff on these trainings before they are allowed to work.
- Conducted an in-service for the weekend supervisor on reviewing medication reconciliation for all new admissions/readmissions and the location of the emergency kit glucagon.
- Implemented monitoring that the DON or designee will review each new admission physician order for accurate transcription at the daily clinical meeting.
- Implemented monitoring that the weekend supervisor or designee will monitor physician orders on weekends.
- Implemented weekly monitoring by the Regional Clinical Nurse during Quality Improvement reviews to ensure the plan of removal education remains in place.
- Implemented oversight by the Administrator to ensure IDT members review physician orders for all new admissions/readmissions at the clinical meeting and review effectiveness at the monthly QAPI meeting.
- Completed a QAPI meeting and implemented a Performance Improvement Plan in conjunction with the Plan of Removal.
Failure to Assess and Notify After Witnessed Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice, the resident’s care plan, and the resident’s choices following a witnessed fall. An elderly male resident with severe cognitive impairment (BIMS score 00), Alzheimer’s dementia, non‑Alzheimer’s dementia, HTN, DM, CKD stage 2, and a history of wandering and fall risk was observed roaming in and out of other residents’ rooms on the memory unit. On the morning in question, an LVN reported that the resident became angry when redirected from another resident’s room, attempted to swing at the nurse, lost his balance, and fell, striking his face/head and torso against a hallway rail. The LVN observed an abrasion to the resident’s right temple/cheek area and applied a bandage. Despite this witnessed fall with head impact and visible injury, the LVN did not complete an immediate, comprehensive post‑fall assessment as required by facility policy and nursing standards. The electronic health record for that day contained no documentation of vital signs, head‑to‑toe assessment, neurological checks, fall assessment, post‑fall monitoring, pain assessment, or any change in condition related to the fall. The LVN later stated he had performed these assessments but acknowledged he did not document them and did not call for assistance from other clinical staff. He also did not notify the physician, DON, ADON, or weekend supervisor of the fall and injury, although he claimed to have verbally informed an unidentified weekend supervisor who, according to the weekend supervisor interviewed, was never notified. The resident’s family was not informed of the fall or injury at the time it occurred. When the responsible party and another family member visited later that day, they observed a bloody bandage on the resident’s cheek and noted increased confusion and changes in alertness. During a three‑way call with the LVN, the nurse disclosed that the resident had fallen earlier that morning, admitted he had not notified the family because he was unaware he needed to do so, and reassured them that the resident was “fine” and being monitored. Concerned about the resident’s condition, the family requested to take him to the hospital and signed him out on leave. At the hospital, the resident was found to have sustained right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s records showed that required post‑fall assessments and notifications were not completed at the time of the incident, and key facility staff, including the DON, ADON, weekend supervisor, and NP, confirmed they were not promptly notified of the fall or the resident’s head injury.
Removal Plan
- Notify the Medical Director.
- Complete an ad hoc QA review to address notification protocols for family and physician for incidents/accidents and change of condition, including proper assessments and documentation.
- DON/designee to educate licensed nurses on proper assessments and documentation for incidents/accidents, including any resident change of condition.
- DON/designee to educate licensed nurses to notify the DON and Administrator of all incidents/accidents and change of condition that require hospital transfer.
- DON/designee to assess all residents with falls in the past 30 days to ensure proper notifications and assessments are in place.
- MDS/designee to update care plans for all residents with falls in the last 30 days.
- Educate all licensed nurses on incident/accident protocols, including notification of the DON, Administrator, physician and family, and resident assessment and documentation prior to working their next assigned shift.
- DON/designee to monitor residents with falls daily to ensure notifications, assessments, and documentation are in place.
- Administrator to review with the DON weekly to ensure continued compliance.
- DON to bring results of all audits to the QAPI committee for review and continued recommendations/compliance.
- Include this protocol in new-hire orientation by DON/designee.
Failure to Notify Physician and Family After Resident Fall With Significant Injuries
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative after an accident that resulted in injury and had the potential to require physician intervention. The affected resident was an elderly male with severe cognitive impairment, Spanish-speaking only, with diagnoses including anemia, HTN, DM, CKD stage 2, Alzheimer’s dementia, and non-Alzheimer’s dementia. His admission MDS showed a BIMS score of 00, indicating he was unable to complete the interview, and he required supervision or partial assistance with mobility, transfers, toileting, and ADLs. He had a history of wandering and behaviors such as restlessness, disorganized speech, abusive or resistant behavior, and was care planned as at risk for falls and wandering, with interventions including frequent visual checks and redirection. On the morning in question, the resident was reported by the primary nurse (LVN-L) to have been roaming in and out of other residents’ rooms and requiring frequent redirection. According to LVN-L’s later interview, at approximately 7:30 AM the resident became angry when redirected, attempted to swing at the nurse, lost his balance, and fell hard against a hallway handrail, striking his face/head and torso. LVN-L stated he observed an abrasion to the right temple/cheek area, helped the resident off the floor, cleaned and bandaged the area, and claimed he completed vitals, skin, fall, and neuro assessments with regular observations, and that the resident was ambulatory, not in pain, and functioning at baseline. However, the resident’s electronic health record for that date contained no clinical documentation of vital signs, fall assessment, post-fall monitoring, neurological assessments, pain assessments, or any change-in-condition assessments related to the fall. There were also no completed post-fall assessments by LVN-L in the record. Later that day, the resident’s family visited and, at about 5:00 PM, observed a bloody bandage on his face and noted a change in his mental status. During a conference call with LVN-L, the family learned for the first time that the resident had fallen and hit his head on the rail earlier that morning. The family questioned why they had not been notified and expressed concern about increased confusion. LVN-L acknowledged to the family and to the surveyor that he had not notified the responsible party, the physician, the DON, the ADON, or the weekend supervisor about the fall and injury, stating he was not aware he needed to notify the family and that he was busy with 60 residents and ongoing behaviors. He told the family the resident was fine and allowed them to sign the resident out and transport him to the hospital on leave rather than arranging emergency transport. Hospital records later showed the resident had right 6th and 7th rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s medical provider (NP-A) reported he was not notified of the fall details until two days later and stated he expected immediate notification when a resident falls with a head injury. Interviews with the Administrator, DON, ADON, weekend supervisor, other nurses, and CNAs consistently described that facility protocol required immediate assessment, documentation, and notification of the physician, responsible party, and nursing leadership after a fall or change in condition, and that this did not occur in this case.
Removal Plan
- Medical Director notified
- Ad hoc QA completed to address notification protocols of family and physician for incident/accidents and change of condition
- DON/designee to educate licensed nurses on proper notification of physician and family for incident/accidents to include any resident change of condition
- DON/designee to educate licensed nurses to notify DON and administrator of all incident/accidents and change of condition that require hospital transfer
- DON/designee performed assessments on all residents with falls in the past 30 days to ensure proper notifications and assessments in place
- MDS/designee updated care plans for all residents with falls in the last 30 days
- All licensed nurses will be educated on incident/accident protocols, to include notification of DON, Administrator, physician and family and resident assessment prior to working their next assigned shift
- DON and/or designee will monitor residents with falls daily to ensure notifications were appropriately made to physician and family
- Administrator to review with the DON weekly to ensure continued compliance
- Results of all audits will be brought to the QAPI committee by DON to review for continued recommendations and compliance
- Protocol will be covered on new-hire orientation by DON/designee
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Security Screening
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents when a cognitively impaired resident was able to leave the building unnoticed during the night and was later found on a public street. The resident was an older female admitted for rehabilitation after a cerebral infarction (stroke) and had a Brief Interview for Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment. Her care plan identified an ADL self-care performance deficit related to weakness and deconditioning from a recent hospital stay, with interventions focused on encouraging participation in care, use of the call bell, explanation of procedures, and PT/OT evaluation and treatment. The care plan did not identify or address elopement risk or specific supervision needs related to her cognitive status. On the night of the incident, nursing documentation shows that at approximately 11:00 p.m. the resident was observed in bed sleeping and vital signs were taken without changes. Around 1:00–1:15 a.m., the RN making rounds discovered the resident was no longer in her bed, checked her bathroom and adjacent rooms, and did not find her. Security was alerted, and the RN searched the stairwell and pool area without locating the resident, then proceeded to the front of the building. A security guard reported that he had allowed a woman to exit the building around that time, believing she was homeless. Staff then searched outside and found the resident walking on a pedestrian walkway along the road to the right side of the building. She was returned to the facility, assessed with no injuries noted, and one-on-one supervision was initiated. Interviews and record reviews revealed multiple failures in supervision and identification that led to the elopement. The security guard stated he saw the resident in the swimming pool area, opened a locked gate for her when she could not open it, and escorted her out the front door without asking her name or any identifying questions, without checking for identification, and without notifying nursing staff. He reported assuming she was homeless based on her statement that she came through a back door used by homeless individuals and stated he did not see any identifying bracelets or clothing that would make him think she was a resident, although the family member reported the resident was wearing a fall-risk bracelet and a visible heart monitor. The facility had a pool area and dog park accessible from emergency exits and gates, and the resident was able to reach these areas and then the front of the building without being recognized or stopped by staff. The family member and speech therapist both described the resident as having significant cognitive and communication deficits, including difficulty understanding verbal instructions, needing repeated explanations and visual aids, and not consistently being oriented to person, place, or time, yet these deficits were not effectively incorporated into supervision practices that would have prevented her from leaving the facility unnoticed.
Removal Plan
- Instituted immediate monitoring of emergency exit doors leading outside to the pool and common areas by assigning a staff person at each door of egress; implemented a sign-in/sign-out sheet and prohibited resident/visitor/staff exit unless there is an emergency; ensured assigned staff are relieved for breaks/lunches with documentation on an assigned form.
- Implemented staff exterior walking rounds with documentation, including hourly rounds in the dog park and pool areas; verified dog park gate and pool gate are secured with staff initials.
- Implemented walkie-talkie protocol: charge nurses check out walkie talkies at the beginning of each shift and return them at the end to enhance communication with security.
- Re-educated staff on emergency exit and fire door usage: staff must not use these doors unless there is an emergency and must investigate each time an alarm sounds.
- Re-educated staff on elopement/missing resident procedures: alert staff by calling a Code Yellow, complete skills check quiz for each employee, and ensure elopement binders are located on the 1st and 2nd floor nurses' stations and at the front desk.
- Provided in-service on abuse and neglect (definitions, types, reporting) and identified the abuse coordinator.
- Provided instant in-service on unfamiliar person protocol to remind staff of obligations to identify all persons on the property.
- Completed elopement risk assessments on all residents in the facility.
- Conducted impromptu QAPI meetings addressing resident elopement, binder use, behavior monitoring, swimming pool concerns, and staff assignment at fire door/egress monitoring.
- Began facility-wide education on emergency exit usage and alarm investigation for all departments; ensured staff not in-serviced would be in-serviced prior to their next shift with documentation.
- Completed facility-wide education on resident elopement/missing resident search procedure, proper notification, resident assessments, and resident monitoring; ensured staff not reeducated would be reeducated before their next shift; began elopement skills testing with documentation.
- Began facility-wide education on abuse and neglect (definitions, abuse coordinator, types, importance of timely notification); ensured staff not reeducated would be reeducated before their next shift; implemented abuse/neglect skills testing once per shift.
- Re-educated security/concierge staff on initial contact and verification of a wandering resident: ask identifying questions, check for identifying markers, call nurses’ stations to verify, and refer to the elopement binder; required retraining prior to returning to duty with documentation.
- Implemented additional communication protocol between nursing and front desk/security using walkie talkies: devices located/charged at concierge desk; at least one security associate and one direct care associate on each floor carry walkie talkies; one issued per floor with sign-out and return at end of shift; education completed prior to next shift with documentation.
- Educated night shift staff on security protocol, unfamiliar persons protocol, and abuse and neglect.
- Provided immediate re-education to all security and concierge staff on safety monitoring protocols: hourly walking rounds in pool and dog park areas, continuous monitoring of pool area via security cameras with feed visible at all times, prompt reporting of adverse findings to leadership, and accurate/timely documentation; documented on an in-service sheet.
- Re-educated the Healthcare Administrator on the facility abuse policy and elopement policy.
- Regional Director of Clinical Services educated the Executive Director and Healthcare Administrator on missing resident policy and swimming pool/spa policy.
- Provided ongoing oversight by the Executive Director and Healthcare Administrator to ensure adherence to protocols, with prompt corrective action and additional training for deviations.
- Placed a staff member at the emergency exit door between the dog park and pool area to redirect anyone attempting to exit unless there is an active emergency; maintained coverage until the gate could be reassessed and an appropriate locking mechanism installed.
- Scheduled a meeting with an approved technology company with the Administrator, Director of Maintenance, and Executive Director to assess and implement an appropriate locking mechanism for the gate between the dog park and pool area.
- Required security to complete hourly walking rounds of the pool and dog park areas; document and report any adverse findings to the Director of Resident Services, Executive Director, and Healthcare Administrator.
- Reviewed the pool area policy and reaffirmed that access is restricted to Independent Living residents and skilled care residents are not allowed access.
- Conducted monitoring observations and interviews across all shifts to verify in-service training completion and staff competencies/understanding, including reenactment drills and knowledge checks.
Failure to Honor Resident’s Documented DNR Status During Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Out-of-Hospital Do Not Resuscitate (OOH DNR) order and documented DNR status when the resident was found unresponsive and staff initiated resuscitation. The resident was an older female with diagnoses including depression, anxiety disorder, ALS, and a tracheostomy, and had a BIMS score of 15, indicating she was cognitively intact. Her care plan, physician orders, and an OOH DNR form signed by the physician and two witnesses all documented that her code status was DNR. Despite this, when she was found unresponsive in her room, staff proceeded with CPR and other resuscitative measures after determining she had no pulse and had stopped breathing. According to interviews and record review, an agency CNA discovered the resident unresponsive and notified an LVN, who assessed the resident and noted she was pale but breathing, with a weak pulse. Another LVN entered, performed a sternal rub and other stimuli without response, while the first LVN rechecked pulses at multiple sites and then reported finding no pulse and that the resident had stopped breathing. At that point, a Code Blue was called. Respiratory therapy staff removed the breathing circuit from the tracheostomy, suctioned the airway, and began manual ventilation with an ambu bag. Another LVN began chest compressions. During this period, staff questioned whether the resident was a DNR or full code, and there was hesitation because the LVN leading the response was unsure of the resident’s code status. Staff reported that the crash cart binder, which they relied on to verify code status, was not up to date and contained DNR information for residents who were no longer in the facility. The LVN in charge stated she attempted to verify the resident’s status by checking the crash cart binder and then the electronic medical record, but resuscitation had already been initiated and continued while this verification was pending. EMS arrived and continued compressions, and a pulse was recovered before the LVN informed EMS that the resident was actually a DNR based on the documentation she eventually located. The resident’s responsible party later confirmed that a DNR had been completed at the hospital and again at the facility, and stated that the resident did not want CPR, including having her ribs cracked, and that the facility did not abide by the resident’s wishes. The facility did not have a specific policy for Out-of-Hospital DNRs, only a general resident rights policy stating that residents have the right to refuse treatment.
Removal Plan
- Provided in-service training to staff on resident rights, including: Timely Emergency Services & Professional Standards for CPR; How to Identify the Resident Code Status; and Abuse & Neglect.
- Required all new hires to complete the in-service trainings on resident rights, code status, and CPR-related standards.
- Implemented a process for night shift nurses to print the daily resident census, highlight residents with DNR status, and place the dated census sheet in each crash cart binder along with a copy of each resident’s DNR.
- Implemented a process for morning-shift ADONs to check crash cart binders for accuracy and needed DNR code status updates.
- Implemented DON review of resident code status and crash cart binder accuracy.
- Implemented use of a Standard of Care (SOC) spreadsheet that includes a DNR column and records the date of any code status change; tracked by the corporate nurse.
- Implemented audits of printed reports for new admissions to verify code status and ensure crash cart binders are updated accordingly.
- Implemented a process for the Social Worker to deliver newly executed DNR documentation to the DON for updating the electronic medical record and adding the DNR to the crash cart binder and SOC tracking.
- Implemented a DON audit of resident charts for DNR documentation.
- Implemented corporate nurse audits of SOCs.
Failure to Recognize and Report Resident’s Deteriorating Condition and Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices when there was a clear change in condition. The resident was an adult male with Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a physician. On the day in question, a medication aide documented hypotensive blood pressure readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., but there was no corresponding change-in-condition assessment completed that day, and the low readings were not effectively communicated to the licensed nurses responsible for his care. Throughout that day and night, multiple staff observed and described significant deviations from the resident’s usual baseline without ensuring appropriate nursing assessment and provider notification. A CNA working the day shift reported that the resident, who normally liked to play on his computer, slept most of the day and did not eat breakfast or lunch except for one cup of vanilla pudding; he stated he told the floor nurse but could not recall who it was or what action was taken. Another CNA on the night shift stated the resident was “out of it,” barely spoke, slept most of the shift despite usually staying up late, had heavy breathing, and only nodded his head with eyes closed in response to questions; she reported communicating these concerns to the night nurse and checking on him several times. The medication aide on the 2:00 p.m. – 10:00 p.m. shift acknowledged that the resident’s blood pressure was low and that he held the resident’s blood pressure medication, but he could not clearly identify which nurse he informed or what the nurse’s response was. Licensed nurses on both shifts reported that they were not made aware of the resident’s low blood pressure readings or his refusal of meals. The day-shift LVN stated she received no notifications from CNAs or medication aides that the resident had low blood pressure or had not eaten, and she indicated she would have contacted the provider if she had known of a systolic reading of 86. The night-shift LVN stated she checked on the resident several times, received nods or brief verbal responses, and did not recognize a change in behavior; she also stated she was told by a CNA that the resident had not eaten breakfast or lunch but believed that CNA had already informed the day nurse. Neither LVN had knowledge of the documented hypotensive readings. The following morning, another LVN found the resident barely responsive, clammy, with an untouched breakfast tray, a blood pressure of 75/54, and unresponsiveness to a sternal rub, at which point EMS was called and the resident was sent to the hospital. Hospital staff and the primary medical doctor later described the resident as having been deteriorating for hours, with findings including blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and he required multiple rounds of CPR. The facility’s own policy titled “Change in Resident Condition” required that when there was a significant change in a resident’s physical, mental, or psychosocial status, the medical provider should be contacted. The DON stated that when the medication aide identified low blood pressure, he should have notified the nurse immediately, and that CNAs and medication aides were expected to provide verbal updates to nurses, who in turn were responsible for notifying the provider, completing documentation, and ensuring oversight. In this case, despite documented hypotension, decreased intake, increased sleepiness, and altered responsiveness over many hours, there was a breakdown in communication and follow-through: the low blood pressure readings were not effectively reported to the LVNs, no change-in-condition assessment was completed on the day of the abnormal readings, and the provider was not contacted about the resident’s change in condition until the following morning when he was found unresponsive and required emergency transfer. The primary medical doctor later stated that the resident was found unresponsive to a hard sternal rub with low blood pressure and vomit around his mouth, and that he appeared to have been deteriorating for hours. A hospital registered nurse reported that the resident was admitted due to unresponsiveness, required three rounds of CPR because his heart stopped, and imaging and cultures showed an infarct and blood infection. A hospital nurse practitioner stated that the resident was positive for a blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and that his unresponsiveness was caused by multiple factors. The resident’s family member reported that his mind had been very sharp despite prior stroke-related mobility issues and expressed gratitude that the LVN who found him unresponsive returned to check on him, stating that this likely saved his life. These findings collectively demonstrate that staff did not act in accordance with the resident’s care plan and facility policy regarding timely recognition, assessment, and reporting of a significant change in condition.
Removal Plan
- Removed medication aide #1 from his assignment pending completion of in-service training on Medication Administration, Reporting of Abnormal Vital Signs to the charge nurse, Abuse/Neglect, and Residents Rights.
- Counseled medication aide #1 and issued a written performance action related to failure to report low blood pressure readings to the charge nurse.
- Re-educated all licensed nurses on the expected change-in-condition process, including: evaluation/assessment; documenting findings (vital signs and Change in Condition assessment/progress note); reporting changes to the medical provider; notifying the resident representative; documenting all actions in the EHR; reviewing medication aide vital sign forms for abnormalities with reassessment/interventions; reporting changes to the oncoming nurse during handoff.
- Required that no nursing staff work their next assigned shift until all required in-service training is completed.
- Educated all certified medication aides on medication administration (five rights) and the requirement to notify the charge nurse of any abnormal vital signs.
- Educated all team members on the Stop and Watch process, including when to use it, completing it in the EHR and/or on paper, communicating it to the nurse, and turning the form in to the charge nurse for nurse follow-up.
- Required the nurse to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
- Required all nursing team members to notify the Director of Nursing when a change in condition is identified and Stop and Watch is completed, including that assessment and provider/representative notifications were made.
- Made blank Stop and Watch forms readily available at the nurse’s station and specified secure storage locations for staff use.
- Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for State surveyor review.
- Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication/orders, documentation, representative notification, and updates to the 24-hour communication report.
- Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
- Ensured all nursing staff on leave/PRN are in-serviced prior to working their shift and that administrative nursing staff provide in-service/education prior to staff working their next assigned shift.
- Implemented ongoing monitoring/verification using a Change in Condition audit tool with audits to ensure compliance.
- Implemented/maintained medication aide vital sign monitoring logs and required medication aides to handwrite vital signs on the designated form and submit to the charge nurse for review.
- Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F684 and the plan of removal.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The deficiency involves the facility’s failure to consult with a resident’s physician when there was a significant change in the resident’s physical, mental, or psychosocial status. The resident was an adult male with multiple serious diagnoses, including Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a doctor. On one day, his blood pressure readings taken by a medication aide were 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., which were hypotensive. There was no documentation that a Change in Condition (CIC) assessment was completed that day, and no progress notes indicated that the physician had been notified of these low blood pressure readings or of any change in condition. Staff interviews and records showed that the resident’s condition had changed over the same period without appropriate escalation to a provider. CNAs reported that the resident, who was normally alert, communicative, and active on his computer, slept most of the day and night, was very sleepy, did not eat breakfast or lunch except for one cup of pudding, and had minimal verbal communication, sometimes only nodding his head with eyes closed and heavy breathing. A CNA stated he informed the floor nurse that the resident had not eaten and was very sleepy but could not recall the nurse’s name or what action was taken. A medication aide stated he held the resident’s blood pressure medication due to low blood pressure and told an unidentified nurse, but he could not say which nurse or what the nurse’s response was. The nurses who worked those shifts stated they were not informed of the low blood pressure readings or the resident’s poor intake and increased sleepiness. The following morning, an LVN entering the resident’s room found him drowsy, barely speaking, with an untouched breakfast tray, clammy to the touch, and with a low blood pressure of 75/54. The LVN documented that the resident was unresponsive to a sternal rub and was sent out due to an acute change in condition, hypotension, increased work of breathing, and unresponsiveness; EMS, the provider, the DON, and family were notified at that time. Subsequent hospital information obtained by surveyors indicated the resident was admitted to ICU for unresponsiveness, required multiple rounds of CPR after his heart stopped, and was diagnosed with a blood infection, septic shock, mucus in his lungs, and an acute stroke, with a blood sugar of 63. The resident’s primary medical doctor reported that when he saw the resident at the hospital, the resident had vomit around his mouth, appeared to have been deteriorating for hours, and had technically passed away twice but was resuscitated. The facility’s DON confirmed that per policy, providers should be informed of all significant changes, and that CNAs and medication aides were expected to report changes to nurses, who in turn were to notify the provider and document the change in condition, which did not occur in this case. An Immediate Jeopardy was identified related to this failure to notify the physician of the significant change in condition.
Removal Plan
- Removed medication aide #1 from assignment pending completion of in-service training on Medication Administration, reporting abnormal vital signs to charge nurse, Abuse/Neglect, and Residents Rights.
- Counseled medication aide #1 and issued a written performance action for failure to report low blood pressure readings to the charge nurse.
- Re-educated all licensed nurses on the expected change-in-condition process: evaluation/assessment, documentation (vital signs and Change in Condition assessment/progress note), reporting to the medical provider, notification of resident representative, and ensuring all steps are documented in the EHR.
- Required licensed nurses to review medication aide vital sign forms to identify abnormal vital signs, re-assess residents, implement interventions, notify the medical provider and resident representative, and document actions in the EHR.
- Required nurses to report identified/suspected changes in condition to the oncoming nurse during shift handoff to ensure continuity of reporting.
- Prohibited any nursing staff (full-time, part-time, PRN, or on leave) from working their next assigned shift until all required in-service training was completed.
- Educated all certified medication aides on medication administration (rights of medication administration) and the requirement to notify the charge nurse of any abnormal vital signs.
- Educated all team members on the Stop and Watch process for subtle changes in condition and expectations for use.
- Required Stop and Watch forms to be completed in the EHR and/or on paper, communicated to the nurse, and paper forms turned in to the charge nurse for nurse follow-up assessment and notifications.
- Required nurses to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
- Required all nursing team members to notify the DON when a change in condition is identified and Stop and Watch is completed, including confirmation that assessment and provider/representative notifications were made.
- Made blank Stop and Watch forms readily available at the nurse's station.
- Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for state surveyor review.
- Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication, orders, documentation, representative notification, and updates to the 24-hour communication report.
- Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
- Ensured all PRN/on-leave nursing staff are in-serviced prior to working their next shift and that administrative nursing staff provide in-service/education prior to staff working.
- Ensured all residents receive appropriate care after a change in condition.
- Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F580 and the plan of removal to lift immediate jeopardy.
- Required certified medication aides to handwrite all vital signs on the designated vital sign form/log and turn it in to the charge nurse.
- Placed a copy of the medication aide vital sign form/log in the Abatement/Plan of Removal binder for state surveyor review.
- Ensured Stop and Watch forms were available in designated locations for staff access and use.
- Required DON notification by phone when a Stop and Watch form is completed and a change in condition is identified.
Single-Staff Hoyer Transfer and Delayed Assessment Lead to Severe Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers and adequate supervision during a mechanical lift transfer for one resident, resulting in serious injuries. The resident was an elderly female with Alzheimer’s disease, dementia, prior stroke, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers. Her care plan and Kardex specified that she was non–weight bearing and required a Hoyer lift with two staff for all transfers. Earlier on the day in question, she had been seen by facility physicians and nursing staff, and had received a shower and Hoyer transfer with two staff, with no bruises, skin tears, edema, or leg injury documented or observed. On the evening and night shift, a CNA assigned to the resident’s hall was instructed to put the resident to bed. The CNA reported that she took a Hoyer lift she had used on another resident and transferred this resident from wheelchair to bed by herself, despite knowing that Hoyer transfers required two staff and that the resident was a two-person Hoyer transfer. She stated she did not ask for help and acknowledged she had been trained that Hoyer lifts required two staff, although she also claimed she had not been trained on the Hoyer at this facility and said she did not check the Kardex because she did not have access. Another CNA confirmed that all Hoyer transfers were supposed to be done with two staff and that the resident’s requirements were available in the Kardex. The facility’s written Safe Resident Handling/Transfers policy required two staff for mechanical lift transfers and mandated that transfers be performed according to the resident’s plan of care. After the single-staff Hoyer transfer, the CNA and another aide assisted with repositioning the resident in bed. During this time, skin tears and bruising on the resident’s arms were observed. The assisting CNA reported that the skin tears appeared bloody and asked what had happened; she was told by the primary CNA that the injuries were old and that the nurse was aware. The primary CNA stated she informed the nurse that the resident appeared in pain, but the nurse allegedly responded that the resident would be screaming if she were in pain. The CNA also reported noticing bruising on the resident’s left leg and said she told her supervisor and the nurse, and was told the leg was always like that or that it was edema and to elevate it. The nurse on duty acknowledged being notified around early morning that the resident’s leg appeared bruised or swollen but did not immediately assess the resident, instead instructing that the leg be elevated while she continued care for another resident. By the following morning, when the day-shift LVN assessed the resident at the request of the night nurse, extensive injuries were found. The assessment revealed bilateral bruising to both arms, multiple skin tears with missing top layers of skin and no flaps, a large bruise on the back, a scratch on the forehead, and swelling, discoloration, and obvious deformity of the left lower extremity. The resident grimaced and moaned with touch or movement. Hospital evaluation documented a forehead abrasion, severe hematoma and contusions of the upper extremities with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling. Police photographs showed purple and red bruising on both hands with fresh and dried blood on the sheets, and the left leg bruised, purple, inflamed, and turned in an abnormal direction. There were no documented falls or incidents that could explain these injuries, and staff interviews did not identify any reported event, leaving the single-staff Hoyer transfer and subsequent lack of timely assessment after reported changes in condition as the central actions and inactions leading to the deficiency. The facility’s internal investigation confirmed that there were no abnormal findings on the resident earlier that day, including during a shower and physician visits, and that no staff reported any fall or incident during the night. The CNA who performed the transfer admitted using the Hoyer lift alone for this dependent, non–weight-bearing resident, contrary to the care plan, Kardex, and facility policy. The night nurse acknowledged failing to assess the resident after being notified of a change in her leg’s condition. The day nurse, who had last seen the resident without injuries the prior evening, found extensive new bruising, skin tears, and leg deformity the next morning. The combination of a one-person mechanical lift transfer for a resident care-planned for two-person Hoyer use, failure to follow the safe transfer policy and plan of care, and failure to promptly assess and document a reported change in condition led to the identified deficiency in ensuring the environment was free from accident hazards and that residents received adequate supervision and assistance to prevent accidents.
Removal Plan
- Completed facility-wide skin assessments with no new or abnormal findings identified.
- Conducted environmental and safety rounds with no hazards or abnormal findings identified.
- Conducted resident safe surveys; residents reported they felt safe in the facility environment.
- Provided staff education on abuse, neglect, and exploitation policies.
- Completed mechanical lift competencies with nursing staff.
- Reviewed electronic records of residents; no issues identified with assessments.
- Held an AD HOC QAPI meeting with the interdisciplinary team and involved police notification, social work, and the Regional Nurse; implemented ongoing daily monitoring of residents.
- Implemented staff training and competency testing/demonstration covering abuse, neglect, reporting, documentation, transfers, resident assessment, and pain assessment.
- Conducted in-services for all direct care staff (in person and/or via phone); staff not present were not permitted to work their assignment until in-serviced; new hires to be in-serviced during orientation; agency staff to be in-serviced prior to working their floor assignment.
- Completed in-service training on falls, documentation, Stop and Watch alert tool in PCC, abuse coordinator identification, and immediate reporting of abuse/neglect with 100% staff trained.
- Completed nursing staff training and competencies for skin assessment and pain assessments with 100% nursing staff trained.
Failure to Assess Change in Condition and Perform Safe Hoyer Transfer Resulting in Severe Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely assessment and care in accordance with professional standards of practice and the resident’s care plan after a reported change in condition. The resident was an elderly female with Alzheimer’s disease, dementia, prior cerebral infarction, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers, requiring a two-person Hoyer lift transfer at all times. Her care plan and Kardex both identified her as non–weight bearing and requiring Hoyer lift with two staff. On the afternoon of the day before the incident, documentation by an LVN indicated no edema or injuries, and a late-night note by another LVN documented edema but did not specify location, grade, or associated pain. During the night shift, a CNA transferred the resident from wheelchair to bed using a Hoyer lift alone, despite knowing the resident required a two-person Hoyer transfer and acknowledging awareness that Hoyer lifts required two staff. The CNA reported not being trained on the Hoyer lift at the facility and not checking the Kardex due to lack of access to the electronic system. After the transfer, while providing incontinence care, the CNA noticed bruising on the resident’s left leg and skin tears on her arms near the wrists. The CNA stated she informed a CNA supervisor, who allegedly said the leg had always been like that and did not check it, and that she also informed the night-shift LVN that the resident appeared to be in pain and asked the LVN to look at the leg. The LVN reportedly responded that the resident would be screaming if she was in pain and later, when shown the resident’s left foot with edema around 5:10–5:15 a.m., told the CNA to elevate the leg and then continued providing care to other residents without immediately assessing the resident. The LVN who had worked the prior day shift and returned for the morning shift stated that the resident had no bruises, edema, or skin tears when she left the previous evening. After receiving morning report, this LVN was asked by the night LVN to assess the resident at approximately 6:40 a.m. Upon pulling back the covers, she observed extensive new findings: discoloration and bruising to both arms and the right thigh, left lower extremity swelling and discoloration, multiple skin tears with missing top skin and no flaps, a knot on the right forearm, a scratch on the forehead, a large bruise on the back, fresh blood on the gown and blankets, and significant pain responses (grimacing, moaning, and frowning) when the resident was touched or moved. The resident was unable to articulate what had happened and denied falling or being harmed when questioned. Hospital evaluation documented a forehead abrasion, obvious deformity of the left lower extremity, severe hematoma of the right upper extremity, bilateral upper extremity contusions with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling, with concern for elder abuse noted. The facility’s investigation found no reported falls or incidents that could explain the injuries, confirmed that the night LVN had been notified of leg changes but did not promptly assess the resident, and classified the situation as an Immediate Jeopardy related to failure to assess and respond to a change in condition and to follow safe transfer requirements.
Removal Plan
- Suspended CNA A and LVN C immediately pending investigation
- Terminated LVN C for failure to assess and document a resident after being notified of a change in condition
- Completed facility-wide skin assessments with no new or abnormal findings
- Conducted environmental and safety rounds with no hazards or abnormal findings identified
- Conducted resident safe surveys with residents reporting they feel safe in the facility environment
- Provided staff education on abuse, neglect, and exploitation policies
- Completed mechanical lift (Hoyer) competencies with nursing staff
- Conducted targeted staff interviews with employees who had direct contact with the resident within the previous 72 hours regarding observed abnormalities and reporting
- Re-educated staff regarding the role of the Facility Abuse Coordinator, incident and accident reporting, documentation requirements, and charting expectations
- Reviewed electronic records of residents for assessment issues; no issues identified
- Held an AD HOC QAPI meeting with the interdisciplinary team to review the incident and identify system improvements
- Implemented staff training and competency testing/demonstration on abuse/neglect/reporting, documentation, transfers, resident assessment, and pain assessment
- Conducted in-services for all direct care staff; staff not present were not permitted to work their assignment until in-serviced
- In-serviced all new hires during facility orientation
- In-serviced all agency staff prior to working their floor assignment
- Completed in-service training on falls, documentation, Stop and Watch alert tool in PCC, and reporting abuse/neglect immediately to the Abuse Coordinator; 100% of staff trained
- Completed nursing staff training and competencies on skin assessments and pain assessments; 100% of nursing staff trained
- Conducted impromptu observations and skills/knowledge checks of Hoyer lift transfers and resident assessments
- Conducted daily reviews of resident records for assessments via daily 24-hour report review
- Monitored staff daily and conducted impromptu knowledge checks
- Reviewed 24-hour reports daily and reviewed resident charts for required charting
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident’s elopement from the building without staff knowledge. The resident was an elderly male with dementia, prior cerebral infarction, hemiplegia/hemiparesis, generalized muscle weakness, and atherosclerotic heart disease. His admission MDS showed a BIMS score of 1, indicating severe cognitive impairment. An Elopement Risk Assessment completed shortly after admission scored him at 16, identifying him as at high risk for elopement, but his care plan dated 03/02/26 did not include elopement risk as a focus with goals or interventions. Progress notes from admission through the date of the incident documented no prior elopement attempts or exit-seeking behaviors. On the night of the incident, the east exit door alarm sounded at approximately 01:00 a.m. The nurse on duty, RN A, reported that she immediately went to the door and looked but did not see any residents; she then conducted a head count and discovered that the resident was missing. The DON stated that RN A did not go outside the building to look for the resident when the door alarm sounded, and the administrator stated it was the nurse’s responsibility to go around the building at the time of the alarm. While the alarm had sounded and staff were searching, a CNA who worked on another floor encountered the resident outside around 12:30 a.m.; the CNA later stated in writing that he thought the man was homeless and did not recognize him as a resident because he worked on a different floor and had never seen him before. After the resident was identified as missing, staff initiated the facility’s elopement/missing resident protocol and searched the building and surrounding premises, and local law enforcement was notified. Within a short time, police contacted the facility to report that the resident had been found wandering off facility grounds and transported him to a hospital for evaluation. The administrator reported that the resident was found near a hospital or a crossing bridge near the hospital, at least as far as the main road and not near the facility, estimating the distance as a 5–10 minute walk or longer for this resident. Hospital evaluation and subsequent skin assessment on return documented no injuries or acute issues. The DON later acknowledged that the resident’s high elopement risk score had been known, that the care plan should have reflected monitoring for elopement/exit-seeking behaviors, and that staff had not notified her when the resident’s initial elopement assessment score exceeded the facility’s high-risk threshold.
Removal Plan
- All staff received training on abuse and neglect as well as training on elopement response with emphasis on the need to check outside the building in response to door alarms.
- All residents were reassessed for elopement risks.
- An AD Hoc QAPI meeting was conducted to review the elopement.
- Door locks and alarms were checked and are checked daily.
- Door alarm monitoring and missing resident/elopement monitoring are completed daily.
- Door alarm codes continue to be changed monthly.
- Elopement drills are conducted three times per week.
- The DON monitors all residents' elopement scores daily by generating and reviewing a daily report for changes and scores over 10.
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