Cavalier Healthcare Of England
Inspection history, citations, penalties and survey trends for this long-term care facility in England, Arkansas.
- Location
- 400 Stuttgart Highway, England, Arkansas 72046
- CMS Provider Number
- 045442
- Inspections on file
- 26
- Latest survey
- July 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cavalier Healthcare Of England during CMS and state inspections, most recent first.
The facility did not consistently review or update care plans after assessments or changes in condition for several residents, including those with severe cognitive impairment, recent falls, new hospice services, and recent admissions. In multiple cases, care plans were not revised to reflect significant events or interventions, and required assessments were not completed within the specified timeframes.
Dietary staff did not follow hand hygiene protocols during meal service, including handling food and food service equipment with bare hands and failing to wash hands between tasks that could cause cross contamination, as required by facility policy.
A resident with severe cognitive impairment and a diagnosis of Alzheimer’s and dementia was not provided with a care plan meeting involving their designated POA, despite facility policy requiring such involvement and care plan interventions that included family participation. Staff interviews confirmed that no care plan meeting had occurred since admission, and the POA was not invited to participate.
A resident with severe cognitive impairment had conflicting advance directive documentation regarding life-sustaining treatment, with forms signed by a family member who was not the legal healthcare POA. The facility did not have a valid POA on file, resulting in unclear and potentially invalid code status for the resident.
A resident who was re-admitted on hospice services after multiple hospitalizations did not have a significant change MDS assessment completed within the required 14-day period. The MDS was started but remained incomplete for over two months, and the care plan was not updated to reflect the resident’s hospice status. The MDS Coordinator confirmed the assessment should have been completed and was unaware of the delay.
A facility did not complete and transmit required MDS assessments, including entry, significant change, and quarterly MDS, within the mandated timeframes for a resident with COPD and pneumonia who experienced changes in care, such as hospice admission. The care plan was not updated to reflect these changes, and the MDS Coordinator confirmed the assessments were incomplete and not submitted as required.
A resident with severe cognitive impairment and incontinence was not checked or changed for an extended period, resulting in saturated clothing and a soiled brief. Despite facility policy and staff training requiring checks every two hours, CNAs admitted the resident was overlooked due to other duties. Nursing staff interviews confirmed expectations for regular incontinence care and repositioning were not met.
The facility failed to maintain proper food temperatures, leading to resident dissatisfaction and potential nutritional issues. Observations revealed that food carts were left open, causing temperature drops in meals served. Residents reported receiving cold food, and staff admitted to procedural lapses. The Dietary Manager acknowledged equipment issues, and facility policies on food temperatures were not adhered to.
The facility failed to ensure proper food storage, hand hygiene, and kitchen cleanliness. Observations included uncovered and undated food items, improper hand hygiene by dietary staff, and unclean kitchen and dishwashing areas. Additionally, a hot food item was found to be below the required temperature, posing a risk of foodborne illness to residents.
The facility failed to ensure that a diabetic resident's nails were clean and trimmed as per her care plan. Despite the responsibility lying with the nurses, the resident was observed multiple times with long nails and a black substance underneath them. The resident indicated that her nails were only cleaned when there was enough help.
The facility failed to ensure a safe and hazard-free environment for two residents. One resident with severe cognitive impairment had hazardous items left accessible in their room, while another resident with moderate cognitive impairment was observed vaping indoors despite a policy prohibiting it. The facility's inconsistent enforcement and communication of safety policies led to these deficiencies.
The facility failed to ensure that refrigerated narcotic medications were stored in a permanently affixed compartment, potentially leading to misappropriation. An LPN confirmed the narcotic box was not affixed, and the DON acknowledged it should be. Facility policy mandates secure storage of medications.
The facility failed to ensure meals were served at acceptable temperatures, affecting residents who received meal trays in their rooms. Residents reported that hot food items were often cold, and cold items were warm. Temperature checks confirmed these observations, with unheated food carts resulting in food items not being maintained at safe and appetizing temperatures.
The facility failed to ensure pureed food items were blended to a smooth, lump-free consistency, posing a risk to residents requiring pureed diets. Observations revealed that pureed lasagna, garlic bread, vegetable blend, bread, and sausage were not prepared correctly, affecting six residents.
The facility failed to ensure that the biohazard and oxygen rooms remained locked at all times, potentially affecting all 57 residents. Unattended keys were found in the Biohazard Room door, and another room containing oxygen cylinders and used syringes was found unlocked. The DON and Administrator confirmed these findings.
The facility failed to ensure that residents had knowledge of the State Inspection Book and that it was accessible to them. Residents were unaware of the book's existence or location, and the survey results binder was found to be kept behind the nurse's station, making it inaccessible to residents and their representatives. The Administrator admitted the book was not returned to its proper location after painting.
Failure to Review and Revise Care Plans After Assessments and Changes in Condition
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment or change in condition for four out of five sampled residents. For one resident with severe cognitive impairment and a history of falls, the care plan had not been updated following multiple falls and hospitalizations, despite documentation of these events in progress notes. Observations also revealed the resident continued to attempt to get out of bed, and interventions such as an extra mattress were implemented without corresponding updates to the care plan. Another resident was admitted with multiple complex diagnoses, but a comprehensive care plan was not developed following admission, nor was a baseline care plan completed within the required timeframe. The MDS Coordinator confirmed that the care plan was overdue and not available for staff reference. Additionally, a resident who was started on hospice services did not have this significant change reflected in their care plan, as the last revision predated the hospice order. A further resident experienced multiple falls over several months, with some falls lacking documented interventions and others having interventions that were not incorporated into the care plan. The care plan did not reflect the resident's recent falls or the interventions implemented, and a significant change MDS assessment was not completed within the required timeframe. The facility's policy required care plans to be reviewed and revised after comprehensive assessments and significant changes, but this was not consistently followed for the sampled residents.
Failure to Perform Hand Hygiene During Food Service
Penalty
Summary
Dietary staff failed to perform proper hand hygiene during meal service, as observed on two separate occasions. On one occasion, a dietary staff member opened a box of rolls without gloves, reached into the box with bare hands, and handled the rolls without washing hands after touching the outside of the box. The staff member acknowledged during an interview that hand washing should have occurred after opening the box and before touching the food to prevent cross contamination. In another instance, the same staff member opened and closed the lids of hot plate warmer containers with bare hands, retrieved plates, and proceeded to the tray line to serve food without performing hand hygiene between these tasks. The facility's policy requires hand washing before food preparation and after handling soiled equipment or utensils, as well as as often as necessary to prevent cross contamination. The administrator and another dietary aide confirmed that the top of the plate warmer was considered dirty, and that staff hands would be considered contaminated after touching it, yet hand hygiene was not performed before returning to food service.
Failure to Involve POA in Care Plan Development for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident’s designated Power of Attorney (POA) was invited to participate in the development and implementation of the resident’s person-centered care plan. The resident, who was admitted with Alzheimer’s and dementia and had severe cognitive impairment as indicated by a Brief Interview for Mental Status score of 04, had a care plan that included interventions requiring family involvement, particularly in nutritional evaluation. Despite this, the POA reported never being invited to a care plan meeting since the resident’s admission. Interviews with facility staff revealed that care plan meetings were supposed to be held quarterly, upon admission, and with changes in condition. However, the MDS Coordinator confirmed that no care plan meeting had been conducted for the resident since admission. The Nurse Manager stated there was no one available to conduct care plan meetings at the time, and the Administrator was unsure if the POA had been contacted, noting that two of the resident’s family members worked at the facility. The DON also acknowledged that care plan meetings should have occurred but could not explain why they had not been held for this resident.
Conflicting Advance Directive Documentation and Lack of Legal Authorization
Penalty
Summary
The facility failed to ensure that a resident's advance directive documentation accurately reflected the resident's wishes regarding life-sustaining treatment. Record review revealed that the resident, who was admitted with severe cognitive impairment and multiple medical diagnoses including dementia and chronic kidney disease, had conflicting information documented regarding their code status. Specifically, two separate acknowledgment forms were signed by a family member—one indicating a Do Not Resuscitate (DNR) order and another indicating a desire for all life-sustaining treatments. Additionally, the family member who signed these documents was not documented as having legal authority as the resident's healthcare Power of Attorney (POA). Further review and interviews confirmed that the facility did not have a healthcare POA on file for the resident, and the family member who signed the forms stated they did not possess POA authority, as the resident was not competent to appoint one. The facility's policy requires that advance directives be honored only if completed prior to a resident being deemed incompetent, and that such directives must be legally valid. The presence of conflicting documentation and lack of a legally authorized decision-maker resulted in unclear and potentially invalid advance directive status for the resident.
Failure to Complete Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident’s physical or mental condition. The resident in question was initially admitted with abnormal blood chemistry and pneumonia, and was later re-admitted from the hospital on hospice services with a diagnosis of acute kidney injury, following multiple hospitalizations in the previous month. Documentation showed that the significant change MDS was started three days after the resident’s re-admission and transition to hospice care, but as of more than two months later, the assessment remained incomplete and pending with the MDS Coordinator. Further review revealed that the resident’s care plan had not been updated to reflect the hospice admission, and the MDS Coordinator confirmed that the significant change MDS should have been completed within 14 days of initiation. The coordinator was unaware of why the assessment did not appear on their dashboard, resulting in the failure to complete the required assessment and update the care plan accordingly. Orders and documentation from the hospice company and physician confirmed the resident’s hospice status, but the necessary MDS and care plan updates were not completed as required.
Failure to Complete and Transmit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to ensure that a comprehensive entry Minimum Data Set (MDS) assessment was encoded and transmitted within the required timeframe for one resident. Record review showed that the resident was admitted with chronic obstructive pulmonary disease and pneumonia, and later had significant changes in care, including admission to hospice services. Examination of the electronic health record revealed that several MDS assessments, including a discharge MDS, an entry MDS, a significant change MDS, and a quarterly MDS, were either not completed or not transmitted as required. The care plan had not been updated to reflect the resident's changes in care. During interview, the MDS Coordinator confirmed that the significant change MDS and other required assessments were incomplete and not submitted within the mandated timeframes, and that the facility did not have a specific policy for MDS timing, relying instead on the RAI OBRA guidelines.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
A deficiency occurred when staff failed to provide timely perineal care and repositioning for a resident with severe cognitive impairment, stroke, dementia, and depression. The resident was observed to have been left in a saturated brief containing stool and soaked clothing, with the last change reportedly occurring early in the morning. Certified Nursing Assistants (CNAs) admitted the resident had been overlooked due to being asked to assist with other residents, and were unsure of the exact time the resident was last changed. The resident was dependent on staff for all activities of daily living and was always incontinent of bladder and frequently incontinent of bowel, as documented in the Minimum Data Set (MDS) and care plan. Facility policy and the resident's care plan required that incontinent residents be checked and changed at least every two hours, and that staff monitor for signs of infection and skin breakdown. The care plan also directed frequent hourly rounds while the resident was in a wheelchair. Interviews with nursing staff, including the RN, treatment nurse, DON, and administrator, confirmed that staff were expected to check and change residents every two hours, especially those with incontinence, to maintain skin integrity and prevent infection. Despite these policies and staff training, the resident was not checked or changed as required, resulting in prolonged exposure to urine and feces. The incident was directly observed by the surveyor, and staff interviews confirmed a lapse in following established protocols for incontinence care and repositioning. Facility documents and in-service records showed that the involved CNAs had been educated on these requirements prior to the incident.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures, which compromised the palatability and nutritional intake of residents. During observations, it was noted that food carts were left open while being loaded and transported, causing significant temperature drops in both hot and cold food items. For instance, cream corn and chili were served at temperatures well below the required 150 degrees Fahrenheit for hot foods, and milk was served above the acceptable 40 degrees Fahrenheit for cold foods. This issue was observed during multiple meal services across different halls. Residents expressed dissatisfaction with the temperature of their meals, with some reporting that their food was cold by the time it reached them. Staff interviews revealed a lack of adherence to proper procedures for maintaining food temperatures, with several CNAs admitting that leaving the cart doors open was faster but resulted in temperature drops. The Dietary Manager acknowledged that the steam table and food carts were not functioning optimally, contributing to the problem. The facility's policies on food temperatures were not followed, as evidenced by the repeated instances of food being served at incorrect temperatures. Despite previous grievances and complaints from residents about cold meals, the facility continued to struggle with maintaining appropriate food temperatures during service. The failure to address these issues effectively led to ongoing resident dissatisfaction and potential impacts on their nutritional intake.
Multiple Deficiencies in Food Storage, Hand Hygiene, and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure food items stored in the refrigerator were covered and dated, and the kitchen vents were cleaned to provide a sanitary environment for food preparation. Observations included an open gallon of enchilada sauce and an opened box of bacon in the refrigerator without proper covering or dating. Additionally, the ceiling tile above the refrigerator had peeling paint, exposing the wood. Similar issues were found in the meat and vegetable freezer, where opened zip lock bags containing onion rings and chicken fried steak were not sealed properly. Dietary staff failed to follow proper hand hygiene protocols, leading to potential contamination. One dietary employee washed his hands but then turned off the faucet with his hands, contaminating them before handling food items. Another dietary employee was observed handling utensils and food items without changing gloves or washing hands after touching dirty objects. These actions were repeated by multiple dietary employees, indicating a systemic issue with hand hygiene practices. The facility also failed to maintain the cleanliness and integrity of the kitchen and dishwashing areas. Observations included peeling paint, water damage, and stains on the ceiling tiles, floors, and walls. The dishwashing room had black/brown stains on the floor, rust stains on the baseboards, and white sediment accumulations on dish racks. Additionally, the temperature of a hot food item on the steam table was found to be below the required 135 degrees Fahrenheit, posing a risk of foodborne illness to residents.
Failure to Maintain Nail Hygiene for Diabetic Resident
Penalty
Summary
The facility failed to ensure that the nails of Resident #2, who has a diagnosis of Type 2 Diabetes mellitus, were clean and trimmed. The resident's care plan specified that nails should be checked, trimmed, and cleaned on bath days and as necessary, with changes reported to the nurse. On multiple occasions, Resident #2 was observed with long fingernails and a black substance underneath them. The resident mentioned that her nails were only cleaned when there was enough help. Both a CNA and an LPN confirmed that nurses were responsible for cutting and cleaning the resident's nails due to her diabetic condition. However, the LPN admitted that there was no excuse for the nails being dirty, even if the resident sometimes refused to have them cut.
Failure to Ensure a Safe and Hazard-Free Environment
Penalty
Summary
The facility failed to ensure a safe and hazard-free environment for two residents, leading to deficiencies in their care. Resident #50, who has severe cognitive impairment due to dementia, was observed multiple times with potentially hazardous items such as aftershave, shaving gel, shave cream, and body lotion left on the dresser by the door. Despite the care plan indicating that staff should ensure a safe environment, these items were not removed. A Certified Nursing Assistant (CNA) acknowledged that these items should not be there and that it was the aides' responsibility to put them away. The Director of Nursing (DON) confirmed that these items should not be accessible to demented and confused residents, as per the facility's policy on avoiding accidents and incidents involving patients. Resident #43, who has moderate cognitive impairment and impaired physical mobility due to a stroke, was observed vaping in their room. The facility's smoking policy was updated to prohibit vaping indoors and only allow it in designated outdoor areas. However, Resident #43 indicated that they were previously allowed to vape in their room and were only informed of the new policy after being observed vaping. The Administrator could not provide a clear answer on when the facility became vape-free, indicating a lack of consistent enforcement and communication of the policy. The updated smoking policy was provided to the resident after the incident, but the initial failure to enforce the policy created a hazardous environment.
Failure to Securely Store Refrigerated Narcotic Medications
Penalty
Summary
The facility failed to ensure that refrigerated narcotic medications were stored in a permanently affixed compartment, which could potentially lead to the misappropriation of resident property. During an observation, an LPN was seen pulling a narcotic medication box out of the refrigerator and placing it on the counter; the box was not affixed to the refrigerator. The LPN confirmed that the narcotic box was not permanently affixed. When questioned, the Director of Nurses was unaware of the reason but acknowledged that the box should be affixed. The facility's policy on drug acquisition, storage, and inspection mandates that medications be stored securely.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents. This deficiency was observed during two meals, affecting residents who received meal trays in their rooms on the A, B, and C halls. Specifically, residents reported that hot food items were often cold, and cold items were warm. For instance, Resident #41 and Resident #30 both indicated dissatisfaction with the temperature of their meals, noting that the food was not served at appropriate temperatures, which impacted their dining experience and nutritional intake. Temperature checks conducted by the surveyors confirmed these observations. On multiple occasions, unheated food carts were used to deliver meal trays, resulting in food items not being maintained at safe and appetizing temperatures. For example, milk temperatures ranged from 45 to 53 degrees Fahrenheit, and hot food items like biscuits with gravy and scrambled eggs were recorded at temperatures between 102.7 and 115 degrees Fahrenheit. These findings indicate a systemic issue with the facility's meal delivery process, affecting the quality and palatability of the food served to the residents.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is essential to minimize the risk of choking or other complications for residents requiring pureed diets. During observations, it was noted that the pureed lasagna prepared by Dietary Employee (DE) #3 was gritty and not smooth. Similarly, the pureed garlic bread was thick, lumpy, and contained pieces of bread. The pureed vegetable blend was initially runny, and even after adding thickener, it remained lumpy and not smooth. These observations were made during two separate meals, indicating a consistent issue with the preparation of pureed foods in the facility. Further observations on the steam table revealed that the pureed bread and pureed sausage intended for residents on pureed diets were also not prepared to the required consistency. The pureed bread was thick, and the pureed sausage was gritty. When asked to describe the consistency of the pureed food items, DE #1 confirmed that the pureed bread was thick and the pureed sausage was gritty, acknowledging that they needed to be smooth. This deficiency had the potential to affect six residents who were on pureed diets, posing a significant risk to their safety and well-being.
Failure to Secure Biohazard and Oxygen Rooms
Penalty
Summary
The facility failed to ensure that the biohazard and oxygen rooms remained locked at all times, which had the potential to affect all 57 residents. On 04/02/2024 at 03:09 PM, the Surveyor observed an unattended set of keys in the doorknob to the Biohazard Room on 300 Hall. The Maintenance staff later removed the keys, admitting they had only been gone for a couple of minutes. The Administrator confirmed the keys were left in the door unattended. Additionally, on 04/03/2024 at 10:11 AM, the Surveyor observed a door on Hall 3 with a sign indicating it should be kept closed at all times, but it was found unlocked and open. The room contained oxygen cylinders, used syringes and needles, disinfecting wipes, a small refrigerator, and multiple PPE items. The DON and Administrator confirmed the room's contents and that the door was unlocked. A document provided by the Administrator titled 'Incident and Accident Reporting' effective 05/15/2024, with a revised date of 08/22/2017, indicated that everything possible should be done to avoid accidents or incidents involving patients. Despite this policy, the facility's failure to keep the biohazard and oxygen rooms locked at all times was observed on multiple occasions, posing a potential risk to the safety of all residents.
Failure to Ensure Accessibility of State Inspection Book
Penalty
Summary
The facility failed to ensure that residents had knowledge of the State Inspection Book and that it was accessible to them. During a Resident Council meeting, four residents stated they were unaware of the State Inspections Book or its location. The surveyor was unable to locate the survey results binder in the facility. The Activity Director indicated that the state inspection results were kept behind the nurse's station, making them inaccessible to residents and their representatives. The Administrator acknowledged that the state inspection book was not returned to its proper location after painting.
Latest citations in Arkansas
A resident with peripheral vascular disease, prior toe amputation, and malnutrition had multiple lower extremity wounds managed by an external Wound Care Clinic, which issued detailed written orders for cleansing, specific dressings, and compression. Facility TAR entries showed generalized leg treatments on a fixed schedule instead of the ordered every-other-day frequency, did not distinguish between multiple wounds on the same leg, omitted documentation of ordered transfer foam and a compression stocking, and added self-adherent wrap that was not ordered. Interviews with the TN and DON confirmed that the TN was responsible for entering and carrying out clinic orders, and leadership could not produce documentation that all ordered treatments were provided or explain the altered treatment frequency, contrary to facility policy requiring treatments to follow provider orders.
Surveyors found that a nurse responsible for wound care and infection prevention failed to follow basic infection control practices while treating two residents with pressure ulcers and one with a suprapubic catheter. The nurse repeatedly handled keys, a phone, and a computer, then accessed and prepared wound supplies without performing hand hygiene, touched gauze with ungloved hands before using it on a wound, and set up supplies on non‑impervious paper towels next to personal items instead of on a properly disinfected, protected surface. During one observation, the nurse cleaned a hip pressure ulcer and then a suprapubic catheter site using separate gauze cups but without changing gloves or performing hand hygiene between dirty and clean tasks, and then applied dressings after glove removal without washing hands. Facility policies required clean technique, use of an impervious barrier, handwashing between dirty and clean steps, and labeling dressings, but these were not followed, and the nurse and leadership acknowledged that the nurse had not received formal wound care training from the facility.
Two residents with complex medical conditions and extensive medication regimens experienced significant medication errors when new LPNs, inadequately oriented and not fully competency-checked, misadministered drugs during med pass. In one case, a new LPN on her first day, unfamiliar with residents and the electronic system, gave another resident’s medications—including a hypoglycemic and an antihypertensive—to a cognitively intact resident with multiple cardiopulmonary and renal diagnoses, leading to hypotension, hypoglycemia, and hospital transfer. In the other case, an LPN in training and her preceptor pulled medications simultaneously from the same cart, and a resident requesting pain medication received an excessive dose of a controlled sleeping pill instead, a drug the pharmacist stated would definitely increase sedation and could depress CNS and breathing. Facility policy required verification of resident identity, triple-checking medication labels, and at least three days of accompanied med rounds for new personnel, but interviews showed these requirements were not fully implemented before the new nurses participated in or conducted medication administration alone or in a hurried, shared-cart process.
The facility failed to implement and complete its nurse orientation and competency validation process for new LPNs, resulting in two separate medication errors. One LPN, new to LTC and unfamiliar with the facility’s computer system, was left alone on the med cart after only partial observation-based training and without a completed competency checklist, and a resident received another resident’s medications. Another new LPN, also without documented competency sign-offs, was in joint med-pass with an untrained preceptor when a resident requesting pain medication was given sleeping pills after the preceptor pulled the wrong controlled medication and the trainee administered it. Preceptors were selected informally from floor nurses without preceptor training, and leadership interviews confirmed that required competency checklists and the facility’s own med-pass orientation policy were not consistently followed or documented.
Two residents who required substantial/maximal assistance with ADLs did not receive consistent nail care, use of protective geri-sleeves, and shaving as outlined in their care plans. One resident with Parkinson’s disease, severe cognitive impairment, and a history of arm skin tears was repeatedly observed with overgrown fingernails and exposed arms without geri-sleeves, despite ADL records indicating weekly nail checks and encouragement of geri-sleeves. Staff interviews revealed uncertainty about who was responsible for applying geri-sleeves and providing nail care, and ADL documentation lacked staff initials. Another resident with tremors and moderate cognitive impairment was observed multiple times with visible chin hair and reported not being offered shaving, even though ADL records showed facial hair checks and shaving as needed were documented as completed without initials. A CNA acknowledged seeing the facial hair earlier and intending to shave the resident later, and the DON confirmed CNAs were responsible for checking and removing facial hair and that documentation should not indicate tasks were done when they were not.
A resident with respiratory failure, heart failure, type 2 diabetes, and COPD was approved to self-administer inhaled medications, but surveyors observed the resident’s corticosteroid and beta2-agonist inhalers left unattended on the over-bed table on multiple occasions, and a medication lockbox kept on the over-bed table with the key left in the lock. The resident reported being told they could use their own inhalers. An LPN stated the resident was approved for unsupervised self-administration but admitted not being familiar with the self-administration policy, while also acknowledging that medications should not be left on the over-bed table and that the lockbox should not have the key in it. The DON and another LPN described that the facility’s process and expectations required assessment of the resident’s ability to self-administer, demonstration of correct use, and secure locked storage out of reach of other residents, and CNAs stated that medications should not be left out in resident rooms.
A resident with terminal Parkinson’s disease and severe cognitive impairment was enrolled in hospice, with hospice aides providing baths and an updated care plan specifying hospice CNA, RN, social services, and chaplain visits. However, no hospice physician order was present in the EHR at the time, no hospice notes appeared in progress notes, and the MDS still reflected that the resident was not on hospice. The MDS Coordinator reported she did not complete a Significant Change in Status Assessment because there was no hospice order in the system to trigger it, later finding that the hospice admission order had been dated earlier but not entered until much later. The DON stated that the nurse on duty at hospice admission should have entered the hospice order and believed nurses knew they were responsible for doing so.
A nonverbal resident with a history of brain stem hemorrhage and intact cognition was admitted with documented unclear speech, rare ability to make themself understood, and reliance on nodding, head shaking, and sign language for communication, yet no communication deficit with individualized interventions was initiated on the comprehensive care plan. Multiple assessments and progress notes by nursing, social services, APRN, and SLP consistently described the resident as nonverbal and using alternative communication methods, but these findings were not incorporated into a person-centered care plan. CNAs, an RNA, and an LPN reported using yes/no questions, body language, facial cues, and the resident’s hand signals to communicate, while also stating they did not know sign language and had not seen communication boards or structured tools, and leadership acknowledged that a communication deficit should have been care planned and that there were no facility policies guiding communication care planning for nonverbal residents.
A resident with neuropathy, non‑weight‑bearing status on one leg, multiple comorbidities, and a known history of falls was care planned as high fall risk and required two‑person assistance with a gait belt for all transfers. After prior incidents where the resident’s legs had given out during transfers, two staff attempted a wheelchair‑to‑toilet transfer by standing and pivoting the resident using the stronger leg while the resident held grab bars, but they did so without a gait belt. The resident’s legs collapsed, the resident went down to the knees, and an abrasion to the knee occurred. Staff and leadership interviews, along with policies and job descriptions, confirmed that a gait belt was required for all assisted transfers and that staff were expected to follow this procedure, but the involved staff admitted they forgot to use the gait belt during this transfer.
A resident with respiratory failure and other comorbidities received O2 via nasal cannula under an order that lacked a start date and was not set up as a scheduled order in the electronic record, even though oxygen use was documented on multiple days. Over several days, the resident’s humidifier bottle was repeatedly observed to be undated or dated but empty while the resident was on 2 L O2, and the resident reported persistent nasal dryness and that the bottle had been empty despite asking staff to change it. An LPN confirmed the order issue and acknowledged the empty, dated humidifier bottle, and leadership reported expectations for changing tubing and humidifier bottles but had no policy addressing oxygen equipment or humidified water.
Failure to Follow Wound Clinic Orders for Lower Extremity Wounds
Penalty
Summary
The deficiency involves the facility’s failure to complete and follow wound care provider orders for one resident with multiple lower extremity wounds. The resident was admitted with diagnoses including peripheral vascular disease, acquired absence of a right toe, and malnutrition, and was documented as alert, oriented, and cognitively intact. The resident received wound care at an external Wound Care Clinic, which issued detailed written orders on two separate dates for multiple wounds on both lower legs, specifying cleansing with normal saline, use of transfer foam or autolytic debridement gel, specific secondary dressings, soft cloth surgical tape, sterile roll gauze, gauze sponges, and, for one right lower leg wound, a compression stocking. Review of the facility’s Treatment Administration Record (TAR) for the same period showed that the treatments documented did not match the clinic’s orders. The TAR listed generalized treatments for the left and right lower legs, including cleansing with normal saline, gauze to the wound bed, and application of self-adherent wrap from toes to bend of leg on a Tuesday, Thursday, Saturday schedule, rather than every other day as ordered. Later TAR entries for bilateral extremities referenced autolytic debridement gel, auto debridement dressing, and elasticated tubular bandage, but still did not clearly distinguish between the multiple wounds on the right lower leg or document all ordered components. There was no distinction on the TAR to ensure both right lower leg wounds were treated, no documentation that transfer foam was applied as ordered, and no documentation that the ordered compression stocking was applied to the specified right lower leg wound. Interviews and record review confirmed these discrepancies and the lack of supporting documentation. The Treatment Nurse described a process in which Wound Care Clinic orders were faxed to the facility, compiled, and then entered onto the TAR by the Treatment Nurse after leadership meetings or by the end of the business day. The DON stated that it was the Treatment Nurse’s responsibility to ensure clinic orders were completed and acknowledged that wounds could deteriorate if not treated per provider orders. During a joint interview, the DON, Administrator, and Nurse Consultant were unable to provide any documentation that the transfer foam treatment was given as ordered or any explanation for why every-other-day orders were carried out on a fixed Tuesday, Thursday, Saturday schedule. Facility policy on Medication and Treatment Orders required that medications be administered per the written order of a licensed provider, which was not followed in this case.
Inadequate Hand Hygiene and Aseptic Technique During Wound and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in a manner that prevented infection for two residents receiving wound treatments. For the first resident, who had cellulitis, type 2 diabetes mellitus, protein-calorie malnutrition, venous insufficiency of both lower extremities, chronic venous hypertension with inflammation, candidiasis of the skin and nails, and a stage 2 pressure ulcer to the sacrum, the Treatment Nurse (TN), who was also the Infection Preventionist (IP), did not consistently perform hand hygiene or maintain a clean field. During wound care, the TN handled personal items such as keys, a cell phone, and the computer, then accessed wound care supplies from the treatment cart without performing hand hygiene afterward. The TN touched gauze pads with ungloved hands, sprayed them with wound cleanser, and later used those same gauze pads to cleanse the resident’s wound. The TN also set up supplies on a bathroom counter using a non‑impervious paper towel as a barrier, contrary to facility policy requiring an impervious barrier, and did not date or initial the new dressing. For the second resident, who had diagnoses including congestive heart failure, protein-calorie malnutrition, hypertension, GERD, neuromuscular bladder dysfunction, a stage 3 pressure ulcer of the right hip, urethrocutaneous fistula, UTI, and an indwelling catheter, the TN again failed to follow infection prevention practices during wound care. The TN unlocked the treatment cart with keys from her pocket, returned the keys to her pocket, and touched the computer before retrieving wound care supplies, then proceeded without performing hand hygiene until later in the process. She prepared gauze pads in cups with wound cleanser while gloved, then removed her gloves and continued the setup. In the resident’s room, she cleaned only half of the bedside table with a wet, soapy paper towel and dried it with another towel, then placed a non‑impervious paper towel as a barrier for wound supplies, while the other half of the table remained cluttered with personal items including a basin with cups and straws hanging over the wound supplies. During the wound care for the second resident, the TN washed her hands in the bathroom for approximately six seconds before donning gloves. She removed the old dressing from the right hip pressure ulcer, changed gloves, and then used gauze from one cup to clean the hip pressure ulcer. Without performing hand hygiene or changing gloves between dirty and clean tasks, she then used gauze from a second cup to clean the resident’s suprapubic catheter site, which she stated had drainage and had been cauterized the previous week. After removing her gloves, she did not perform hand hygiene before placing a split drain gauze around the suprapubic catheter and applying calcium alginate and a bordered foam dressing to the right hip wound. The TN later acknowledged that she did not wash her hands when going from dirty to clean tasks, that she should have changed gloves before moving to the secondary dressing, and that she had not received wound care training from the facility despite functioning as the wound care nurse and IP. Facility policies required clean technique, prevention of supply and surface contamination, use of an impervious barrier, handwashing after removing dirty gloves and before donning clean gloves, and labeling new dressings with initials, date, and time, as well as adherence to handwashing guidelines consistent with CDC recommendations for at least 15 seconds of rubbing. Interviews with the TN, Nurse Practitioner (NP), and Director of Nursing (DON) further clarified the expectations and deviations from practice. The TN stated she believed she performed hand hygiene when entering rooms and after touching anything dirty, but acknowledged she did not wash her hands between dirty and clean tasks and recognized that setting up wound supplies next to personal items would be an infection control issue. The NP stated that the suprapubic catheter and pressure ulcer should be cleaned one at a time and not treated simultaneously, and that she would not want wound contaminants introduced to the suprapubic catheter. The DON reported that the TN had been performing wound care since around November, had no wound care certification, and had received no specific wound care training from the facility, although the DON believed the TN had prior wound care experience elsewhere. The DON stated that staff should clean hands and change gloves when going from dirty to clean tasks, that separate areas such as a suprapubic catheter and a pressure ulcer should not be treated at the same time due to infection concerns, that dressings should be dated as a standard practice, that bedside tables should be clean, uncluttered, and disinfected rather than just washed with soap and water, and that a brief six‑second handwash was not appropriate.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents during medication administration. For the first resident, who had multiple complex diagnoses including pneumonia, COPD, CHF, atrial fibrillation, pulmonary hypertension, peripheral vascular disease, chronic kidney disease stage 3, hypertension, hyperlipidemia, and aortic valve stenosis, a nurse on her first day at the facility administered another resident’s medications in error. The resident was cognitively intact and receiving numerous scheduled medications, including diuretics, anticoagulants, antihypertensives, electrolyte replacements, and oxygen. A Medication Error Report documented that the resident was mistakenly given four incorrect medications intended for another resident, including a blood sugar–lowering medication, an antidepressant, a uric acid–lowering medication, and an antihypertensive with side effects of hypotension and hyperkalemia and label warnings related to diabetic medications. The error for the first resident occurred when an LPN, new to LTC and to the facility’s computer system, misidentified the resident and pulled the wrong medications. The LPN reported that it was her first day, she had limited orientation time with an RN preceptor that morning, and she had not been checked off as competent to administer medications independently. She stated she did not yet know the residents, found the electronic photos too small to distinguish individuals, and did not know how to enter orders into the computer. She described feeling overstimulated and attempting to work independently. The UM, who was simultaneously functioning as wound nurse, UM, and preceptor, left the LPN alone on the cart after the LPN stated she felt comfortable, despite the UM not having observed her passing medications and not having completed the medication portion of the competency checklist. The RN who precepted earlier in the day stated the LPN had only observed her, had not performed tasks independently, and had not been checked off to administer medications alone. Following the wrong-medication administration to the first resident, vital signs later showed hypotension and hypoglycemia, and the resident was sent to the hospital. Hospital records documented treatment for a medication error, hypotension, hypoglycemia, elevated heart enzymes, and acute kidney injury, with very low blood pressure on arrival and the resident reporting feeling like they were dying. Documentation from the hospital indicated facility staff reported the resident had been hypotensive for two hours. The pharmacist, after reviewing the resident’s scheduled medications and the medications given in error, stated she would have monitored for low blood pressure, low blood sugar, and oversedation, and identified multiple medications that could contribute to these effects. The NP stated it was difficult to determine whether the medication error caused the event, noting the resident’s existing pneumonia and kidney function issues. The resident’s representative reported being notified of a severe drop in blood pressure and stated that a physician advised seeking legal advice. The second resident involved in the deficiency had multiple diagnoses including critical illness myopathy, metabolic encephalopathy, cerebral edema, diabetes, morbid obesity, respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, cognitive communication deficit, dysphagia, hyperlipidemia, bipolar disorder, hypertension, and chronic kidney disease, and was cognitively intact. This resident was on a complex medication regimen including antipsychotics, antidepressants, anticoagulants, antibiotics, diuretics, opioids, and hypoglycemics. A Medication Error Report documented that the resident was accidentally given two sleeping pills instead of two pain pills. The error occurred while an LPN in training and her preceptor were both pulling medications from the same cart, with the trainee pulling non-controlled medications and the preceptor pulling narcotics. For the second resident, the trainee LPN reported that the resident had requested a pain pill but was given sleeping pills instead. She stated that the mistake was discovered later when controlled medications were counted and that the sleeping pill, a controlled medication, was stored in the narcotic box with other controlled medications. She reported that the preceptor punched the medication from the wrong card, that the pills were both small white tablets, and that they were trying to hurry. The trainee LPN stated she did not recall any specific competency check-offs and that her license had simply been verified. The pharmacist stated that the dose of sleeping medication given exceeded the recommended daily dose and would definitely increase sedation, with potential for amnesia, CNS depression, and breathing interruptions if the resident did not use a pressurized mask while sleeping, as well as possible sleepwalking episodes. The NP later reported there were no adverse side effects observed in this resident. The facility’s written Medication Administration policy required that medications be administered in accordance with orders, that the individual administering medications verify resident identity before administration, and that the label be checked three times to ensure the right resident, medication, dose, and route. The policy also stated that medications ordered for one resident may not be administered to another, and that new personnel authorized to administer medications would not be permitted to prepare or administer medications until oriented to the facility’s medication administration system. It further required that a charge nurse accompany new nursing personnel on medication rounds for a minimum of three days to ensure procedures were followed and proper resident identification methods were learned. Interviews with the UM, RN preceptor, and LPNs indicated that the new nurses involved in both medication errors were allowed to participate in or conduct medication passes without full completion of competency checklists, without consistent direct observation, and while preceptors were performing multiple roles or sharing the cart, contributing to the misadministration of medications to both residents.
Failure to Implement Effective Nurse Orientation and Competency Validation Leading to Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective nurse training and competency program for new LPN staff, resulting in incomplete orientation and unverified competencies for at least two nurses. The facility maintained a New Trainee Folder and a Licensed Nurse Competency Skills Check-off form intended to cover unit safety, communication, infection control, nursing care, emergency procedures, equipment, medication administration, pain management, resident rights, abuse, dementia care, QAPI, person-centered care, cultural competency, and HIPAA. Human Resources reported that the competency checklist was to be printed and placed in a staffing binder, completed by the preceptor over the first three days, and then signed off by leadership. However, for both reviewed LPNs, these competency checklists were not completed, and there was no documented verification that they had met medication administration or other required competencies before functioning independently. One LPN, on her first day working in the facility and with no prior LTC experience, was involved in a medication error in which a resident received another resident’s medications. This LPN reported that she had only been trained by an RN from 6 AM to 10 AM on how residents took their medications and who had swallowing issues, and that she did not know how to enter orders into the computer system and was unfamiliar with the software. The RN preceptor stated that the LPN had only observed her and had not performed any tasks independently before the RN left, and that she had not checked the LPN off to administer medications alone. The Unit Manager acknowledged that the LPN had no LTC experience, that she did not complete the medication portion of the competency checklist, and that she left the LPN alone on the cart after the LPN stated she felt comfortable, despite not having seen her pass medications. The facility’s Medication Administration policy required that new personnel not administer medications until oriented to the system and that a charge nurse accompany them on medication rounds for a minimum of three days, but this process was not followed or documented for this LPN. Another new LPN, also without a completed competency checklist, was involved in a separate medication error in which a resident requesting pain medication received sleeping pills instead. This LPN reported that she was in training with a preceptor, and that both nurses were pulling medications from the same cart, with the preceptor handling controlled substances. The error occurred when the preceptor punched a sleeping pill from the wrong card, and the trainee LPN administered it, noting that the pills were both small and white and that they were trying to hurry. The LPN stated she did not recall any specific competency check-offs being done beyond a license check. The Unit Manager and ADON both confirmed that preceptors were simply floor nurses who had been at the facility longer, with no formal preceptor training, and that the current training program had only recently started. Employee files for both LPNs lacked completed Licensed Nurse Competency Skills Check-off forms as of the survey date, and leadership interviews showed uncertainty about when competency checklists should be completed and how much training the LPNs had actually received before being allowed to function independently.
Failure to Provide Regular Nail Care, Protective Sleeves, and Shaving for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide regular nail care and use of protective geri-sleeves for one resident and shaving/personal grooming for another resident, as required by their care plans and ADL needs. For Resident #91, surveyors observed on multiple occasions that the resident’s fingernails extended over the tips of the fingers, despite a care plan intervention directing staff to check nail length and trim and clean nails on bath day and as necessary. The resident had Parkinson’s disease with dyskinesia, severe cognitive impairment (BIMS score of 04), required substantial/maximal assistance with showering and personal hygiene, and had a history of skin tears on the right arm. The care plan also included an intervention to encourage use of geri-sleeves due to potential skin integrity impairment, but the resident was repeatedly observed with arms exposed and without geri-sleeves in place. Record review for Resident #91 showed ADL tasks for checking, cutting, and filing nails weekly, and for encouraging geri-sleeves as tolerated, were marked as completed on several dates; however, there were no staff initials to identify who performed these tasks. During interviews, CNAs and a MA-C demonstrated uncertainty about who was responsible for placing geri-sleeves on the resident, when they should be applied, and whether the resident was supposed to wear them at all. One CNA believed hospice aides provided nail care and that they visited three times a week, while another CNA stated she provided nail care when needed and that the resident did not wear geri-sleeves, even though she acknowledged the resident would need them due to fragile skin. The DON reported there was no facility policy for ADLs and did not provide skills check-offs for the CNAs involved. For Resident #107, surveyors twice observed visible hair on the resident’s chin, and the resident reported that staff had not offered to shave the chin. The resident had a diagnosis of other specified forms of tremors, moderate cognitive impairment (BIMS score of 09), and required substantial/maximal assistance with showering and personal hygiene. The care plan required staff assistance with bathing/showering and personal hygiene, and the ADL task list showed scheduled bath days and documented completion of a task to check for facial hair and shave as needed on several dates, again without staff initials. Progress notes did not show any refusal of shaving by the resident. A CNA stated she determined needed care by looking in the resident’s closet care plan, that CNAs were responsible for bathing/showering, and that staff checked for facial hair on shower days and should check daily. She acknowledged seeing facial hair that morning and intended to shave the resident later. The DON stated CNAs were responsible for checking and removing facial hair during showers and as needed, and that CNAs should not document facial hair removal when it had not been done.
Failure to Safely Manage Self-Administration of Inhalers and Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident approved for self-administration of medications could follow instructions so that medications were not left at the bedside. The resident had diagnoses including respiratory failure, heart failure, type 2 diabetes, and COPD, and was receiving oxygen via concentrator. Record review showed orders for a beta2-agonist inhaler and a corticosteroid inhaler, but no physician order for self-administration rights was initially found. The facility’s policy required that residents who self-administer be assessed by the IDT to ensure they could safely administer and store medications out of reach of other residents. On multiple observations, surveyors found the resident’s inhalers and lockbox not secured as required. During one observation, the resident was resting in bed with eyes closed, the oxygen concentrator running at two liters via nasal cannula, but the nasal cannula was not in place, and both the corticosteroid and beta2-agonist inhalers were left unsupervised on the over-bed table. The resident stated they had been told they could use their own inhalers. On a later observation, a lockbox with the key left in the lock was seen on the over-bed table, and the resident stated the lockbox contained prescription inhalers but could not recall when it was provided. On another observation, the lockbox with the key still in the lock remained on the over-bed table while the resident was resting with oxygen in place. Interviews with staff confirmed that the resident had been approved for self-administration but revealed gaps in adherence to policy and lack of staff familiarity with self-administration procedures. An LPN stated the resident had been approved to self-administer inhalers at the bedside unsupervised and acknowledged not being familiar with the self-administration policy, while also stating that medications should not be left unattended on the over-bed table and that the lockbox should not have the key in the lock. The DON described the process for approving self-administration, including assessment, demonstration of use, and locked storage, and stated it would not be appropriate to leave a key in the lock or medications out on the over-bed table. Another LPN reported there had not been prior residents with self-administration rights and agreed that medications should not be stored on the over-bed table or in a lockbox with the key in place. CNAs stated that any medications found on the over-bed table would be reported to a nurse and that residents were not allowed to have unstored medication out in the open in their rooms.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days of a resident’s hospice service election, as required by the CMS RAI Manual. The resident had a terminal prognosis related to Parkinson’s disease and a quarterly MDS dated 02/20/2026 showed severe cognitive impairment (BIMS score of 4) and no hospice services. The care plan, reviewed on 03/16/2026 and revised on 04/07/2025, was updated with an intervention initiated on 04/20/2026 indicating that a named hospice provider would supply a CNA up to five times weekly, an RN weekly and PRN, social services monthly and PRN, and chaplain services monthly and PRN, with a contact number listed. A CNA reported that the resident’s baths were being provided by hospice aides who visited about three days a week. Record review showed no physician’s order for hospice services in the electronic health record at the time of survey, and progress notes from 03/01/2026 through 04/24/2026 contained no hospice notes. During interview, the MDS Coordinator stated she completes all MDS assessments and had not done a significant change MDS for this resident’s hospice admission because there was no physician’s order in the system to alert her. Upon review, she identified that an order to admit the resident to hospice services was dated 03/24/2026 but was not entered into the system until 04/23/2026, and acknowledged that the ARD should have been set within 14 days of hospice election, by 04/07/2026. The DON stated that the nurse on duty when the resident was admitted to hospice should have entered an admission order for hospice and expressed that she believed nurses understood they were responsible for adding such orders, treating them like any other order.
Failure to Care Plan Communication Deficit for Nonverbal Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a communication deficit for a nonverbal resident. The resident had been admitted with diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, major depressive disorder, and anxiety disorder, and was unable to move the right side of the body, including the face and mouth, due to a stroke. The admission MDS documented unclear speech, that the resident rarely or never made themself understood, sometimes understood others, and responded adequately only to simple, direct communication, while the BIMS score was 15, indicating intact cognition. The Baseline Care Plan noted the resident did not communicate easily with staff, but on review of the Comprehensive Care Plan initiated at admission, no communication deficit with corresponding interventions had been initiated. Record review showed multiple assessments and notes documenting the resident’s nonverbal status and alternative communication methods, but these findings were not translated into a specific communication care plan problem with individualized interventions. The Nursing Admit/Readmit/Quarterly Assessment described the resident as soft spoken and mouthing words, and progress notes indicated the resident was very soft spoken, nonverbal, able to shake the head yes and no, and utilized sign language. A social services admission assessment documented that the resident’s speech was clear, that the resident was nonverbal, used sign language as another mode of communication, and rarely or never was able to make themself understood but could understand others. An APRN note and an SLP evaluation further confirmed that the resident communicated by nodding or shaking the head and had impaired communication skills. Interviews with staff demonstrated that, in the absence of a care-planned communication deficit with defined interventions, staff relied on general approaches and did not have consistent tools or guidance for communicating with the resident. CNAs and an RNA reported communicating with the resident by asking yes/no questions, observing body language and facial cues, and noting that the resident used the left hand to indicate numbers or point to areas of pain, while also stating they did not know sign language and had not seen communication boards or other aids. An LPN reported talking to nonverbal residents as to verbal residents, using facial expressions to interpret needs, and was unaware of any communication boards or specific interventions for nonverbal residents. The MDS coordinator and DON acknowledged that a communication deficit should have been triggered and care planned at admission for a nonverbal resident, and the DON further stated the facility did not have policies for care plans, comprehensive care plans, communication, or communicating with nonverbal residents.
Failure to Use Required Gait Belt During Transfer Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to utilize appropriate transfer equipment, specifically a gait belt, during a toilet transfer for one resident, resulting in a fall and knee abrasion. The resident had medical diagnoses including a left lower leg blood clot, stage 4 kidney disease, type 2 diabetes, neuropathy, and was care planned as high risk for falls with gait and balance problems and limited mobility related to weakness. The resident was also non‑weight bearing on the left lower extremity and required assistance of two staff members with all transfers. The admission MDS showed the resident was cognitively intact and had a history of a fall in the prior months. Prior to the cited incident, the resident had experienced multiple falls at the facility. An unwitnessed incident report documented that the resident slid out of a wheelchair while trying to pick up a ring from the floor, with no injury. A later witnessed incident documented that the resident’s legs gave out during a transfer, and the resident was assisted to the floor without injury and then transferred back to the wheelchair using a gait belt and two staff. These events established that the resident had recurrent episodes of legs “giving out” and required two‑person assistance and a gait belt for safe transfers. On the date of the deficiency, during a transfer from wheelchair to toilet in the bathroom, two staff members (a MA‑C and a CNA) attempted to stand and pivot the resident using the right leg while the resident held onto grab bars, but they did not use a gait belt. The resident’s legs collapsed, and the resident went down to the knees, sustaining an abrasion to the right kneecap, which the resident attributed to the lack of a gait belt. Interviews with the resident, nursing staff, therapy staff, and administration confirmed that the resident was non‑weight bearing on the left leg, required two‑person assistance and a gait belt for transfers, and that facility expectations and policy required use of a gait belt for all assisted transfers. Staff involved acknowledged they “forgot” to use the gait belt during this transfer, and other staff confirmed that gait belts were expected to be used with every transfer when assistance was needed.
Failure to Maintain Active Oxygen Orders and Humidified Oxygen for Resident Comfort
Penalty
Summary
The deficiency involves the facility’s failure to ensure that oxygen therapy orders were properly scheduled and active before administration and to provide humidified oxygen in accordance with a resident’s preferences and comfort needs. Resident #125, who had diagnoses including respiratory failure, heart failure, and type II diabetes, had an active order entered on 04/15/2026 for oxygen at 2–4 liters via nasal cannula, but the order lacked a start date and did not appear as a scheduled order in the electronic record. The admission MDS in progress with an ARD of 04/20/2026 did not indicate that the resident was receiving oxygen therapy, despite documentation on the resident’s oxygen saturation summary that the resident was on oxygen on multiple dates in April. An LPN confirmed that the oxygen order had been present since 04/15/2026 but was not set up as a scheduled order and had no active date. The facility also failed to provide and maintain humidified water for the resident’s nasal comfort over several days. On multiple observations from 04/20/2026 through 04/22/2026, the resident’s humidifier bottle was found undated or dated but empty, while the resident was receiving 2 liters of oxygen via nasal cannula. The resident repeatedly reported that their nose was very dry and that the humidifier bottle had been empty since Monday, and stated they had asked staff to change the water bottle but could not identify to whom. An LPN acknowledged that the humidified water bottle dated 04/21/2026 was empty and stated it should not have been empty at 2 liters of oxygen, suspecting that someone may have dated an empty bottle without actually changing it. The administrator and DON stated their expectation that humidified water bottles be changed on Tuesday evenings with the tubing or when empty, but there was no facility policy addressing oxygen tubing, storage, or humidified water bottles, and the existing oxygen safety policy only addressed handling oxygen, not equipment.
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