Pine Bluff Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Pine Bluff, Arkansas.
- Location
- 6810 South Hazel Street, Pine Bluff, Arkansas 71603
- CMS Provider Number
- 045379
- Inspections on file
- 43
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pine Bluff Transitional Care during CMS and state inspections, most recent first.
Surveyors found the 400-hall shower room in unsanitary condition, with a strong odor, standing water, discolored grout and flooring, and wet debris on the floor, while shower supplies were stored on the floor. Staff interviews revealed inconsistent understanding of who was responsible for cleaning, with housekeeping reporting daily cleaning and CNAs describing routinely cleaning the shower themselves using solutions from housekeeping, without formal training or knowledge of required contact times. A resident who used this shower reported that the floor often had a lot of water and that staff would not clean it, and the DON acknowledged concerns about the shower but was unaware of any specific cleaning actions taken, while product information for the cleaning agents lacked clear use instructions.
Medication Refrigerator Stored at Improper Temperatures: The facility failed to keep a medication refrigerator within the required 36 to 46 degrees F range. RN and DON observations found the unit reading as low as 32 degrees F on multiple logged checks, with frozen ice packs inside and medications including insulin, an injectable antianxiety medication, and other resident medications stored in the refrigerator. The DON and pharmacist acknowledged the temperature problems, and prior pharmacy consultant reports also noted the refrigerator was out of range.
A resident with moderate cognitive impairment, behavioral symptoms, a history of falls, and an active PRN pain medication order returned from the hospital at night and repeatedly requested pain medication for head pain. A CNA reported the requests multiple times to the only LPN on duty, who had the keys to all med carts, but the LPN did not assess the resident on that hall or administer any pain medication, stating that another LPN (who was not present or on the staffing log) was supposed to pass meds there. Review of the eMAR and staffing records confirmed that no pain medication was given during this period despite the resident’s repeated requests and an active PRN order, constituting a failure to provide ordered and requested pain management.
The facility did not have a full-time DON for about a month, leaving the position vacant and disrupting the chain of command among nursing staff. Staff reported increased stress and uncertainty due to the lack of clinical leadership, and documentation confirmed the vacancy and ongoing efforts to fill the role.
A resident with severe cognitive impairment and psychiatric diagnoses alleged being physically abused by a staff member. Although the allegation was reported internally and investigated by the Interim Administrator, it was not reported to the State Survey Agency or other required authorities within the mandated timeframe, as required by facility policy and federal regulations.
A CNA failed to change gloves and perform hand hygiene during incontinence care for a dependent resident with severe cognitive impairment. The CNA handled clean items and applied cream to the resident's perineal area while wearing contaminated gloves, contrary to facility protocols and infection control policies. Staff interviews confirmed that proper hand hygiene and glove changes were expected but not performed in this instance.
A resident with severe mental impairment and a history of daily aggressive behaviors repeatedly initiated altercations with others, including hitting and entering other residents' rooms, without consistent documentation of interventions or provider notification. Staff were aware of the risks but sometimes left the resident unattended, and standing orders did not address aggression. A behavioral health evaluation was not completed as ordered, and required follow-up for affected residents was often missing.
A resident with a history of wandering and delusional behaviors was able to exit the facility multiple times due to malfunctioning secured unit doors, inconsistent use of a wander guard, and inadequate alarm systems. Staff and maintenance were aware of these issues, and a gate code was posted in plain sight, further compromising security. Despite care plans and physician orders, effective interventions to prevent elopement were not implemented, resulting in repeated incidents where the resident left the premises.
The facility did not consistently provide enough nursing staff to meet the needs of all residents, as evidenced by discrepancies between staffing logs and actual staff present, frequent instances of CNAs working alone on halls, and the absence of a DON for an extended period. Staff interviews confirmed that these shortages led to missed showers, incomplete treatments, and concerns about resident safety.
The facility did not report a resident elopement that required police involvement, nor did it report multiple resident-to-resident altercations, including one that resulted in injury. These incidents involved residents with cognitive impairment and behavioral issues, and were not communicated to the State Survey Agency as required by facility policy.
Two residents with pressure ulcers or at risk for pressure ulcers did not receive wound care as ordered by physicians, with incomplete or missing documentation on the TAR and inconsistent weekly skin assessments. Staff interviews confirmed that wound care was likely not performed if not documented, and leadership attributed the deficiencies to inadequate staffing.
The facility was found to have significant sanitation and food safety deficiencies, including the presence of pests, improper food storage, and inadequate hand hygiene practices. Roaches were observed in the kitchen, and food items were not stored according to professional standards, with expired products not discarded. Staff failed to maintain proper hand hygiene, and food temperatures were not kept within safe ranges, posing potential health risks to residents.
The facility did not develop or implement a current facility-wide assessment to determine necessary resources for resident care. The Administrator, in her role since late 2023, acknowledged responsibility but could not explain the absence of the assessment. An outdated tool from 2017 was provided, lacking relevant information.
The facility did not consistently implement its antibiotic stewardship program for a resident on Doxycycline for a skin infection. The Nurse Consultant updated infection control logs but lacked information for October. The ADON provided reports for June to September, missing critical tracking details. The resident's medication order lacked a specified duration or stop date, contrary to the facility's policy requiring complete antibiotic orders.
The facility did not designate a qualified Infection Preventionist (IP) to manage the infection prevention and control program. Documentation showed the absence of an IP, and no infection control trainings were conducted from October 2023 to October 2024. The Administrator acknowledged the lack of a designated IP, and the facility's policy outlined unfulfilled responsibilities due to this absence.
The facility failed to maintain privacy for two residents during care procedures. An LPN left a resident's door open while performing tracheostomy care, violating privacy. Another resident's catheter bag was visible without a privacy bag, contrary to their care plan. The ADON confirmed these actions breached the facility's policy on resident dignity and privacy.
The facility failed to report and investigate incidents of injury of unknown source for two residents within the required timeframe. One resident sustained a fractured mandible from an unwitnessed fall, while another resident rolled out of bed, resulting in a facial abrasion. The facility did not adhere to its policy requiring immediate reporting and investigation of such incidents.
The facility failed to investigate incidents of injury for two residents. One resident was found with a fractured mandible after an unwitnessed fall, and no investigation was conducted. Another resident rolled out of bed, sustaining a facial abrasion, but the incident was not reported or investigated. The facility did not adhere to its policies on incident investigation and reporting.
The facility failed to transmit accurate and complete MDS assessments to CMS within the required 14-day timeframe for two residents. One resident's assessments were exported but not accepted, and the facility lacked an MDS Coordinator, contributing to the delay. Another resident's admission record showed multiple diagnoses, but the facility's policy did not address MDS completion timeliness. The facility experienced turnover in the MDS Coordinator position and relied on external assistance to complete assessments.
The facility failed to follow physician's orders for a resident with a wound, as weekly skin evaluations were not completed. The resident's wound was initially documented as a diabetic ulcer but later identified as a pressure ulcer. Additionally, another resident's MDS inaccurately classified Risperdal as an anti-anxiety medication instead of an antipsychotic, despite the resident's diagnosis of a psychotic disorder. The DON confirmed the medication should have been documented as an antipsychotic.
The facility failed to develop comprehensive care plans for residents, leading to unmet needs in personal hygiene and physical care. A resident's care plan lacked ADL requirements, resulting in inconsistent grooming. Another resident's care plan did not address a flaccid arm and contracted hand, with no interventions observed. Additionally, a resident's care plan inaccurately noted contractures, while their legs were locked straight. These deficiencies highlight the facility's failure to address residents' individualized care needs.
The facility failed to update care plans for three residents, leading to unaddressed care needs. A resident with severe cognitive impairment was transferred using a mechanical lift without proper assistance, and their care plan lacked details on high-risk medications. Another resident's care plan did not include necessary information on anticoagulants and insulin, while a third resident's care plan failed to reflect a diabetic foot ulcer. The ADON confirmed these oversights.
The facility failed to maintain proper hygiene and grooming for three residents, leading to deficiencies in care. A resident with cerebral palsy and glaucoma was repeatedly observed with facial hair despite being dependent on staff for personal hygiene. Another resident, also dependent on staff, was found unshaved, and their care plan lacked specific ADL care. Additionally, a resident with severe cognitive impairments did not receive regular scheduled baths, with only six baths recorded over two months. Staff interviews confirmed these lapses in maintaining residents' hygiene and dignity.
The facility failed to conduct weekly skin evaluations for several residents as ordered, and did not provide appropriate treatment for a resident with a contracture. One resident had an open wound on their leg, but skin assessments were not performed weekly. Additionally, a resident with a flaccid arm and contracted hand did not have a device to prevent further decline, and their care plan did not address these issues.
A facility failed to properly use a mechanical lift for a cognitively impaired resident with physical limitations, as the care plan lacked specific transfer instructions. A CNA used the lift without assistance, violating policy. Additionally, a resident with severe cognitive impairment and respiratory issues was not assessed for smoking safety and was observed smoking without a protective apron. Staff confirmed the absence of required assessments and adherence to safety protocols.
Two residents received improper incontinence care, leading to potential health risks. A resident with cognitive impairment was found with a wet ring around the buttock area, and a CNA failed to clean the entire genital area after an incontinence episode. Another resident, who was cognitively intact, was improperly cleaned with a back-and-forth motion, risking infection. The facility's administrator acknowledged these issues, emphasizing the importance of proper cleaning to prevent infections.
A resident with a tracheostomy complication did not receive care as ordered, with observations revealing improper infection control practices by an LPN. The LPN failed to sanitize hands, use sterile gloves, or wear PPE during tracheostomy care. The obturator was not replaced despite visible contamination, and necessary supplies were not stored correctly. Interviews confirmed these deficiencies, highlighting a failure to adhere to the facility's tracheostomy care policy.
The facility did not maintain full-time DON coverage, with no DON or interim DON from August 10 to August 18, 2024. Check stubs showed inconsistent full-time hours for the DON, and the administrator admitted to occasional lack of coverage. The facility's staffing policy required sufficient skilled staff for resident care.
The facility did not post daily staffing information visibly for residents and visitors, as required by policy. A surveyor noted the absence of a visible posting and a tally of actual hours worked per shift. An LPN was unaware of the requirement to include specific details in the posting. The Administrator confirmed the lack of a complete daily staffing posting. The facility's policy mandates posting daily staffing details, including the facility name, date, census, and staff categories.
A facility failed to accurately account for a controlled medication for a resident with bipolar disorder, leading to discrepancies in the narcotic log for Clonazepam. Additionally, another resident with hypertension received an incorrect dosage of Nifedipine ER due to a pharmacy error, which was not corrected before the resident's discharge. The errors were confirmed by the Nurse Consultant and ADON, highlighting a failure to adhere to the facility's medication administration policies.
The facility failed to address pharmacist recommendations for psychotropic medication management for three residents. A resident with bipolar disorder had an unaddressed recommendation for Trazodone dose reduction. Another resident with catatonic schizophrenia had a PRN Haloperidol order that required re-evaluation, which was not addressed. Additionally, a resident with a psychotic disorder had multiple psychotropic medications with unaddressed dose reduction recommendations. The facility did not follow its policy on tapering medications and gradual dose reduction.
A facility's medication error rate reached 24.14% due to multiple administration errors by an RN and an LPN. Errors included early administration of Albuterol, withholding Carvedilol without parameters, and late administration of Phenobarbital, Apixaban, Metoprolol Tartrate, and Gabapentin. The facility's policy defines medication errors as deviations from physician's orders or accepted standards.
The facility failed to prepare and serve meals according to the planned menu, impacting residents' nutritional needs. Observations showed dietary staff used incorrect ingredients and portion sizes, serving 1.4 ounces of ham instead of the required 3 ounces, and using black-eyed peas instead of lima beans. These actions led to insufficient servings and deviation from the menu.
The facility failed to ensure pureed foods were blended to a smooth, lump-free consistency for residents on pureed diets. Observations revealed that black-eyed peas, turnip greens, ham, and cornbread were not adequately pureed, resulting in inconsistent textures. A dietary aide confirmed the inadequacies, noting that the foods were either mushy, watery, or thick with visible pieces.
The facility failed to implement enhanced barrier precautions for a resident with a PEG tube, lacked a comprehensive water management program, and demonstrated poor infection control practices. Observations revealed improper handling of laundry, inadequate PPE use, and lapses in hand hygiene during resident care, leading to potential cross-contamination. Additionally, tracheostomy care was not performed according to policy, with issues in sterile technique and PPE use.
The facility failed to provide a pneumococcal vaccine to a resident and did not document education after another resident declined the influenza vaccine. The first resident's records lacked documentation of consent or refusal for the pneumococcal vaccine, while the second resident's records did not include the date of influenza vaccine refusal or documentation of education provided.
A facility failed to ensure a resident with impaired cognitive function and a history of suicidal ideation was safe to self-administer medications. The resident's care plan required medication administration and monitoring, yet over-the-counter medications were found in the resident's bathroom. The Nurse Consultant and Administrator confirmed that the resident was not assessed for self-administration, and facility policy requires an interdisciplinary team assessment for such authorization.
The facility did not ensure residents received mail on Saturdays, violating their right to prompt mail delivery. The Activity Director only delivers mail Monday through Friday, and the Administration confirmed no mail delivery occurs on Saturdays, contrary to the facility's Resident Rights policy.
A facility failed to notify the Ombudsman of a resident's hospital transfer. The resident, diagnosed with catatonic schizophrenia and severely cognitively impaired, was sent to a hospital due to decreased LOC. Although the resident's relative was informed, the Ombudsman was not notified. The ADON indicated that Social Services was responsible for this task, but it was not communicated clearly, leading to the oversight.
The facility failed to complete timely MDS assessments for a resident, lacking both Admission and Quarterly MDS. Staffing challenges contributed to this oversight, with two RNs resigning shortly after hire and an LPN from a sister facility assisting. An RN was contracted to perform MDS tasks remotely.
A resident with a PEG tube was not properly managed as the facility failed to check tube placement before administering fluids and medications, and did not follow the physician's order for the enteral feeding rate. The feeding rate was set at 95 ml/hr instead of the prescribed 90 ml/hr, and the feeding bottle lacked necessary labeling information. A nurse admitted to not receiving training on checking tube placement, contributing to the deficiency.
A facility failed to complete Monthly Medication Regimen Reviews (MMR) for a resident with moderate cognitive impairment who was on high-risk medications for depression, anxiety, and fluid retention. The facility's Administrator could not provide documentation to prove that MMRs were conducted, despite a policy requiring monthly reviews by the Consultant Pharmacy.
A facility failed to conduct weekly skin evaluations for a resident with a stage 3 wound on the left big toe, as ordered by the physician. The resident's wound was initially documented as a diabetic foot ulcer but later reclassified as a pressure ulcer. Despite the care plan highlighting the need for preventive measures due to fragile skin, no evaluations were conducted between August and October, as confirmed by interviews with facility staff.
Two residents with severe cognitive impairment did not receive proper wound care as per physician orders, leading to deficiencies in pressure ulcer management. Dressings were not changed as required, and there was confusion among staff regarding responsibility and access to supplies. The facility lacked a wound care policy, contributing to inconsistent care and monitoring.
The facility failed to employ a full-time DON. The Administrator confirmed that the facility had been without a DON since March 2024 and lacked a policy for DON coverage.
The facility failed to maintain an effective pest control program, resulting in flies and roaches being present in the kitchen, dining room, resident rooms, and hallways. Observations and staff interviews confirmed the widespread issue, despite the facility having a pest control contract.
A facility failed to complete a discharge summary for a resident with type 2 diabetes and diabetic peripheral angiopathy with gangrene. The resident, who was cognitively intact and required maximum assistance with ADLs, was discharged without a discharge summary in their medical records. Interviews revealed that nurses are responsible for completing discharge summaries, but the facility lacks a discharge policy.
A resident with unspecified protein-calorie malnutrition and severe cognitive impairment was not served a meal in a timely manner, despite being seated at the feed assist table. Interviews with staff, including the Dietary Manager and ADON, revealed no clear reason for the oversight. The facility lacked a policy on timely meal service.
The facility failed to secure smoking materials and provide adequate supervision during smoke breaks, leading to a resident with Dementia and COPD having unsupervised access to cigarettes and a lighter. Staff interviews revealed inconsistencies in supervision and storage of smoking materials, contrary to the facility's smoking policy.
Unsanitary and Poorly Maintained 400-Hall Shower Room
Penalty
Summary
The facility failed to maintain the 400-hall shower room in a clean and sanitary condition. On multiple observations, the surveyor noted a pungent odor, standing water on the floor, brownish-black discoloration of the grout on the lower back wall of the shower, greenish discoloration on the floor behind the drain, and a white, wet material on the floor around a white pipe. Three bottles of shampoo and body wash were observed on the floor. A CNA who entered the room confirmed an odor like mold, mildew, and wetness, and described the grout as brown and black and the floor as wet with a brown color and old, wet tissue paper around the pipe. Another CNA reported that the shower room floor was normally wet and that she used a towel or blanket to clean up the water. A resident who received showers in this room reported that the shower room floor had a lot of water and expressed that staff would not clean it. Housekeeping staff stated that the shower room was cleaned daily with cleanser, with walls and toilets wiped and the shower cleaned twice daily, and indicated that housekeeping was responsible for cleaning and mopping the shower room. However, CNAs described cleaning the shower room themselves using a cleaning solution provided by housekeeping, with one CNA stating he had only been the shower aide for about one and a half weeks and was trained informally by another CNA. The CNA was not aware of any required contact time for the cleaning solution. The former shower aide CNA reported she did not receive any training from facility staff on what to use to clean the shower room and that she typically cleaned it on certain days and when leaving the building, but did not work weekends. The DON acknowledged having seen the 400-hall shower and having concerns about it, but was unaware if anything had been done to the floor or walls. Product information and safety data sheets for the cleaning agents provided by the Administrator and housekeeping supervisor did not include clear instructions for use on cleaning, though one product sheet described disinfection and sanitization times and its suitability for removing hard water buildup and soap scum from showers.
Medication Refrigerator Stored at Improper Temperatures
Penalty
Summary
The facility failed to store medications at proper temperatures to preserve the integrity of the medications in one medication refrigerator. During an observation of the Medication Room, RN #1 opened the refrigerator and stated the interior temperature was 44 degrees F based on a thermometer inside the unit. The refrigerator contained insulin, an antianxiety medication, and other medications, and 4 ice packs in the top left corner were observed frozen solid. RN #1 stated the correct temperature range for the medication refrigerator was 36 degrees F to 46 degrees F and acknowledged that 32 degrees F was freezing and not acceptable for refrigerated medications. Review of the refrigerator checklist taped to the door showed logged temperatures of 34, 34, 32, 34, 34, 32, and 32 degrees F for the first seven days of April 2026, despite posted guidance stating medication refrigerators must be maintained between 36 and 46 degrees F. The DON confirmed the logged temperatures were out of range and observed the thermometer reading 42 degrees F with the same frozen ice packs present. A handwritten medication list showed the refrigerator contained two stock vials of an injectable antianxiety medication and refrigerated medications for three residents, including insulin. The DON and pharmacist also acknowledged prior temperature issues, and pharmacy consultant reports from September 2025, December 2025, and January 2026 indicated the refrigerator temperature was out of range.
Failure to Provide PRN Pain Medication After Resident’s Return From Hospital
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed and requested PRN pain medication to a resident following a return from the hospital. The resident had been admitted with diagnoses including bipolar disorder, current episode manic severe with psychotic features, and had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident’s MDS documented verbal behavioral symptoms directed toward others, dependence for toileting/personal hygiene, a history of multiple falls, and use of high‑risk medications including antianxiety agents, antidepressants, opioids, and anticonvulsants. The care plan, revised in late February, identified a behavior problem of agitation related to communication, including that the resident would throw themself on the floor if verbalized demands were not instantly met, and also identified a risk for pain with an intervention to anticipate the resident’s need for pain relief and respond immediately to any complaint of pain. The eMAR for January showed an active PRN pain medication order to give one tablet orally every four hours as needed for pain, with ongoing pain monitoring orders. On the night in question, the resident returned from the hospital around 10:30 PM. After being put to bed, the resident requested pain medication for head pain. CNA staff reported informing an LPN that the resident was requesting pain medication. The CNA later stated that around 12:30 AM, the resident continued calling out for help and reporting pain, and the CNA again went to the nurse. The CNA further reported that around 5:00 AM, the resident was still awake and asking for medication for head pain, and the CNA again approached the same LPN, who refused to administer pain medication, stating that another LPN, who was not present in the building, had agreed to pass medications on that hall. The CNA stated that the LPN did not go to the resident’s room at all during the shift and did not provide any pain medication despite multiple requests relayed by the CNA. Documentation and interviews showed that the LPN on duty had accepted the keys to all medication carts and was the only nurse listed on the staffing log for that night, with no timecard entries indicating that the other LPN was working or present. The LPN’s own witness statement indicated they signed for the resident’s return from the hospital and that a co‑worker handled all medications for the hall where the resident resided, and that they rarely appeared on that hall. However, the daily staffing log and timecard records showed no other LPN assigned or clocked in after an earlier date. The DON and another LPN stated that the nurse who accepts the keys to all medication carts and is the only nurse in the building is responsible for addressing any resident’s request for medication, including pain medication. Review of the MAR during the facility’s investigation confirmed that no pain medication was administered to the resident during the period when the resident repeatedly requested it after returning from the hospital. Additional interviews supported that the resident was distressed the following morning. Social Services reported finding the resident lying on a mat on the floor the morning after the incident, with the resident voicing being mad, though not specifying the reason. The Administrator stated that there was no written communication from the LPN about what was occurring in the resident’s room and that the LPN did not always communicate back with administration. Facility policies on administering medications required that medications be administered in a safe and timely manner as prescribed, and the Abuse Prevention Program policy required the administration to protect residents from abuse and neglect. The Office of Long‑Term Care Incident and Accident report categorized the event as abuse and neglect, noting that the resident was sent to the hospital after a fall and, upon return, requested pain medication twice with no medication provided, and that the alleged perpetrator was a facility employee.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure the presence of a full-time Director of Nursing (DON), as required by regulations, which affected all 60 residents. Record review showed that the DON position was documented as vacant in the Facility Assessment. Interviews with the Administrator and the Vice President of Operations confirmed that the facility had not had a DON for approximately one month, and there were no nursing waivers in place. The Administrator was unable to specify when the previous DON left, and documentation showed that the position had been posted for hire since early May. Staff interviews revealed that the absence of a DON disrupted the chain of command among nursing staff. The Medical Records Nurse indicated that the lack of a DON had broken the chain of command for floor staff, and an LPN described the situation as stressful due to uncertainty in the absence of leadership. The DON job description outlined responsibilities including directing nursing services, care planning, and administrative functions, all of which were unfulfilled during the vacancy.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the State Survey Agency within the required two-hour timeframe. On 06/05/2025, a CNA reported to an LPN that a resident, who had severe cognitive impairment and multiple psychiatric diagnoses, alleged being punched in the genital area by a night shift staff member. The LPN assessed the resident, who reported soreness, and notified the Interim Administrator. However, there was no documentation that the State Survey Agency, medical provider, family, or law enforcement were notified of the allegation as required. The Interim Administrator conducted an internal investigation, including interviews with staff and the resident, but did not report the allegation externally because the resident's account was inconsistent and the administrator believed the claim could not be substantiated. The facility's abuse prevention policy required reporting all allegations of abuse within federal timeframes, but the administrator did not follow this procedure. The lack of timely reporting was confirmed through record review, interviews, and policy review, and no further documentation of required notifications was provided.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
During an observation, a Certified Nursing Assistant (CNA) was seen performing incontinence care for a resident with severe cognitive impairment and total dependence on staff for personal care. The CNA initially performed hand hygiene and donned gloves, but after removing the resident's soiled brief, the CNA, while still wearing the same contaminated gloves, searched through the resident's bedside drawer and dresser to retrieve a tube of cream. The CNA then applied the cream to the resident's perineal area and placed a clean brief on the resident, continuing to wear the same gloves throughout these tasks. The CNA also repositioned the resident and handled clean linens without changing gloves or performing additional hand hygiene. Interviews with the CNA and an LPN confirmed that hand hygiene and glove changes should have occurred when moving from dirty to clean tasks and when touching the resident's environment. Facility policy and protocols reviewed indicated that staff were trained to avoid touching clean items or surfaces with soiled gloves and to perform hand hygiene when moving between contaminated and clean body sites. The failure to follow these procedures was directly observed and acknowledged by staff and facility leadership.
Failure to Protect Residents from Abuse Due to Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents on the secure unit from abuse by not developing and implementing effective interventions for a resident with a history of aggressive behaviors. This resident, who was severely mentally impaired and had diagnoses including seizure disorder, traumatic brain injury, psychotic disorder, and schizophrenia, exhibited daily physical behavioral symptoms such as hitting, kicking, pushing, and wandering. Multiple documented incidents showed the resident initiating altercations with other residents, including hitting, knocking down, and jumping on others, often without adequate follow-up or assessment of the affected residents. Staff did not consistently document interventions or notify providers after these altercations, despite facility policy requiring such actions. In several cases, there was no record of assessment or status for the recipients of the altercations, and provider notification was missing for specific incidents. Interviews with staff revealed a general awareness of the resident's aggressive tendencies, but also indicated that staff were sometimes left alone on the unit, resulting in the resident being left unattended and able to enter other residents' rooms unsupervised. Additionally, standing orders provided to staff did not address agitation or aggression, and a behavioral health evaluation ordered for the resident had not been completed due to leadership and resource issues. The lack of timely provider notification, incomplete documentation of interventions, and failure to implement effective behavioral management strategies contributed to repeated altercations and placed all residents on the secure unit at risk.
Failure to Maintain Secured Unit Doors and Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that entrance and exit doors to the secured unit were functioning properly, resulting in the inability to safeguard residents and prevent elopement. Multiple observations and interviews revealed that a resident with a history of wandering and elopement risk was able to exit the facility on several occasions, including through a window and various doors. The resident was known to have delusional behaviors and was assessed as being at risk for elopement, with care plans and physician orders specifying the use of a wander guard and regular checks for its placement and function. However, documentation and staff interviews confirmed that the wander guard was not consistently in place, and there were periods when no replacement was available after it was lost. Facility records and staff statements indicated that exit doors and alarms were not consistently operational. Some doors did not alarm as intended, and in one instance, the alarm was so faint it could barely be heard. The front door, which was supposed to alarm when a wander guard was near, was reported to have malfunctioned, and the resident was able to exit. Additionally, a piece of paper with the gate code was posted next to an exit door, making it accessible to residents who could read, further compromising security. Maintenance staff acknowledged ongoing issues with door functionality and a lack of monitoring while repairs were pending. Staff interviews revealed that the resident had eloped multiple times, sometimes requiring law enforcement intervention to locate and return the resident. The resident was moved off the secured unit despite ongoing behavioral concerns and a history of elopement. Staff also reported that leadership was aware of the malfunctioning doors and alarms but did not implement effective interventions to prevent further incidents. There was no pertinent information in the facility's policy to support adequate prevention of elopement, and the administrator admitted that effective interventions were not in place to prevent the resident from leaving the facility.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff each day to meet the needs of every resident, as required by regulation. Multiple reviews of daily staffing logs and corresponding time sheets over a three-month period revealed frequent discrepancies between the facility's reported staffing levels and the actual number of staff present. On numerous occasions, the number of staff working was less than what was documented on the staffing logs and below the facility's own minimum staffing plan, as outlined in the facility assessment. These discrepancies affected all shifts, including day, evening, and night, and occurred while the facility census ranged from 62 to 68 residents. Interviews with staff and administration further confirmed the staffing shortages. Several CNAs reported working alone on their assigned halls, which prevented them from providing scheduled showers or ensuring resident safety when attending to other residents. One CNA stated she worked alone on the hall three to four times a month and could not provide showers under those circumstances. Another CNA expressed concern about being unable to monitor residents for safety, especially when caring for one resident left others unsupervised. An LPN reported being responsible for two halls and wound care, indicating an excessive workload due to insufficient staffing. The Maintenance Director also noted that there should always be two staff members on the secured unit, but this was not consistently the case. The facility was also without a Director of Nursing (DON) for nearly a month, as confirmed by the Administrator, which further contributed to the staffing challenges. The Administrator acknowledged that the facility did not have enough staff and identified staffing as the root cause of issues such as elopements, incomplete treatments, and missed showers. The facility's own policy stated that sufficient numbers of staff with the necessary skills and competency would be provided to meet all residents' needs, but this was not consistently achieved during the period reviewed.
Failure to Report Elopement and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report several significant incidents to the State Survey Agency as required by both facility policy and regulatory standards. Specifically, an elopement involving a cognitively intact resident with a history of wandering and delusional behaviors was not reported. The resident exited the facility, evaded staff supervision, and entered nearby woods, prompting a police search with dogs. Despite the seriousness of the event and the involvement of law enforcement, the incident was not reported to the appropriate authorities. Additionally, the facility did not report multiple resident-to-resident altercations, some resulting in injury or with the potential to cause injury. One resident with severe cognitive impairment and a history of physical aggression was involved in several altercations, including an incident where another resident was punched in the face, resulting in a busted lip. Other altercations involved residents being hit or jumped on, though no injuries were recorded in those cases. These incidents were documented internally but not reported externally as required. Interviews with the facility Administrator confirmed that these incidents were not reported to the State Survey Agency, despite facility policies mandating immediate reporting of abuse, neglect, and altercations. The facility's own policies specify that all such incidents, including resident-to-resident altercations, must be reported to the appropriate agencies. No additional documentation or evidence of reporting was provided by the facility during the survey.
Failure to Follow Physician Orders for Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that physician's orders for wound care were followed for two residents with pressure ulcers or at risk for pressure ulcers. For one resident with diabetes and moderate cognitive impairment, documentation showed no current skin issues, but a podiatry visit identified a stage 3 pressure ulcer on the left great toe. Despite orders for daily wound care to the right great toe, there was no evidence on the Treatment Administration Record (TAR) that any dressing changes were completed, and the wound was actually on the left foot. Observations confirmed the presence of a dressing on the left foot, and staff interviews indicated that if wound care was not documented on the TAR, it was likely not performed. Weekly skin assessments were also not up to date. For another resident with moderately impaired cognition and two stage 4 pressure ulcers, care plans and physician orders required daily wound care to the sacrum-coccyx area and scrotum. Review of the TAR revealed that wound care was only documented as completed on 16 of 31 days in one month and 7 of 14 days in the following month. Staff interviews confirmed that wound care was not completed daily as ordered, and weekly skin evaluations were inconsistently performed depending on staff availability. The Director of Nursing and Administrator acknowledged that the lack of documentation and incomplete wound care was due to inadequate staffing, which resulted in missed treatments and outdated skin assessments. There was no information in the facility's policies to support the deficient practice.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary and pest-free kitchen environment, as evidenced by the presence of roaches near the handwashing and food preparation sinks. The kitchen floor and equipment, such as the oven and grill, were observed to have accumulations of grease and food crumbs. Additionally, food items were improperly stored, with an opened bottle of grape jelly left unrefrigerated against manufacturer's instructions. In the walk-in refrigerator, several food items were improperly stored and expired products were not discarded. Diced tomatoes showed signs of spoilage, and leftover pasta sauce was stored beyond the recommended three-day period. Expired dairy products, such as cottage cheese and sour cream, were found, and bread products were not kept frozen as required. In the freezer, multiple opened boxes of food items were not covered or sealed, and expired marinara sauce was found. Similar issues were noted in the storage room, with opened and unsealed bags of grits, oatmeal, salt, and rice. The facility also failed to maintain proper hand hygiene and food temperature standards. Staff members were observed contaminating their hands after washing and then handling clean equipment without re-washing. Food temperatures were not maintained within safe ranges, with steak fingers and egg salad sandwiches found at unsafe temperatures. The ice machine was found with a slimy residue, indicating inadequate cleaning. These deficiencies highlight significant lapses in food safety and hygiene practices within the facility.
Failure to Implement Facility-Wide Assessment
Penalty
Summary
The facility failed to develop and implement a comprehensive facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. Upon the survey team's entry on 10/07/2024, the Administrator provided documents for review, but a facility assessment was not included. On 10/11/2024, the Nurse Consultant was informed of the need for the facility assessment, but it was revealed that the facility did not have one in place. During an interview on 10/14/2024, the Administrator, who assumed her role on 11/23/2023, acknowledged her responsibility for completing the assessment but could not explain why it had not been done. The Assistant Director of Nursing later provided an outdated Facility Assessment Tool from 2017, which contained no relevant information for the current facility needs.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently implement its antibiotic stewardship program for a resident who was taking an antibiotic. The Nurse Consultant, who had been at the facility for only a few days, managed to catch up on four months of infection control tracking logs but did not provide information for October 2024. The Assistant Director of Nursing provided antibiotic stewardship infection mapping and an Order Listing Report for June to September 2024, which lacked a tracking log indicating the resident's signs/symptoms, the start date of symptoms, whether lab tests were required, and criteria for antibiotic necessity. The September Order Listing Report showed that a resident was taking Doxycycline for a skin infection without a specified duration of therapy or stop date. The facility's Antibiotic Stewardship policy, revised in December 2016, required complete antibiotic orders, including drug name, dose, frequency, duration, route, and indication for use, which was not adhered to in this case.
Failure to Designate an Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the infection prevention and control program. Upon the survey team's entry on 10/07/2024, the Administrator provided documentation indicating the absence of an IP. Further review of the facility's in-service binder revealed no infection control trainings from October 2023 to October 14, 2024. The Assistant Director of Nursing acknowledged the lack of infection control in-services and stated she would investigate. The Administrator admitted to not designating a staff member to act as IP until a new hire was made. The facility's policy, revised in July 2016, outlined the IP's responsibilities, including coordinating infection control policies, data analysis, and staff education, none of which were being fulfilled due to the absence of a designated IP.
Privacy Violations During Resident Care
Penalty
Summary
The facility failed to ensure privacy for residents during care procedures, resulting in dignity concerns. For Resident #13, who was admitted with a tracheostomy complication, the Licensed Practical Nurse (LPN) did not close the door while performing tracheostomy care. The LPN left the room to get more gauze and upon returning, continued the care with the door open, which was confirmed as a privacy violation by both the LPN and the Assistant Director of Nursing (ADON). Additionally, Resident #216, who has an indwelling catheter, was observed with the catheter collection bag hanging visibly from the side of the bed without a privacy bag. This was noted on two separate occasions, despite the resident's care plan indicating the need for the catheter bag to be positioned away from the entrance and door. The ADON confirmed that the catheter should have been in a privacy bag, aligning with the facility's policy on resident rights, which emphasizes dignity and privacy.
Failure to Report and Investigate Injuries of Unknown Source
Penalty
Summary
The facility failed to report an incident of injury of unknown source to the Administrator within the required 2-hour timeframe, leading to a delay in initiating an investigation and protective measures. This deficiency involved two residents. The first resident was found on the floor with a cut to the forehead and was later diagnosed with a fractured mandible. Despite the severity of the injury, the incident was not reported to the Administrator or documented in an Incident and Accident Report, as confirmed by interviews with the Administrator and Nurse Consultant. The second resident, who had multiple medical conditions including dementia and muscle wasting, rolled out of bed onto a fall mat, sustaining a facial abrasion. The resident was sent to the hospital for evaluation, but the Administrator was not aware of the incident and did not have any reportables for the month. This lack of reporting was contrary to the facility's policy, which mandates prompt reporting and investigation of such incidents. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately, but no later than two hours if serious bodily injury is involved. The policy also outlines the roles and responsibilities of the Administrator in ensuring investigations are conducted and reported to the appropriate agencies. However, in these cases, the facility did not adhere to its own policies, resulting in a failure to report and investigate the incidents in a timely manner.
Failure to Investigate Resident Injuries
Penalty
Summary
The facility failed to ensure that an incident involving an injury of unknown origin was immediately and thoroughly investigated, as evidenced by the case of Resident #50. On 7/13/2024, Resident #50 was found on the floor with a cut to the forehead and was referred to the hospital for observation. The following day, the hospital informed the facility that x-ray results showed a fractured mandible, necessitating a soft foods diet and follow-up with an ENT specialist. Despite these findings, the facility did not conduct an investigation into the unwitnessed fall that resulted in a major injury. Interviews with the Administrator and Nurse Consultant confirmed the absence of an investigation and analysis (I&A) report for this incident. Another deficiency was identified in the case of Resident #59, who was admitted with multiple diagnoses, including amputated toes, difficulty in walking, and dementia. On 9/25/2024, Resident #59 rolled out of bed onto a fall mat, sustaining a 2 cm abrasion across the right eyebrow and was sent to the hospital for evaluation. Despite the severity of the incident, the Administrator did not have any reportable incidents for September and did not acknowledge awareness of Resident #59's fall and subsequent hospital transfer. The facility's policies on Abuse Investigation and Reporting, as well as Accidents and Incidents - Investigating and Reporting, require that all incidents be promptly reported and thoroughly investigated. The Administrator is responsible for assigning investigations and ensuring protective measures are in place. However, in both cases, the facility failed to adhere to these policies, resulting in a lack of investigation and documentation for significant resident injuries.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to electronically transmit encoded accurate and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days for two residents. For one resident, the discharge return anticipated MDS and entry MDS were exported but not accepted by CMS. The resident was discharged to the hospital and later expired there. The Assistant Director of Nursing confirmed that the facility lacked an MDS Coordinator, which contributed to the failure to complete and submit the necessary assessments within the required timeframe. Another resident's admission record showed multiple diagnoses, including type 2 diabetes mellitus and schizophrenia, but the facility's policy on MDS Error Correction did not address the timeliness of MDS completion. The facility had experienced turnover in the MDS Coordinator position, with two Registered Nurses starting and resigning shortly after. The facility was relying on an LPN MDS Coordinator from a sister facility to help complete the MDS assessments and had contracted with an RN to perform MDS tasks remotely.
Failure to Follow Physician's Orders and Inaccurate MDS Assessment
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with a wound, as weekly skin evaluations were not completed as ordered. The resident had a stage 3 wound on the left big toe, which was initially documented as a diabetic foot ulcer but later identified as a pressure ulcer. Despite the physician's order for weekly skin evaluations, there were no evaluations recorded between August 19, 2024, and October 12, 2024. Interviews with the LPN, ADON, and Nurse Consultant confirmed the lack of weekly evaluations, which was a deviation from the physician's orders. Additionally, the facility did not accurately assess the quarterly Minimum Data Set (MDS) for another resident, as the medication Risperdal was incorrectly classified. The resident, who had a diagnosis of a psychotic disorder and moderate cognitive impairment, was taking Risperdal for psychosis. However, the care plan inaccurately reflected Risperdal as an anti-anxiety medication instead of an antipsychotic. The Director of Nursing confirmed that the medication should have been documented as an antipsychotic on the care plan and MDS.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure that comprehensive care plans addressed individualized appropriate care and services for four residents. Resident #45's care plan did not include their Activities of Daily Living (ADL) requirements, despite being dependent on staff for showering and bathing. Observations showed that the resident was often unshaven and had hair on their face, indicating a lack of personal grooming care. The care plan's omission of ADL requirements led to inconsistent personal hygiene care, as evidenced by the shower log showing infrequent bathing. Resident #13's care plan did not address their flaccid right arm and contracted right hand, despite having a diagnosis of paralysis affecting the right side. Observations confirmed the absence of any device or intervention for the contracted hand, and interviews with staff confirmed the lack of care planning for these conditions. Similarly, Resident #35's care plan inaccurately noted contractures, while observations revealed that the resident's legs were locked in a straight position, unable to bend. These deficiencies highlight the facility's failure to develop and implement comprehensive, person-centered care plans that meet the residents' physical and functional needs.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were revised to reflect the most recent care needs for three residents. For Resident #21, a Certified Nursing Assistant (CNA) was observed using a mechanical lift without assistance, contrary to the resident's care needs, which were not updated in the care plan. The resident had severe cognitive impairment, required substantial assistance, and was on high-risk medications, including insulin and antipsychotics, none of which were reflected in the care plan. The CNA involved was unaware of the requirement for two-person assistance with the mechanical lift. Resident #13's care plan did not address the use of anticoagulants, insulin, or the monitoring of diuretic side effects, despite the resident's severe cognitive impairment and medication regimen. Similarly, Resident #16's care plan was not updated to reflect a diabetic foot ulcer, despite ongoing assessments and progress notes indicating the presence of the wound. The Assistant Director of Nursing confirmed the oversight, acknowledging that the care plan should have been revised to include current wound care interventions.
Deficiencies in Resident Hygiene and Grooming
Penalty
Summary
The facility failed to ensure proper personal hygiene and grooming for three residents, leading to deficiencies in care. Resident #35, who has cerebral palsy and glaucoma, was observed multiple times with hair on their chin despite being dependent on staff for personal hygiene. The resident's care plan indicated a need for assistance with activities of daily living due to confusion, yet the resident was not properly groomed. Similarly, Resident #45, who is also dependent on staff for hygiene, was observed with unshaved facial hair. The care plan for Resident #45 did not include specific ADL care, indicating a lack of proper planning and execution of hygiene tasks. Additionally, Resident #32, who has severe cognitive impairments and is dependent on staff for all needs, did not receive regular scheduled baths or showers. The resident's bath schedule indicated they should receive baths three times a week, but records showed only six baths over two months. The facility's failure to adhere to the bathing schedule and ensure regular hygiene care for these residents was confirmed by staff interviews, highlighting a significant lapse in maintaining the residents' personal hygiene and dignity.
Failure to Conduct Weekly Skin Evaluations and Address Contracture
Penalty
Summary
The facility failed to ensure that residents with physician orders for weekly skin evaluations received the necessary assessments. Specifically, four residents with orders for weekly skin evaluations did not have their skin evaluated as required. For instance, one resident had a dressing on their right lower leg for an open wound, but the skin assessments were not conducted weekly as ordered. The care plan for this resident required monitoring and documentation of the skin injury, including measurements and any notable changes, but the assessments were not performed consistently. Additionally, the resident's Minimum Data Set (MDS) inaccurately documented that the resident was not at risk for pressure ulcers and had no skin problems. Furthermore, the facility did not provide appropriate treatment for a resident with a contracture. The resident had a flaccid right arm and a contracted right hand, but no device was present to prevent further decline. The care plan did not address the flaccid arm or contracted hand, and staff confirmed the absence of a device. The facility's policy on contracture treatment emphasized the importance of preventing the progression of contractures through measures such as handrolls, but these were not implemented for the resident in question.
Deficiencies in Mechanical Lift Use and Smoking Safety Assessment
Penalty
Summary
The facility failed to ensure the proper use of a mechanical lift for a resident with severe cognitive impairment and physical limitations. The resident, who had a diagnosis of joint contracture and muscle atrophy, required substantial assistance for transfers. However, the care plan did not specify the transfer method or the number of staff required. A CNA was observed using a mechanical lift to transport the resident without assistance, contrary to the facility's policy and the lift's manual, which stated that two staff members were needed for safe operation. Additionally, the facility did not assess a resident for smoking safety, despite the resident having severe cognitive impairment and a history of respiratory issues. The resident was observed smoking without a protective apron during designated smoke breaks, and there was no documented assessment of the resident's ability to smoke safely. The facility's smoking policy required an evaluation of residents' smoking habits and safety, which was not conducted for this resident. Interviews with staff confirmed the lack of proper assessments and adherence to safety protocols. The CNA involved in the lift incident was unaware of the requirement for two staff members, and both the LPN and ADON confirmed the absence of a smoking assessment for the resident. The facility's policies on safe lifting and smoking were not followed, leading to potential safety hazards for the residents involved.
Improper Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide incontinence care in a clean and sanitary manner for two residents, leading to potential health risks. Resident #33, who was cognitively intact and occasionally incontinent of bowel and bladder, was observed receiving improper cleaning from a CNA. The CNA used a back-and-forth motion with one wipe, which can spread germs and cause urinary tract infections. The CNA admitted to not being trained to wipe more than once with one wipe without folding. Resident #32, who had severe cognitive impairment and was dependent on staff for care, was found lying in bed with a wet ring around the buttock area. During incontinence care, a CNA failed to clean the entire genital area exposed to urine and potentially feces. The CNA did not clean the resident a second time after an incontinence episode, citing difficulty due to the resident's contracture. The facility's administrator acknowledged that a wet sheet indicated a lack of care and emphasized the importance of cleaning the entire genital area to prevent infections.
Deficient Tracheostomy Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, as observed by a surveyor. The resident, who had a tracheostomy complication diagnosis, was found with light brown gauze around the tracheostomy site, indicating dried blood. The resident confirmed that the gauze had not been changed regularly. The physician's orders required tracheostomy care every 24 hours and as needed, but the care was not consistently documented or performed according to the Treatment Administration Record (TAR). Additionally, the facility's procedure for tracheostomy care was not followed, as the care was not performed using sterile techniques, and necessary supplies were not readily available at the bedside. During an observation, an LPN was seen performing tracheostomy care without following proper infection control protocols. The LPN did not sanitize the bedside table before placing a sterile field, did not wear sterile gloves, and failed to sanitize hands before changing gloves. The LPN also did not use personal protective equipment (PPE) during the procedure. The obturator, which was visibly contaminated with mucus, was not replaced with a new one, and the spare obturator was not stored at the head of the resident's bed as required. The LPN admitted to not following the sterile procedure and was unable to locate the spare obturator. Interviews with the Nurse Consultant and the Assistant Director of Nursing confirmed the deficiencies in tracheostomy care and infection control practices. They acknowledged that the LPN should have sanitized hands, worn sterile gloves, and used PPE during the procedure. They also confirmed that the spare obturator should be kept at the head of the resident's bed and that tracheostomy care was not performed as ordered. The facility's policy emphasized minimizing infection risks and ensuring supplies for tracheostomy care are readily accessible, which was not adhered to in this case.
Lack of Full-Time DON Coverage
Penalty
Summary
The facility failed to ensure full-time Director of Nursing (DON) coverage, as required by regulations. From August 10, 2024, to August 18, 2024, there was no DON or interim DON employed at the facility. Additionally, check stubs provided to the surveyor on October 14, 2024, indicated that the DON did not consistently work full-time hours over a two-week period. The facility's administrator acknowledged that there were times when DON coverage was not available. The facility's staffing policy stated that sufficient numbers of staff with the necessary skills and competency should be provided to care for all residents in accordance with the facility assessment.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted visibly for residents and visitors, as required by their policy. On October 10, 2024, at 9:00 AM, a surveyor observed that there was no visible posting of the daily staffing and resident census. Additionally, the sign-in sheet lacked a tally of actual hours worked per shift for direct care staff. Later that day, the facility's Staff Coordinator, an LPN, admitted to being unaware of the requirement to include the facility name, date, census, nursing staff responsible for direct care, and a tally of actual hours worked per shift in the posting. On October 14, 2024, the Administrator confirmed that the facility did not have a daily staffing posting with all the required components. The facility's policy, titled 'Posting Direct Care Daily Staffing Numbers,' mandates that such information be posted daily for each shift, including the number of nursing personnel responsible for providing direct care to residents, the facility name, date, census, category of licensed and unlicensed staff working each shift, and actual time worked for each category.
Medication Administration and Dosage Errors
Penalty
Summary
The facility failed to accurately account for a controlled medication for a resident diagnosed with bipolar disorder. The resident was prescribed Clonazepam 0.5 mg to be taken as needed for anxiety. However, discrepancies were found in the narcotic log, where Clonazepam 1 mg was documented instead of the prescribed 0.5 mg. Additionally, there was a lack of proper documentation for the administration of Clonazepam 0.5 mg, as the narcotic log did not reflect the correct dosage or administration records. The LPN responsible for the medication administration was unable to locate the correct documentation for the prescribed dosage, and the discrepancy was reported to the ADON and Administrator. Another resident with a diagnosis of Essential Hypertension was affected by a medication dosage error. The resident was prescribed Nifedipine ER 60 mg to be taken twice daily, but instead received Nifedipine ER 90 mg from the pharmacy. This error persisted from the start of the prescription until the resident's discharge, without the pharmacy being notified of the incorrect dosage. The Nurse Consultant and ADON confirmed the error, acknowledging that the resident did not receive the physician-ordered dose. The facility's policies on pharmacy services and medication orders emphasize the importance of timely and accurate medication administration, which was not adhered to in these cases.
Failure to Address Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to address pharmacist recommendations for psychotropic medication management for three residents. Resident #50, diagnosed with bipolar disorder, was prescribed Trazodone and had a recommendation for dose evaluation and reduction from a pharmacy medication regimen review dated 08/17/2024, which remained unaddressed by the physician as of 10/08/2024. Resident #57, with catatonic schizophrenia, had a PRN order for Haloperidol that required a 14-day stop date and physician re-evaluation, which was not addressed by 10/08/2024. The facility's policy on tapering medications and gradual dose reduction was not followed, as the necessary evaluations and adjustments were not made. Resident #8, with a diagnosis of a psychotic disorder, was on multiple psychotropic medications, including Risperidone, Mirtazapine, and Duloxetine, since 12/2023. A recommendation for dose evaluation and reduction was noted on 07/28/2024 and 08/18/2024, but the medical director did not provide a rationale for not attempting a gradual dose reduction. The administrator confirmed that the suggestion for a gradual dose reduction for Resident #8's Risperdal was not addressed or attempted, indicating a lapse in following the facility's policy and addressing pharmacist recommendations.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 24.14% during an observation of medication administration involving four residents. The errors were identified during the administration of medications by one RN and one LPN. For Resident #36, the RN administered Albuterol inhalation 90 mcg two hours early and withheld Carvedilol without notifying the provider, despite no parameters being indicated for withholding the medication. Additionally, the RN omitted Zinc Gluconate for Resident #31 because Zinc Sulfate was available instead, and the order was later changed to Zinc Sulfate after consultation with a Nurse Practitioner. Further errors were observed with Resident #37, where Phenobarbital was administered two and a half hours late by the LPN. For Resident #54, the LPN administered Apixaban, Metoprolol Tartrate, and Gabapentin three hours late, disrupting the scheduled medication times. The facility's policy on medication errors, revised in April 2014, defines such errors as deviations from physician's orders, manufacturer's specifications, or accepted professional standards, including wrong drug administration and incorrect timing.
Failure to Adhere to Planned Menu and Portion Sizes
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which was intended to meet the nutritional needs of the residents. During an observation, it was noted that the dietary staff used a 4-ounce spoon to puree black-eyed peas instead of the lima beans specified on the menu. Additionally, the dietary staff incorrectly calculated the number of servings needed for pureed ham, resulting in insufficient portions being prepared. Specifically, 30 small pieces of ham were used to make 3 servings, although 4 servings were required, and 60 pieces were used to make 6 servings when 13 were needed. Further observations revealed that residents on regular diets received only 1.4 ounces of ham instead of the 3 ounces specified in the menu. The dietary staff also added extra bread to the pureed meat mixture, which was not part of the planned menu. These discrepancies indicate a failure to adhere to the menu, potentially compromising the nutritional intake of the residents. The dietary staff's actions and inactions led to the deficiency, as they did not follow the planned menu or ensure the correct portion sizes were served.
Inadequate Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. During an observation, it was noted that the dietary staff used a 4-ounce spoon to place black-eyed peas into a blender, which were then pureed and poured into a pan. The consistency of the pureed black-eyed peas was described as mushy and not formed. Similarly, turnip greens were pureed and placed in a pan, resulting in a watery consistency that was not formed. Additionally, small pieces of ham, dinner rolls, and bread were blended with broth, but the resulting mixture was thick with visible pieces of ham skins. Further observations revealed that hot water cornbread was pureed with milk, resulting in a thick consistency. During an interview, a dietary aide confirmed that the pureed turnip greens were not smooth, the black-eyed peas resembled a milkshake, the pureed ham was thick like mashed potatoes with skin, and the pureed cornbread appeared like raw dough. These findings indicate that the facility did not adequately prepare pureed foods to meet the dietary needs of residents, potentially increasing the risk of choking or other complications.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. During an observation, it was noted that the resident's care plan did not include instructions for using enhanced barrier precautions, and a registered nurse admitted to not wearing a gown while administering medication through the PEG tube. The nurse also could not recall receiving training on enhanced barrier precautions, and the facility was unable to provide a policy for these precautions upon request. The facility's water management program was found lacking as it did not include Legionella monitoring or a comprehensive description of the building's water system. The Maintenance Supervisor admitted to not having information on Legionella monitoring and planned to attend a meeting to gather more information. The facility's water management policy was outdated and did not align with current recommendations from the Centers for Disease Control and other relevant bodies. Infection control practices were further compromised by improper handling of laundry and inadequate use of personal protective equipment (PPE) during resident care activities. Observations revealed that laundry was transported without proper covering, and staff failed to change gloves or sanitize hands during care activities, leading to potential cross-contamination. Additionally, tracheostomy care for a resident was not performed according to the facility's policy, with lapses in hand hygiene, PPE use, and sterile technique noted during the procedure.
Deficiencies in Vaccine Administration and Documentation
Penalty
Summary
The facility failed to ensure that a pneumococcal vaccine was provided to a resident, identified as Resident #59, who was admitted on 06/22/2023. The resident's electronic health record lacked documentation indicating whether the resident consented to or declined the pneumococcal vaccine. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2024 showed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, yet the pneumococcal vaccine was not offered. When questioned, the Assistant Director of Nursing (ADON) was unable to provide any information regarding the pneumococcal vaccine for this resident. Additionally, the facility did not document the education provided to another resident, identified as Resident #33, after the resident declined the influenza vaccine. The immunization screen for this resident indicated a refusal of the influenza vaccine but did not include the date of refusal. The resident's Order Summary Report confirmed a diagnosis of type 2 diabetes mellitus with hyperglycemia, and a significant change MDS with an ARD of 06/01/2024 indicated the resident was cognitively intact with a BIMS score of 14. The ADON was unable to provide documentation of the declination consent or the education provided, as the immunization screen only noted the refusal without a date.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as having impaired cognitive function and a history of suicidal ideation, was safe to self-administer medications. The resident's plan of care, revised on 09/11/2024, included interventions to administer medications as ordered and monitor for side effects and effectiveness. However, over-the-counter medications were observed in the resident's bathroom on multiple occasions by the surveyor, indicating that the resident had access to medications without proper assessment or authorization to self-administer. The Nurse Consultant confirmed that no residents on the hall where the resident resided were authorized to self-administer medications, and the resident had not been assessed for the ability to do so safely. The Administrator also stated that no residents in the facility were assessed to self-administer medications, and medications should not be accessible to the resident without supervision. The facility's policy on self-administration of medications requires an interdisciplinary team assessment to determine if it is clinically appropriate and safe for a resident to self-administer medications, which was not conducted in this case.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays, which is a violation of their right to send and receive mail promptly. During a meeting with the resident council members, it was revealed that mail is not delivered on Saturdays. The Activity Director confirmed that she only delivers mail from Monday to Friday, as these are her working days. The Administration also stated that no one is assigned to deliver mail on Saturdays. This practice is contrary to the facility's policy on Resident Rights, which stipulates that residents have the right to receive mail promptly.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital. The incident involved a resident with a diagnosis of catatonic schizophrenia, who was severely cognitively impaired and receiving antipsychotic medications. On August 26, 2024, the resident was sent to a local hospital due to a decreased level of consciousness, and the resident's relative was notified. The resident returned to the facility on September 5, 2024. However, the facility did not notify the Ombudsman of the transfer, as required. The Assistant Director of Nursing (ADON) stated that Social Services was responsible for notifying the Ombudsman, but it was not made clear to the responsible staff member, resulting in the notification not being completed. This oversight was identified during a review of the resident's records and an interview with the ADON on October 14, 2024.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete timely quarterly assessments for a resident, as required by regulations. The Minimum Data Set (MDS) for the resident showed that only an entry MDS was completed, with no Admission or Quarterly MDS conducted. The facility's policy on MDS Error Correction did not address the timeliness of completing MDS assessments. The Administrator revealed staffing challenges, with two Registered Nurses (RNs) resigning shortly after being hired, and an LPN from a sister facility assisting with MDS completion. The facility had contracted an RN to perform MDS tasks remotely. The Administrator acknowledged that the resident should have had both an Admission and a Quarterly MDS completed by this time, indicating an oversight in the process.
Deficiency in PEG Tube Management and Enteral Feeding Rate
Penalty
Summary
The facility failed to ensure proper procedures were followed for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Specifically, the facility did not check the PEG tube for placement before administering fluids and medications, and did not adhere to the physician's orders regarding the enteral feeding rate. The resident, who had a diagnosis of dysphagia and required attention to a surgical opening for a feeding tube, was observed with an enteral feeding rate set at 95 ml/hr, contrary to the physician's order of 90 ml/hr. Additionally, the feeding bottle lacked the necessary information such as the time it was hung and the nurse's initials. The facility's policy on Enteral Feedings-Safety Precautions, revised in May 2014, required checking the rate of administration and ensuring the formula label included initials, date, and time. However, the policy did not specify the method for checking tube placement. During an interview, a registered nurse admitted to not receiving training on checking PEG tube placement and described using a method involving air injection and listening for a sound, which was not specified in the facility's policy. This lack of training and adherence to physician orders contributed to the deficiency in care for the resident with a PEG tube.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that Monthly Medication Regimens (MMR) were completed at least monthly for a resident with moderate cognitive impairment. The resident, identified as having a score of 11 on the Brief Interview of Mental Status (BIMS), was taking high-risk medications for depression, anxiety, and fluid retention. A review of the resident's plan of care, revised in May 2024, indicated the use of antidepressant medication for depression. During an interview, the facility's Administrator admitted that there was no documentation available to prove that the MMRs were completed as required. The facility's policy on Medication Regimen Reviews mandates that the Consultant Pharmacy review each resident's medication regimen at least monthly.
Failure to Conduct Weekly Skin Evaluations for Resident with Wound
Penalty
Summary
The facility failed to follow physician's orders for a resident with a wound, specifically regarding the completion of weekly skin evaluations. The resident, who had a stage 3 wound on the left big toe, was supposed to receive weekly skin assessments as per the physician's orders. However, the records show that there were no skin evaluations conducted between August 19, 2024, and October 12, 2024, despite the order for weekly assessments. This lapse in care was confirmed by interviews with the LPN, ADON, and Nurse Consultant, who acknowledged that the evaluations were not completed as required. Additionally, the resident's wound was initially documented as a diabetic foot ulcer but was later reclassified as a pressure ulcer. The change in classification was confirmed by the Nurse Consultant, who noted that the wound was not a diabetic ulcer as previously documented. The resident's care plan highlighted the potential for skin integrity issues due to fragile skin, emphasizing the need for preventive measures and adherence to treatment protocols. Despite these directives, the facility did not conduct the necessary weekly evaluations, leading to a deficiency in care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers for two residents. Resident #10, who has severe cognitive impairment and multiple medical conditions including a stage 4 pressure ulcer, did not receive wound care as per physician orders. The orders specified daily dressing changes for the sacral wound and changes three times a week for the leg amputation wounds. However, observations revealed that the dressings had not been changed since 06/28/2024, indicating a lapse in following the prescribed wound care regimen. Additionally, the last skin audit for this resident was conducted on 05/22/2024, suggesting a lack of regular monitoring. Resident #11, also severely cognitively impaired, had a care plan that required daily wound care for a sacral wound, including cleansing, packing with collagen, and covering with a bordered foam dressing. Despite these orders, the dressing observed on 07/01/2024 was dated 06/28/2024, indicating that the wound care was not performed daily as required. The facility's staff, including the ADON and LPNs, confirmed that the treatment nurse was primarily responsible for wound care, but when unavailable, charge nurses were expected to perform these duties. However, there was confusion and inconsistency among staff regarding access to wound care supplies, which may have contributed to the failure in providing timely care. The facility lacked a wound care policy or guideline, which may have contributed to the deficiencies observed. The Administrator acknowledged that the treatment nurse was responsible for ensuring wound care was performed according to physician orders, but there was no clear accountability or process in place for when the treatment nurse was absent. The last skin audit for Resident #11 was dated 05/28/2024, further indicating a lack of consistent monitoring and documentation of skin conditions.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure a Director of Nursing (DON) was employed full-time. On July 1, 2024, at 9:15 AM, the Administrator provided a list of key personnel, which did not include a DON. Later that day, at 12:30 PM, the Administrator confirmed that the facility had not had a DON since March 20, 2024, and acknowledged that there was no policy for DON coverage. By 2:30 PM, the Administrator reiterated that the facility should have a full-time DON.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and roaches throughout the building, including the kitchen, dining room, resident rooms, and hallways. Observations by the surveyor on multiple occasions revealed flies on resident food, in common areas, and in the kitchen where food was being prepared. Staff interviews corroborated these findings, with several staff members acknowledging the presence of flies and roaches in various parts of the facility, including the kitchen, dining areas, and resident rooms. The facility's pest control policy states that there should be an ongoing program to keep the building free of insects and rodents. However, despite having a contract with a pest control company, the problem persisted. The Administrator acknowledged awareness of the issue and mentioned that the pest control company had been engaged to address the problem, but the presence of pests continued to be a significant concern, affecting the quality of care and environment for the residents.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for one of the four sampled residents who were discharged. Resident #3, who had a diagnosis of type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, was cognitively intact with a BIMS score of 15 and required maximum assistance with activities of daily living. Upon review of Resident #3's medical records on July 1, 2024, it was found that there was no discharge summary present. Interviews conducted on July 2, 2024, revealed that the nurses are responsible for completing the discharge summary upon a resident's discharge, and the facility's administrator confirmed that a discharge summary was not completed for Resident #3. Additionally, it was noted that the facility does not have a policy for discharges.
Failure to Serve Meals Timely to Resident with Malnutrition
Penalty
Summary
The facility failed to serve food in a timely manner to a resident diagnosed with unspecified protein-calorie malnutrition, who was observed sitting at the feed assist table without a meal tray while most other residents had finished their meals. The resident's cognitive skills for daily decision-making were severely impaired, as noted in a recent assessment. During interviews, both the Dietary Manager and the Assistant Director of Nursing (ADON) were unable to explain why the resident had not been served. A Restorative Aide mentioned returning from an appointment, but this did not clarify the delay. The ADON later acknowledged that the resident should not have to wait long periods to be fed, and the Administrator confirmed the absence of a policy on timely meal service.
Failure to Secure Smoking Materials and Provide Adequate Supervision
Penalty
Summary
The facility failed to keep smoking materials secured and provide adequate supervision during all smoke breaks, which could potentially lead to injury. Resident #1, who was cognitively intact with a BIMS score of 14 and had diagnoses of Dementia and COPD, was observed with smoking materials unsecured in their room on multiple occasions. Specifically, a blue package of cigarettes and a white disposable lighter were found on the over-bed table, and two blue packages of cigarettes were found in the bedside table drawer. There were no physician orders or care plan entries addressing the resident's smoking status, and no smoking assessment was located in the resident's health record. Interviews with staff revealed inconsistencies in the supervision of smoke breaks and the storage of smoking materials. LPN #1 and LPN #2 both indicated that residents were not supposed to keep their own smoking supplies, but they had observed residents smoking unsupervised outside of designated smoke break times. CNA #1 confirmed that the responsibility for supervising smoke breaks was not clearly assigned, stating that the activity person was supposed to supervise but that it often fell to whoever had time. The facility's smoking policy, which was reviewed, stated that residents without independent smoking privileges should not have smoking articles except under direct supervision, but this policy was not being followed in practice.
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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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