A resident with aphasia and chronic kidney disease was admitted with documented redness on the right thigh and a physician order for weekly skin assessments. The admission evaluation instructed staff to complete a thorough head-to-toe skin assessment, but the next-day skilled documentation by an LVN indicated the resident had no skin conditions. Later that day, a hospital documented redness and bruising to the hip, back, and leg, and the DON reported to a hospital physician that bruising had been present on admission but had enlarged. Facility CNAs and an LVN gave inconsistent accounts of seeing or not seeing bruising, with one LVN stating she used only bathroom light and that night nurses did not typically perform full skin assessments. The DON and ADON acknowledged that admitting nurses were responsible for initial skin assessments, that staff generally did not measure skin conditions, and that a recent EMR change contributed to incomplete documentation. These actions and omissions resulted in incomplete and inaccurate skin assessment and documentation, contrary to the facility’s Skin Management policy and the physician’s orders.
AED Not Properly Checked or Staff Competency Not Ensured: Staff failed to demonstrate competency with the facility’s only AED, which was found beeping with a red X indicator and disconnected electrode pads. Multiple LPNs said they were not trained on the specific AED in use and did not know what the warning indicators meant, while the DON confirmed readiness checks were assigned to night nurses and that prior training had used a different AED.
An LVN independently removed a resident’s PICC line used for IV antibiotics, despite facility policy and Texas Board of Nursing guidance that only an RN may perform PICC insertion or removal. The resident, who had multiple cardiac conditions and moderate cognitive impairment, reported that the line was removed at the facility and denied pain or complications, and surveyors observed an intact, non-infected site. Documentation and staff interviews confirmed that the LVN performed the removal alone under a provider discontinue order, while the RN, ADON, DON, and Administrator all acknowledged that PICC removal is outside LVN scope and should be done by an RN.
Nursing staff lacked adequate competency and training in controlled medication management, leading to multiple discrepancies and unsafe practices. For one resident with seizure disorder and severe cognitive impairment, an RN’s control count sheet for Lacosamide did not match the actual volume on the cart, and the RN reported no recent skill check‑off or training on medication administration or control counts. For another resident with dementia and pain management needs, a tramadol blister pack was found with a punched, half‑exposed tablet, and the same RN stated she did not know how to handle the situation and had not been trained on control counts. For a third resident receiving PRN acetaminophen‑codeine for pain, an LVN’s control sheet showed one more tablet than was present in the blister pack; the LVN admitted administering a dose without signing it out on the control sheet or MAR and indicated she had not received medication administration training beyond brief floor orientation, despite facility policy requiring nursing leadership to ensure staff competency.
A resident with Alzheimer’s disease, expressive language disorder, osteoporosis, and total dependence for ADLs was care planned to require a Hoyer lift with two staff for transfers. During an observed transfer, two CNAs used a mechanical lift but one CNA failed to lock the wheels before lifting and moving the resident, resulting in a wheel lifting off the floor and the CNA standing on the lift to force the wheel down while the other CNA guided the resident into a wheelchair. One CNA stated she believed the wheel lock was broken, that this was the only usable lift because others were not charged, and that she had reported the issue and previously refused to use the lift. The DON reported that mechanical lift use required two staff, locked wheels, and competency check-offs on hire and annually, but documentation showed one CNA lacked a mechanical lift competency on hire and no such record was found for the other CNA, despite facility policy requiring competency evaluations.
A resident with cerebral palsy, severe mobility limitations, and high fall risk required two-person assistance with a mechanical lift, but a CNA attached the sling to a handling strap instead of the proper attachment loop during a transfer, causing the resident to fall and sustain a fractured clavicle. The resident reported that only one staff member performed the transfer, despite her usual two-person assist requirement, and later experienced pain with a replacement sling during subsequent transfers. Surveyors found no documented mechanical lift competencies for CNAs or nursing staff, and the DON and DOR were unable to demonstrate or clearly explain safe lift use, sling inspection responsibilities, or how competencies were validated. Observations of additional transfers showed CNAs failing to center the sling and manage lift wheels correctly, and multiple staff could not describe required safety measures, leading to an Immediate Jeopardy finding for failure to ensure competent nursing staff for mechanical lift transfers.
Two CNAs failed to follow proper infection control practices during incontinent care for a resident with chronic conditions, cognitive impairment, continuous incontinence, and a documented UTI. Surveyors observed both CNAs enter the resident’s room without performing hand hygiene, don gloves, and complete the entire perineal care procedure—including handling a urine-soiled brief, cleansing the perineal and rectal areas, applying barrier ointment, and adjusting clothing—without changing gloves between dirty and clean tasks. In interviews, the CNAs reported they believed gloves only needed to be changed if visibly soiled with feces, despite having prior skills check-offs in perineal care and infection control, while facility leadership confirmed that these actions were inconsistent with established hand hygiene and glove-change requirements.
A resident sustained a distal femur fracture after being transferred with a mechanical lift by an untrained aide working alone, despite facility policy requiring two staff for such transfers. Multiple aides were working full time without CNA certification or documented mechanical lift training, yet were providing unrestricted direct care. Interviews with aides, the AIT, ADON, and MD confirmed that aides lacked required competencies, that orientation and skills checklists were missing or incomplete, and that nurses were expected but failed to consistently supervise aides performing transfers. These conditions led surveyors to cite the facility for failing to ensure competent nursing staff for resident care.
A resident with severe cognitive impairment, respiratory disorders, and a tracheostomy required ongoing trach care and had care plan directions for emergency management if the tube was coughed out. On two occasions, the trach became dislodged while nurses were providing care, leading to hospital transfers; in one case, staff reinserted the trach but were unsure of correct placement. Interviews showed that an RN and an LVN assigned to the resident did not feel comfortable or did not know how to replace a dislodged trach and were unaware of or untrained in using emergency equipment, while another LVN knew how to replace the trach but had not received trach training or a skills checkoff at this facility. The DON and RCS demonstrated confusion about trach sizes and the specific size ordered for the resident, despite documentation that nurse trach competencies had been marked as met, and the prior ADON reported that most nurses, including those involved, had not attended prior hands-on trach training and were uncomfortable with this care. These findings led surveyors to determine that the facility failed to ensure competent nursing staff for tracheostomy care and emergency response.
A newly hired CNA on her first orientation day was allowed to assist a resident with dementia, muscle wasting, and dysphagia with eating without supervision, despite the resident’s care plan requiring substantial/maximal assistance and specific positioning to reduce choking and aspiration risk. The CNA provided hands-on feeding for a period reported to be up to 45 minutes alone, contrary to the ADON’s description that first-day orientation should be shadowing only and the facility’s CNA orientation policy requiring instruction on skill weaknesses before performing tasks.
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