TOWERS NURSING HOME
Non profit - Corporation
120 Beds
WELLSENTIAL HEALTH
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
46/100
#596 of 1168 in TX
Photo by Towers Nursing Home
Photo by Towers Nursing Home
Photo by Towers Nursing Home
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Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Towers Nursing Home has a Trust Grade of D, indicating below-average performance with some concerns about care quality. It ranks #596 out of 1168 facilities in Texas, placing it in the bottom half, but is #2 of 5 in Bastrop County, meaning it has only one local competitor that performs better. The facility is improving overall, with reported issues decreasing from eight in 2024 to three in 2025. Staffing is a significant weakness, rated at just 1 out of 5 stars, with a 56% turnover rate, which is about average for Texas. There have been serious incidents, including a resident being hospitalized due to medication errors and another who fell out of bed because proper assistance was not provided during care. Additionally, food safety practices were lacking, with issues like improperly stored food that could lead to potential health risks for residents. Overall, while there are improvements in health inspections and quality measures, significant concerns remain regarding staffing and safety.
- Trust Score
- D
- In Texas
- #596/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $15,239 in fines. Higher than 59% of Texas facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 12 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 12 deficiencies on record. Higher than average. Multiple issues found across inspections.
46/100
Bottom 49%
Review needed
8 → 3 violations
★★★☆☆
3.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 3 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Texas average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 56%
Near Texas avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $15,239
Below median ($33,413)
Minor penalties assessed
Chain: WELLSENTIAL HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Texas average of 48%
The Ugly 12 deficiencies on record
1 life-threatening 1 actual harm
Jul 2025
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident # 27 and Resident #30) out of 8 residents reviewed for call lights. The facility failed on 07/29/2025 to ensure Resident # 27 and Resident #30's call light was within reach to use. This failure could affect all residents who needed assistance and could result in needs not being met.Findings included: Review of Resident #27's face sheet, dated 07/30/2025, reflected [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #27 had diagnoses which included unspecified dementia, mild, with psychotic disturbance ( memory and thinking problems that are mild and not specifically identified and includes behaviors such as delusions- a false belief of reality), unsteadiness on feet (a lack of stability or coordination while walking or standing), need assistance for personal care ( a person needs assistance with daily living activities such as: bathing, dressing, toileting, and grooming), and age related physical debility (characterized by decreased in strength, endurance, and balance, often leaing to a higher risk of falls, disability, and hospitalization). Review of Resident #27's Quarterly MDS, dated [DATE], reflected the resident BIMS assessment was completed by staff. Resident #27 had poor short- and long-term memory recall (having difficulty remembering things that have just happened or been learned). She required partial /moderate assistance (helper does less than half the effort) with personal hygiene, dressing, showers, transfers, and toileting. Resident #27 did not reject care. Review of Resident #27's Comprehensive Care Plan, with a completion date 06/29/2025, Resident #25 had an ADL self-care performance deficit. Interventions: Resident required partial/moderate assistance with transfers, dressing, personal hygiene, and picking up objects. Resident #25 was high risk for falls related to impaired cognition with poor safety awareness, inability to bear weight without assistance. Intervention: Ensure Resident #27's call light was within reach and encourage the resident to use the call light for assistance as needed. She required prompt response to all requests for assistance. Resident #27 needed a safe environment with a working and reachable call light. Observation and interview on 07/29/2025 at 7:15 AM, revealed Resident #27 was lying in bed. Her call light was approximately 8 feet from her bed lying on the over the bed rolling table. Resident #27 was unable to reach her call light. She stated yes when asked if she knew how to use a call light. Resident #27 stated leave my room. Interview on 07/29/2025 at 7:18 AM CNA C entered Resident #27's room and stated Resident #27's call light was on the floor and Resident #27 was unable to reach the call light. She stated Resident #27 did use the call light. CNA C stated all residents call light was required to be within reach of all residents when a resident was in their room. She stated if a resident was unable to reach their call light and needed assistance, there was a possibility a resident may need nursing assistance. She stated a resident may attempt to assist self out of bed and fall trying to get assistance. She stated Resident #27 was a fall risk. She stated she had been in-serviced on placing call lights within resident's reach. CNA C stated she did not recall the date of the in-service. She stated if the nursing staff was not near the resident's room, it was a possibility the staff would not hear a resident yell for help. CNA C stated any staff entered a resident room was responsible to ensure the call light was within reach of the resident. Review of Resident #30's face sheet, dated on 07/29/2025, reflected a 88- year-old- female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia ,unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety (memory and thinking problems that are mild and not specifically identified without behaviors), unsteadiness on feet (a lack of stability or coordination while walking or standing), and need assistance for personal care (a person needs assistance with daily living activities such as: bathing, dressing, toileting, and grooming). Review of Resident #30's Quarterly MDS Assessment, dated 06/06/2025, reflected Resident #30 had a BIMS score of 1, which indicated her cognition was severely impaired. Resident #30 did not reject care. She required partial/moderate assistance (helper does less than half the effort) with personal hygiene, showers, toileting and lower body dressing. She required supervision/or touching assistance (helper provides verbal cues and/ or touching assistance) with the following: upper body dressing, and oral hygiene. Review of Resident #30's Comprehensive Care Plan, with a completion date 06/28/2025, reflected Resident #30 had an ADL self-care performance deficit. Interventions: Encourage Resident #30 to use call light for assistance. She required assistance with personal hygiene, showers, dressing, and toileting. Resident #30 was a high risk for falls related to generalized weakness and poor safety awareness. Intervention: Resident #30 needs a safe environment including a working and reachable call light. Observation and interview on 07/29/2025 at 7:28 AM, revealed Resident #27 was lying in bed. Her call light was on the floor approximately 6 feet from her bed. Resident #27 was not interviewable. Interview on 07/31/2025 at 9:20 AM CNA D stated all residents call lights were expected to be placed within reach of the resident when a resident was in their room. She stated if a resident was sitting in a wheelchair the call light was expected to be attached to the wheelchair. CNA D stated i a resident was lying in bed the call light was expected to be attached to the pillowcase, the sheet or the bedspread where the resident was able to reach it when they needed assistance from nursing staff. She stated if a call light was on the floor or lying on bedside table and the resident was not able to reach the call light, there was a possibility a resident may fall trying to stand up from wheelchair or from the bed when they needed assistance. She stated it was everyone's responsibility to ensure the residents call light was within reach. CNA D stated if a CNA was in the shower and a nurse was in a resident's room, the nursing staff may not be able to hear a resident yell for help. Interview on 07/31/2025 at 10:20 AM ADON stated if a resident was in their room lying in bed or sitting in a wheelchair, the call light was expected to be within reach of the resident. She stated if a resident was unable to reach their call light there was a potential a resident may fall from the bed or wheelchair if the call light was not within reach and the resident needed assistance. The ADON stated any staff who entered a resident's room was expected to check the call lights of the residents and if the call light was not in reach, any staff could place the call light within reach of the resident's wheelchair or bed. She stated in-service had been given to staff on placing call lights within reach of residents when they are in their room. The ADON stated she did not recall the date of the in-service. Review of the facility's Policy on Call Lights: Accessibility and Timely Response, dated 10/13/2022 reflected, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. Staff will ensure the call light is within reach of resident and secured, as needed. 2. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.3. Special accommodations will be identified on the resident's person-centered plan of care and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.)4. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activitie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 30 and Resident # 65) reviewed for ADL care. The facility failed on 07/29/2025to ensure Resident #30, and Resident #65's fingernails were cleaned. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Review of Resident #30's face sheet, dated on 07/29/2025, reflected a 88- year-old- female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety (memory and thinking problems that are mild and not specifically identified without behaviors), lack of coordination (the inability to smoothly and precisely control movements), and need assistance for personal care (a person needs assistance with daily living activities such as: bathing, dressing, toileting, and grooming). Review of Resident #30's Quarterly MDS Assessment, dated 06/06/2025, reflected Resident #30 had a BIMS score of 1, which indicated her cognition was severely impaired. Resident #30 did not reject care. She required partial/moderate assistance (helper does less than half the effort) with personal hygiene, showers, toileting and lower body dressing. She required supervision/or touching assistance (helper provides verbal cues and/ or touching assistance) with the following: upper body dressing, and oral hygiene. Review of Resident #30's Comprehensive Care Plan, with a completion date 06/28/2025, reflected Resident #30 had an ADL self-care performance deficit. Interventions: required assistance with personal hygiene, showers, dressing, transfers and toileting. Observation and interview on 07/29/2025 at 7:28 AM, revealed Resident #30 was in her lying in bed. She had a blackish/ brownish substance underneath the middle and ring fingernails on her right hand. Resident #30 was not interview able. Record review of Resident # 65's face sheet dated 07/31/2025 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #65 had diagnoses which included unspecified dementia with mood disturbance (memory and thinking problems that are mild and not specifically identified and includes behaviors), need for assistance with personal care (a person needs assistance with daily living activities such as: bathing, dressing, toileting, and grooming), and muscle weakness (a reduced ability to generate force in one or more muscles, impacting physical performance and daily activities). Record review of Resident #65's Quarterly MDS Assessment, dated 06/28/2025, reflected Resident #65 reflected the resident BIMS assessment was completed by staff. Resident #65 had poor short- and long-term memory recall (having difficulty remembering things that have just happened or been learned). Resident #65 required substantial/maximal assistance (helper does more than half the effort) with the following: personal hygiene, dressing, showers, toileting, oral hygiene, and transfers. Record review of Resident #65's Comprehensive Care Plan, with completion date of 07/02/2025, reflected Resident #65 had an ADL self-care performance deficit related to weakness. Intervention: Resident #65 required substantial/maximal assistance with personal hygiene, dressing, transfers showers, toileting and oral hygiene. Observation and interview on 07/29/2025 at 7:40 AM, revealed Resident #65 was in her room lying in bed. She had a blackish/ brownish substance underneath the middle ring and fore fingernails on her right hand. Resident #65 was not interview able. In an interview on 07/29/2025 at 7:18 AM, CNA C stated the CNAs (Certified Nurse Assistant) were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes (a disease occurs when blood sugar is too high). She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA C stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as vomiting and diarrhea. CNA C stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 30 and Resident #65, and they did not refuse nail care. In an interview on 07/31/2025 at 9:45 AM, LVN E stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. CNA C stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as stomach problems nausea and vomiting. She stated she was in- serviced on nail care, however, she did not recall the date. She stated she would need to ask staff questions for the reason nail care was not completed on Resident #30 and Resident #65. In an interview on 07/31/2025 at 9:20 AM, CNA D stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA D stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA D stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 30 and Resident #65, and they did not refuse nail care. CNA D stated she did not know the last time these residents' nails were trimmed or cleaned she would need to check the medical records. In an interview on 07/31/25 at 10:20 AM, ADON stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes. She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The ADON stated the nurse supervisor was responsible for monitoring CNAs giving ADL care which included nail care, and the ADON and DON was responsible for monitoring the nurse supervisors. Review of the facility's Policy on Activities of Daily Living (ADLs), dated 05/26/2023, reflected The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal, and oral hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for two of six residents (Resident #10 and Resident #93) reviewed for infection control practices. The facility failed to ensure: MA B followed good nursing practices when preparing medications to prevent cross contamination of oral medications for Resident #93 on 07/30/2025 when MA B failed to perform hand hygiene and don gloves prior to touching Resident #93's medications with contaminated, ungloved hands. RN A used sanitary supplies during medication administration via g-tube (a tube inserted into the stomach) for Resident #10 when on 07/30/2025 RN A did not sanitize a tray table prior to use supplies and medications on while administering medications to Resident #10 via gastrostomy tube. This failure could place the resident at risk for cross contamination and infection. Findings included: 1. Review of Face sheet for Resident #93 reflected a [AGE] year-old female, admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (dementia that damages the brain), Congestive Heart Failure (heart disease that affects pumping action of the heart muscles), Legal Blindness (visual impairment limiting everyday tasks), and Gastro-esophageal reflux disease (acid from the stomach frequently backs up into the esophagus). Review of Annual Assessment MDS for Resident #93 dated 06/26/2025 reflected a BIMS score of 5 (severe cognitive impairment). Section B- Hearing, Speech, and Vision section indicated she was able to understand others and is able to make her ideas and wants known to others. Review of Care Plan for Resident #93 reflected a Problem section stating, [Resident #93] has impaired cognitive function or impaired thought processes r/t Alzheimer's. Date Initiated: 04/10/2018, with related Interventions stating, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 04/10/2018 and [Resident #93] needs supervision with all decision making. Date Initiated: 09/07/2020. Review of Physician Orders for Resident #93 reflected an order for, Regular diet, Regular texture, Regular Liquids consistency started on 03/05/2019. Observation of Medication administration for Resident #93 on 07/30/2025 at 7:54AM revealed that MA B performed hand hygiene prior to dispensing medications. She then touched the medication carts, medication cards, and computer keyboard prior to using ungloved hands to remove two pills from the medication cup for Resident #93. In an interview with MA B on 07/30/2025 at 8:00AM, she stated that she should have cleaned her hands and put on gloves before taking the pills out of the cup. She stated that the potential risk to the resident was that they, could get sick. 2. Review of Face sheet for Resident #10 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Aphasia (difficulty using or comprehending language), Dysphagia (difficulty swallowing), and Gastrostomy status (gastrostomy tube in place, a tube inserted into the stomach). Review of Quarterly Assessment MDS for Resident #10 dated 05/05/2025 reflected a BIMS score of 12 (moderate cognitive impairment). Section B-Hearing, Speech, and Vision indicated that Resident #10 is usually able to understand others and usually able to make his ideas and wants known to others. Review of Care Plan for Resident #10 reflected a Problem area stating [Resident #10] has the need for Enhanced Barrier Precautions due to a feeding tube Is at risk for infection, depression, feelings of isolation, and decline in physical activity Date Initiated: 05/10/2024 and a related Intervention stating, Administer medication as ordered. Date Initiated: 05/10/2024. Review of Physician Orders for Resident #10 reflected and order for, NPO (nil per os-nothing by mouth) diet, NPO texture, Nectar Thickened Liquids consistency with a start date of 07/04/2025 and medication orders are all noted to be administered via G-Tube or PEG-Tube (percutaneous gastrostomy tube-a type of gastrostomy tube that is inserted into the stomach). Observation of medication administration for Resident #10 on 07/30/2025 at 10:49AM with RN A revealed that she asked another staff member to bring her a tray table from the resident room directly across the hall from Resident #10. She then used the tray table from the other room to set all of her supplies and medications on while administering medications to Resident #10 via gastrostomy tube. In an interview with RN A on 07/30/2025 at 12:11PM, who stated that she should have cleaned the tray table before she used it for Resident #10. She stated that the risk of sharing un-sanitized equipment between residents is the potential for infection. In an interview on 07/31/25 at 1:00PM, the ADMIN who stated that she expected staff to follow the infection control practices for the facility. She stated she would not expect staff to touch medications with their bare hands. She stated that she expected staff to disinfect items that are used between residents. She stated that the risk to the residents of not following the infection control guidelines is the possibility of infection. In an interview on 07/31/25 at 1:02PM, the DON stated that staff are not supposed to touch pills with their bare hands. She stated that she expected staff to wash their hands prior to preparing the medications also. She stated that they should also observe any special instructions with medications regarding need for PPE (Personal Protective Equipment). She stated that any equipment used between residents should be sanitized between use. She stated the risk to the residents of not following the facility infection control guidelines is the possibility of infection. Review of facility policy for Infection and Prevention and Control Program dated 5/13/23 reflected: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.e. Environmental cleaning and disinfection shall be performed according to facility policy. Review of facility policy for Medication Administration dated 10/01/19 reflected: Medications are administered as prescribed in accordance with good nursing principles and practices only by persons legally authorized to do so. B. Handwashing and Hand Sanitation: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and medications given via enteral tubes. Examination gloves are worn when necessary.
Aug 2024
1 deficiency
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were free of any significant medication errors fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of four residents reviewed for medication errors.
The facility failed to ensure Resident #1's glucose was monitored, and insulin was administered regularly from 07/21/24 - 08/02/24. She was sent to the ER on [DATE] with a glucose level of 649 and a diagnosis of DKA.
The noncompliance was identified as PNC. The IJ began on 08/02/24 and ended on 08/09/24. The facility had corrected the noncompliance before the survey began.
This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.
Findings included:
Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end-stage renal disease , dependence on renal dialysis, type I diabetes, long-term (current) use of insulin, and history of DKA (a serious complication of diabetes that happens when the body does not have enough insulin, causing the body to break down fat for energy).
Review of Resident #1's admission MDS assessment, dated 07/22/24, reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section N (Medications) reflected she received insulin injections. Section O (Special Treatments, Procedures, and Programs) reflected she required dialysis.
Review of Resident #1's admission care plan, dated 07/17/24, reflected she had chronic renal failure related to end-stage renal disease with an intervention of monitoring vital signs as ordered or as needed and monitoring for changes in mental status.
Review of Resident #1's physician order, dated 07/17/24, reflected Insulin Glargine Subcutaneous Solution Pen-Injector - 100 unit/ML - Inject 8 unit subcutaneously one time a day (9:00 AM) for diabetes.
Review of Resident #1's MAR, July 2024, reflected she was not administered the Insulin Glargine Solution on 07/25/24, 07/29/24, and 07/30/24.
Review of Resident #1's MAR, August 2024, reflected she was not administered the Insulin Glargine Solution on 08/02/24.
Review of Resident #1's physician order, dated 07/21/24, reflected Insulin Lispro Injection Solution - Inject as per sliding scale:
If 71 - 149 = 0
150 - 199 = 2 units;
200 - 249 = 4 units;
250 - 299 = 6 units;
300 - 349 = 8 units;
350 - 399 = 10 units;
Greater than 399 = 12 units and notify Provider
Three times a day for Diabetes before meals
Review of Resident #1's MAR, July 2024, reflected her BS was not checked and she was not administered the Insulin Lispro Injection on 07/25/24 (11:00 AM and 4:00 PM), 07/26/254 (4:00 PM), 07/29/24 (7:00 AM and 4:00 PM), and 07/30/24 (11:00 AM and 4:00 PM).
Review of Resident #1's MAR, August 2024, reflected her BS was not checked and she was not administered the Insulin Lispro Injection 08/02/24 (7:00 AM).
Review of Resident #1's Change of Condition Communication form, dated 08/02/24, reflected the following:
Signs/Symptoms: high blood sugar greater than 300, low blood pressure, change in mental status .increased confusion . slurred speech . decreased appetite.
Review of Resident #1's progress notes, dated 08/02/24 at 1:15 PM and documented by LVN B, reflected the following:
At 11:45 (AM) [Resident #1]'s [FM D] called inquiring about [Resident #1]. Stated her blood sugars were elevated, didn't feel good and was not going to dialysis. Shortly after the phone call, [LVN A] came and informed me that [Resident #1]'s BS was high . I notified the NP which was present in the facility.
12:10 PM - NP gave an order to administer 12 units of insulin, hydrate with water, and to recheck in 30 minutes.
12:35 PM - BS rechecked - still elevated - NP provided another order of 12 units per sliding scale to be administered. [Resident #1] had been exhibiting changes in mental status.
12:40 PM - NP assessed [Resident #1] and decided to send her to the hospital for evaluation and management.
1:15 PM - [Resident #1] loaded on stretcher and left facility by Ambulance to (hospital).
Review of Resident #1's progress notes, dated 08/02/24 at 11:44 PM and documented by LVN B, reflected the following:
Around 12:00 (PM), [LVN A], LVN charge nurse came and informed me that [Resident #1]'s BS was reading High (glucometer unable to read) VS 102/42, 90, 99.1. [Resident #1] in bed with [FM D] at bedside - had been exhibiting changes in mental status. [LVN A] rechecking her blood sugars while I went and notified the NP.
Review of Resident #1's NP assessment, dated 08/02/24, reflected the following:
[Resident #1] is seen today to follow up accucheck reading of high and refusing dialysis d/t not feeling well. This was reported to this provider and orders were given to [LVN A] to admin 12 units of SSI now, vital signs, encourage water, recheck blood sugar in apx 30 mins, monitor closely and report changes/concerns.
I am here now to follow up with [Resident #1] after interventions administered above, nurse rechecked accucheck s/p insulin, result reads high, therefore new orders given to nurse to administer 12 additional units of SSI. On exam, [Resident #1] appears more confused than baselined, oriented to self, unable to follow commands, notable leg jerking, she endorses headache and dizziness. D/t hx of diabetes with DKA and ESRD , recommend transfer to ED to eval and treat.
Review of Resident #1's hospital medical records, dated 08/02/24, reflected the following:
.BIBEMS after reportedly altered at nursing home earlier this afternoon. Nursing home reports that [Resident #1] is usually AOx4, but found confused and altered, only oriented to self.
.[Resident #1] with recent admission on [DATE], briefly: . [Resident #1] was altered/not oriented on arrival, found to be in DKA and admitted to (hospital) .admitted w/DKA w/significant acidosis. Reported missed insulin dose while at SNF, which was likely precipitation factor for DKA.Found altered in nursing home by staff; given 24 lispro in nursing home, 500 mL in EMS and 1 L LR in ED. BG 574 -> 649 . Started on DKA protocol .
During an interview on 08/20/24 at 10:34 AM, the ADM stated it was the DON's responsibility to ensure the MARs were completed and medication doses were not being missed. He stated she had been working closely with LVN E because she was new to long-term care. He stated once he was made aware of the medication discrepancies and lack of oversight by the DON, both LVN A and the DON were terminated.
During an interview on 08/20/24 at 11:24 AM, LVN B stated Resident #1's FM D had called the nurses station on 08/02/24 around 12:00 PM. She stated FM D was upset because Resident #1 did not feel well and did not want to go to dialysis. She stated she located LVN A who told her the glucometer was reading high when she tested Resident #1's blood sugar. She stated the glucometer stops reading blood sugar levels when they are above 500. She stated she asked LVN A what her levels were that morning and LVN A stated, I did not do them. She stated she asked her why she had not checked her blood sugar, but LVN A had no answer for her. She stated missing doses of insulin repeatedly could lead to DKA. She stated it was hard to say if the missing dose of insulin on 08/02/24 was what caused Resident #1 to go into DKA, but she did have a history of it, so it was likely. She stated the importance of checking blood sugar levels and not missing insulin doses was to avoid situations like that one. She stated it was important when someone's body was not producing insulin that insulin gets administered. She stated the nurses were recently in-serviced on glucometer checks and administering insulin.
During an interview on 08/20/24 at 11:55 AM, LVN C stated she worked with Resident #1 and had heard about her requiring hospitalization for DKA. She stated Resident #1 was a type I diabetic which made it more imperative that her blood sugar levels were checked regularly, and no doses of her insulin were missed. She stated with type I diabetics, they were unable to produce insulin, so no matter what they ate, the sugar levels would always spike high. She stated it was a life-or-death situation and missed doses could lead to coma, DKA, or death, especially for someone like Resident #1 who had a history of DKA. She stated the nurses had recently been in-serviced on accuchecks and insulin administration.
During an interview on 08/20/24 at 1:14 PM, the NP stated when the nursing staff alerted her on 08/02/24 that Resident #1's blood sugar was reading high, she ordered 12 units of insulin, asked them to push fluids, and to re-check her levels in an hour. She stated when it was still high, she gave orders for more insulin. She stated that along with Resident #1's comorbidities and her being altered for her baseline, she made the decision to send her to the hospital at that time. She stated that there were multiple risk factors for DKA and did not believe missing the insulin doses was what caused her to go into DKA.
During an interview on 08/20/24 at 1:37 PM, the MD stated if a resident was missing multiple doses of insulin, it would concern him as it could cause blood sugar to be unstable. He stated Resident #1's blood sugar was controlled until that day (08/02/24), so he would not say the missed dose that morning was what had caused DKA. He stated individuals with type I diabetes go into DKA a lot.
During an interview on 08/20/24 at 4:15 PM, LVN E stated the nursing staff had recently been provided in-serviced on accuchecks, insulin, following physician orders, and administering medications timely. She stated they also did check-offs with the DON. She stated it was important for insulin to get administered as ordered because it could lead to coma or death.
During an inteview on 08/20/24 at 4:33 PM, the Interim DON stated she reviewed a report of missed medications the prior day that was generated by their EMR system every morning to investigate the reasoning for the missed doses.
On 08/20/24, several attempts were made to contact LVN A. A returned call was not received prior to exiting .
Review of the facility's QAPI Meeting Agenda, dated 08/02/24, reflected the ADM, the DON, the MD, the ADON, and the RNRCS were in attendance to discuss diabetics, accuchecks, physician orders, changes in condition, and medication administration.
Review of the DON an LVN A's termination documents, dated 08/04/24, reflected both were terminated.
Review of a statement, dated 08/02/24 and documented by the ADM, reflected the following:
[Pharmacist] consultant was notified via phone by the Administrator regarding the medication error that occurred on 08/02/24. Administrator request a pharmacist visit to review all resident in facility with orders for accuchecks and or insulin orders/antidiabetic medications. Visit was scheduled for 08/09/24.
Review of an audit conducted by the Pharmacist, dated 08/09/24, reflected no recommendations were made.
Review of an audit conducted by the DON/clinical team, dated 08/02/24, reflected no residents with orders for accuchecks and insulin had been affected and had been receiving treatments according to physician orders.
Review of in-services entitled AccuChecks/Medication Administration, from 08/02/24 - 08/06/24 and conducted by the DON and ADON, reflected all nurses were in-serviced on timely accuchecks and medication administration:
Importance of Timely Accuchecks and Medication Administration
- Resident Safety: Consistent and timely blood glucose checks and medication administration are vital to managing chronic conditions like diabetes, preventing adverse events such as hypo- or hyperglycemia.
- Compliance with Physician Orders: Adherence to prescribed schedules ensures that residents receive their treatments as intended by their healthcare providers.
- Legal and Regulatory Compliance: Accurate and timely documentation is necessary to meeting regulatory requires and avoid potential legal liabilities.
Review of in-services entitled Accu Checks/Medication Administration, from 08/02/24 - 08/03/24 and conducted by the DON and the ADON, reflected all nurses were in-serviced on timely accuchecks and medication administration.
Review of in-services entitled Medication Administration, from 08/02/24 - 08/06/24 and conducted by the DON and the ADON, reflected all nurses were in-serviced on their Medication Administration Policy.
Review of the facility's Medication Administration Policy, dated 10/01/19, reflected the following:
Medications are administered as prescribed in accordance with good nursing principles and practices only by persons legally authorized to do so.
Review of Medication Pass and Obtaining Blood Sugar Readings checkoffs, dated 08/02/24 - 08/07/24, reflected all nurses and medication aides completed competency checkoffs with no concerns.
The noncompliance was identified as PNC. The IJ began on 08/02/24 and ended on 08/09/24. The facility had corrected the noncompliance before the survey began.
Jun 2024
7 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that the residents environment remained as free...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that the residents environment remained as free of accident hazards as was possible for one (Resident #45) of thirty-three residents reviewed for hazards.
The facility failed to ensure that Resident #45 was assisted by two care providers during peri-care resulting in her rolling out of the bed onto the floor and sustaining facial lacerations.
This failure could place residents at risk of accidents and injury.
Findings Include:
Review of Resident #45's Face Sheet dated 06/05/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Cerebral Infarction (result of disrupted blood flow to the brain due to problems with the blood vessels that supply it resulting in lack of oxygen and vital nutrients which CAN cause parts of the brain to die off), Parkinson (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), and Morbid (Severe) Obesity (complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions).
Review of Resident #45's MDS admission Assessment, dated 05/09/2024 revealed Resident #45 had a BIMS Score of 15, which indicates cognition is intact. Resident #45's MDS revealed in Section GG - Functional Abilities and Goals - admission A. Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed indicated 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity , or the assistance of 2 or more helpers is required for the resident to complete the activity.
Review of Resident #45's Comprehensive Care Plan revealed a problem area [Resident #45] has an ADL self-care performance deficit r/t muscle weakness, contracture, pain and decreased mobility Date Initiated: 05/02/2024 with an intervention for BED MOBILITY: [Resident #45 requires total assist by 2 staff to turn and reposition in bed as necessary. Date Initiated: 05/13/2024.
Review of Occupational Therapy OT evaluation & Plan of Treatment, start of care date 05/03/2024 revealed, Resident #45 Assessment Summary: Clinical impressions: Resident #45 presents with multiple impairments that have contributed to decline in independence with functional ADLs and safety that will be addressed by skilled OT services in order to facilitate pt return to PLOF. Impairments include: decreased strength and flexibility, impaired coordination, activity tolerance, balance reactions, and decreased Independence with ADLs.
Review of Transfer Related Incident Report, prepared by RN A, dated 05/10/2024 at 12:00 PM. Resident #45 was found after fall lying on the floor parallel to her bed, lying face down, hollering and crying. Description: Complete head to toe skin assessment. NVS initiated. Wound care provided. PRN pain medication administered. Physician notified. Orders to send to ER for evaluation and treatment if indicated. Resident taken to Hospital? Y. Witnesses: CNA H, Relation: Staff, Date 5/10/2024, Statement: I was changing resident, resident was capable of talking to this CNA, helping this CNA and acknowledged that she knew what she need to do during peri care. This CNA asked resident, CAN you please turn your body to the right? resident said, Yes, I will help as much as I can. Then this CNA said, CAN you allow yourself to go to the side of the bed to hold on the edge of the bed? and resident said, Yes. As she held on to the edge of the bed, she proceeded to put more force with her own body, and that allowed her to tip more weight to her right side, allowing her to go from the bed to the floor. Resident was on floor parallel to her bed, face down, and then nurse was notified to come to resident's room. Notes: 5/10/2024 Resident sent to hospital for x-rays returned with no acute injuries, education provided to staff that she is a 2 person assist with all aspects of care.
Review of [Medical Facility Emergency Department Record dated 5/10/24 revealed, Patient Complaint: Facial Lacerations, Triage Assessment: Facial Lacerations. Review of [Medical Facility] Emergency Physician Record dated 5/10/2024 revealed, Adult Injury lac to nose.
Review of facility's progress notes in their electronic records system for Resident #45 revealed the following:
5/10/2024 19:30 (7:30 PM) NURSING - Nurse Note Late Entry (unidentified staff): Note Text: resident brought to room per wheelchair per two staff members. Transferred to bed. was awake and able to make needs known. v/s 96.4 t, 20r, 96o2 at room air, 70 hr., 138/74. Status post injury to face and bruising to left hand. Stated some pain to face. Call light within reach, bed on low.
5/11/2024 17:03 (5:03 PM) NURSING - Nurse Note Text (unidentified staff): S/P witnessed fall day 1, resident with small steri-strips to nose and small band aid to upper lip CDI, mentation at baseline, up per normal routine, currently sitting in wheelchair in main dining room for dinner, resident taking Ibuprofen prn for pain and is effective.
5/11/2024 20:32 (8:32 PM) NURSING Nurse Note Text (unidentified staff): 2nd day status post fall. resident lying in bed and awake. able to answer questions appropriately at this time. v/s: 96.2 forehead, 18r, 93O2 sat on RA, 67 hr., 116/64. face continues with steri-strips to bridge of nose and band aid to upper lip. is able to make needs known. call light within reach, bed on low.
5/13/2024 19:51 (7:51 PM) NURSING - Nurse Note Text (unidentified staff): resident had a fall out of bed on 05/10/24 which she ended up in the ER for evaluation for trauma to face. resident does c/o pain to face. resident requested ibuprofen 400mg, which was effective. she is a 2-person assist with transfers and changes.
Observation and interview on 06/05/2024 at 8:09 AM, Resident #45 was observed lying in her bed and had some discoloration under both of her eyes, which appeared to be diminishing. Resident #45 stated that approximately one month ago she requested that an add assist her with peri-care. Resident #45 stated a CNA assisted her and as she started to roll her to her side she was not able to stop her momentum and rolled off the bed onto the floor. Resident #45 stated when she fell it caused bruising to her face. Resident #45 stated the CNA was provided the care by herself and that her rolling off the bed was an accident. Resident #45 was observed to be heavy set and did not appear to have much core strength or the ability to assist with her care.
Interview on 06/05/2024 at 3:19 PM, RN A stated she was at work on 5/10/24, when Resident #45 fell from her bed. RN A stated she was at the nurse's station when CNA G came and told her that Resident #45 had fallen. RN A stated that when she entered the room of Resident #45 she observed CNA G and CNA H present and believed the bed was in the low position. RN A stated she observed Resident #45 on the floor between her bed and the wall and observed she was bleeding and possibly injured in the area of her nose and eyes. RN A stated she did a full assessment of Resident #45, who stated she was alright. RN A stated she then used the mechanical lift with the assistance of the CNAs to place Resident #45 back in her bed. RN A stated she notified the DON, Administrator, RP, and both ADONs were present. RN A stated after assessment and contact with NP, Resident #45 was sent to the emergency room due to contact with her head and face to ensure no head trauma or fractures. RN A stated she spoke with and obtained a statement from CNA H, who told her Resident #45 asked to help her clean up (peri-care). RN A stated CNA H told her she was rolling Resident #45 to her side by herself, and she just continued to roll over and out of the bed. RN A stated she would assume Resident #45 was a 2 person assist for bed mobility / peri-care due to her weight. RN A stated in her opinion if peri-care was being performed on Resident #45 she should have been assisted by 2 CNAs.
Interview on 06/05/2024 at 3:30 PM, CNA H was contacted by phone and stated that she was at work. CNA H stated she could not speak due to being in the presence of patients and would call back at approximately 5:30 PM when she left work.
Interview on 06/05/2024 at 3:44 PM, CNA G stated he was at work on 05/10/2024 and was in the area of Resident #54 when he heard what he described as desperate screaming. CNA G stated he entered the room of Resident #45 and saw CNA H standing by the bed with a look of shock on her face. CNA G stated he saw Resident #45 on the floor on the other side of her bed and observed that she was bleeding. CNA G stated he asked CNA H what happened, and she did not respond. CNA G stated he went quickly and got RN A to come to the room. CNA G stated he moved Resident #45's bed out of the way and stated he believed it was in the mid position, which would be standard for peri-care. CNA G stated RN A assessed Resident #45 and then they placed her back in the bed using a mechanical lift to do so. CNA G stated he heard RN A ask CNA H what happened, and she told her she was trying to change Resident #45 and she rolled out of the bed. CNA G stated he worked 7 AM to 1 PM on the day of the fall and left shortly after but did see EMS arrive and knew the AIT was on location. CNA G stated when he returned to work after the fall that Resident #45 was back in the facility. CNA G stated he and all staff were trained and instructed that Resident #45 was to be a 2 person assist for all care and transfers. CNA G stated he had never attempted peri-care on Resident #45 by himself prior to or after the fall and did not know of anyone other than CNA H during this incident who had. CNA G stated common sense should have been enough for CNA H to know that she should not have attempted peri-care on Resident #45 by herself. CNA G stated he does not believe CNA H wanted this to occur and is a very caring person. CNA G stated he knew after the incident that CNA H was removed from the hallway and did not provide further care for Resident #45.
Interview on 06/05/2024 at 4:09 PM, ADON B stated she was in the facility on 05/10/2024, when Resident #45 fell out of the bed. ADON B stated she was notified of Resident #45's fall from the bed and went to the room. ADON B stated CNA H stated she was providing peri-care for Resident #45 and when she rolled her on her side she continued to roll and fell off the bed. ADON B stated it was not appropriate for CNA H to have been performing peri-car on Resident #45 without assistance. ADON B stated Resident #45 had blood coming from her mouth and nose and was transported by EMS. ADON B stated after Resident #45's fall they trained all staff on 2-person transfers / assist and ensured that staff knew that Resident #45 was a 2-person assist.
Interview on 06/05/2024 at 4:33 PM, the DON stated she was not in the facility on 05/10/2024 but was notified by the Administrator of Resident #45's fall. The DON stated after the incident all staff were in-serviced that Resident #45 was a 2-person assist with all care. The DON stated she went and spoke to Resident #45 after the fall, and she stated she felt safe in the facility. The DON stated she knew Resident #45 was a 2-person assist after this incident but was unsure if that was the case prior due to her limited time in the facility before the fall. At 4:49 PM, the DON stated she checked the records and that Resident #45 was in fact a two person transfer at the time of the fall and that CNA H should not have been provided peri-care on Resident #45 by herself.
Interview attempted on 06/05/2024 at 7:04 PM with CNA H, who had not called as she stated she would. CNA H did not answer, and the call was sent to voicemail.
Follow-up interview on 06/06/2024 at 8:03 AM, CNA G stated they are trained to review the [NAME] before providing care to ensure patients' needs are bed and proper assistance is provided. CNA G stated if they ever go to another hallway to assist they CNA look at the [NAME] but are also informed verbally of assist requirements by the CNAs regularly assigned to the hall. CNA G stated during the in-service they were instructed that Resident #45 was to be a 2-person full assist and that they received specialized training to include interactive participation and demonstration. CNA G stated during the in-service training they were also instructed on proper brief size for residents during peri-care. CNA G stated since Resident #45's fall and the staff in-service that he has never seen or heard of anyone attempting care on Resident #45 by themselves and does not believe Resident #45 would allow them to do so if they did try.
Interview on 06/06/2024 at 8:15 AM, the Administrator stated Resident #45 was sent to the emergency room on the day of the fall for a CT-Scan to rule out any bleeds / fractures, or any other injuries received during the fall. The Administrator stated no treatments were required and that the fall resulted in bruising to the area of both eyes and her nose. The Administrator stated he was working to obtain her medical records to provide as confirmation of no further injuries.
Interview on 06/06/2024 at 8:50 AM, the AIT stated he was in the facility on 05/10/2024 when Resident #45 fell from her bed. The AIT stated he spoke by phone with the Administrator and notified him of Resident #45's fall. The AIT stated he met with Resident #45 after the fall, and she stated she felt safe in the facility. The AIT stated he never spoke directly with CNA H about the incident. The AIT stated he could not state whether it was appropriate for CNA H to have performed 1-person peri-care due to his current limited role as a trainee in the facility and the matter being handled by the Administrator.
Interview on 06/06/2024 at 9:20 AM, the Therapy Director stated Resident #45 would obviously need 2-person assistance because she requires mechanical lift. Therapy Director stated due to Resident #45's size and lack of truck control there should not be less than two assisting her with bed mobility / peri-care. Therapy Director stated in his professional opinion CNA H should not have attempted peri-care on Resident #45 by herself.
Interview on 06/06/2024 at 9:40 AM, the ADON stated she was in the facility on 05/10/2024 when Resident #45 fell. The ADON stated she went to Resident #45's room after notification and observed that Resident #45 was back in her bed. The ADON stated she observed blood on the floor by Resident #45's bed and observed she was bleeding from her nose and mouth. The ADON stated she told RN A to contact the Administrator and physician. The ADON stated Resident #45 need to be sent to the emergency room for a CT-Scan due to contact with her head and to ensure she had no other injuries. The ADON stated CNA H should not have performed peri-care on Resident #45 by herself. The ADON stated after the fall they immediately put interventions in place to prevent further occurrences. The ADON stated all staff were in-serviced that Resident #45 was a 2-person total care. The ADON stated Resident #45 was changed to a bariatric bed, which was wider to minimize risk of recurrence. The ADON stated when she spoke with Resident #45 after the fall that she told her that it was an accident. The ADON described CNA H as approximately five foot seven and one hundred and sixty pounds. The ADON stated CNA H walked out during a shift approximately two weeks after this incident and was no longer in the facility.
Interview on 06/06/2024 at 9:56 AM, CNA I stated she was new to the facility and was currently on her second day of training in the 300 hallway. CNA I stated the facility trained their CNA staff by each individual hallway before being assigned to ensure they know the residents and their needs. CNA I stated she has been trained to review the [NAME] to ensure proper care and assistance is provided to residents. CNA I stated assistance for peri-care was provided under the continence tab. CNA I stated in addition to the electronic files she was walked down the 300 hallway by staff on the first day and verbally advised of each residents level of assistance with bed mobility and transfer. CNA I stated she has been trained and believed that even if a resident was indicated for 1-person assist that she would only provide the care by herself if she was sure that she could safety and correctly do so. CNA I stated they have to consider everything from how heavy the resident was, to their fragility. CNA I stated failure to ensure adequate assistance with task for residents could result in injury.
Follow-up interview on 06/06/2024 at 3:00 PM, Resident #45 was seated in her wheelchair in the lobby. Resident #45 stated she had always had care provided by at least two staff members prior to his incident. Resident #45 stated since her fall she has never had care provided by less than two staff members. Resident #45 stated the injury to her mouth must have occurred when she accidentally bit herself during the fall. Resident #45 stated she did not believe this was an intentional act and stated she loves it at this facility and does not believe anything like this would ever happen again.
Interview on 06/06/2024 at 3:08 PM, the Administrator stated he investigated the fall during peri-care involving Resident #45 and CNA H. The Administrator stated staff were in-serviced on transfers and ensured that all knew Resident #45 was a 2-person assist. The Administrator stated he interviewed Resident #45 after the fall and she indicated to him that this was an accident that took place during care. The Administrator stated Resident #45 was upset because she did not like that CNA H did not stop her from falling and then did not immediately react after her fall. The Administrator stated he interviewed Resident #45 a second time and she again indicated that this incident was an accident that occurred during her peri-care. The Administrator stated during peri-care / transfers that it is his expectation that, a resident is never put in a situation that could cause harm.
Review of Imaging Services Report from [Medical Facility] with an indicated film date of 5/10/2024 revealed, Impression: No acute infarction, hemorrhage, or mass effect.
Review of personal / training file for CNA H revealed, Restorative Nursing Assistant Competencies Checklist, Areas of Skill 3. Bowel & Bladder 11/06/2023 Pass, 6. Bed Mobility 11/06/2023 Pass. Candidate Clinical Card for CNA H indicated initials by Pericare F and Pos on side.
Review of Form 5497 Texas Nurse Aide Performance Record revealed Section VII, Personal Care Perineal Care / Incontinent Care - Female (With or Without Catheter), Classroom / Online 10/23/23, Skill Lab 11/28/2023, Clinical 11/20/2023. Certificate of Completion from [Nursing Facility] to CNA H in recognition of completion of the requirements for [Nursing Facility] Nurse Aide Training Program #TX44989 completed on 12/06/2023. The facility did provide documentation of all mandatory background checks within the past calendar year.
Review of undated [Nursing Facility] In-Service Training Report for All Staff, Topic [Resident #45], Summary of Training Session: Resident is a 2 person care at all times with all aspects of care.
Review of the facility's Activities of Daily Living (ADLs) policy dated 05/26/2023 revealed, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 2. Transfer and ambulation; Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to complete preadmission screening for a resident with a mental disord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to complete preadmission screening for a resident with a mental disorder.
The facility failed to review and correct a PASSR evaluation for Resident #45 .
This failure could result in the resident not receiving correct and approved treatments, medications and quality of life enhancements.
Findings include:
Review of the Face Sheet for Resident #85 reflected she was admitted on [DATE] with diagnosis of: Myocardial Infarction, Dementia, and bipolar Disorder unspecified.
Review of the entry MDS for Resident #85 dated 5/17/24 reflected no cognitive assessment, a 00 BIMS score. Her physical assessment reflected she needed assistance or supervision with all ADL's, she ambulated via wheelchair and walker. She was assessed as having an indwelling catheter. She was assessed as frequently incontinent of bowel and bladder.
Review of the Care Plan for Resident #85 reflected interventions were in place for: ADL performance deficit, Impaired cognitive function, High risk for falls, Psychotropic medications, Indwelling catheter for urinary retention, impaired visual function.
In an interview on 6/05/24 at 2:25 PM the MDS nurse stated the facility had received an incorrect PASSR for Resident #85 on admission [DATE]) and was submitting a Form 1012 to have it corrected (not completed on 6/05/24). The MDS nurse stated Resident #85's primary diagnosis should be changed from Myocardial Infarction to Dementia. She stated the change might be made if or when she was changed to long term care. The MDS nurse stated it had been approximately two weeks since Resident #85's admission and the physician should have signed it by now. The MDS nurse stated it was her responsibility to check the PASSER forms were accurate.
In an interview on 6/06/24 at 10:20 am LVN M stated Resident #85 had not displayed any manic or depressive behaviors in her time at the facility. She stated daily monitoring for behaviors was ordered.
In an interview on 6/06/24 at 10:35 am LVN P stated she had observed Resident #85 daily since she was admitted . She stated Resident #85 liked to sit with other residents and was normally quiet and calm.
In an interview on 6/06/24 at 11:00 am the DON stated Resident #85 had arrived with an incorrect PASSR evaluation and the facility should have corrected it immediately. She stated it was not known if Resident #85 would be staying long term and there was no way to know if her primary diagnosis could be changed to Dementia. She stated Resident #85 was diagnosed with Bipolar.
In an interview on 6/06/24 at 11:40 am the administrator stated the facility policy was not followed for Resident #85. The administrator stated the PASSR for Resident #85 was incorrect and should have been resubmitted for correction. He stated the MDS normally reviews and refers to the source of the assessment when a correction was needed. He stated the correction for the diagnosis of Bipolar disorder unspecified should have been clarified, such as Bipolar Depressive or Bipolar Manic. The administrator stated the facility followed state guidelines to complete and submit PASSR evaluations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activiti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received
the necessary services to maintain good grooming and personal hygiene for 1 of 8 residents, in that:
Resident 29 was not provided fingernail care.
This failure affected one resident and could place her at risk of infection and diminished self-esteem.
Findings include:
Record review of resident's 29 face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of: type 2 diabetes with diabetic neuropathy, dementia, hypertension, hypokalemia, overactive bladder, atrial fibrillation, hypothyroidism, gastro esophageal reflux disease, restless leg syndrome, and osteoarthritis.
Record review of the quarterly minimum data set (MDS) assessment for resident 29 dated 04/25/24 reflected a brief interview for mental status (BIMS) score of 00 indicating impaired cognitive function. Her physical assessment for functional abilities and goals reflected she required supervision for eating, maximum assistance for all other ADLs, always incontinent of bladder, and frequently incontinent of bowel.
Record review of the care plan for resident 29 dated 04/25/2024 reflected she had an ADL self-care performance for personal hygiene deficit related to impaired cognition, muscle weakness, pain, and lack of coordination. Interventions: Requires extensive assistance by one staff with personal hygiene. Care plan reflected resident was at risk for signs or symptoms of covid 19 and an intervention included assisting resident in practicing hand hygiene. Note: Care plan reflected resident 29 is resistive to care at times. No documentation reflected or staff interviews stated resident 29 refused personal hygiene or nail care. Care plan did not address resident 29 digging in brief with her hands.
Record review of resident 29 medication administration record (MAR) and TAR (treatment administration record) reflected no records of nail care being provided.
Record review of task list for resident 29 in point click care (PCC) reflected nail care is scheduled to be provided by CNA on days.
Record review of order summary for resident 29 did not reflect any order for nail care.
Observation on 6/04/2024 at 10:22 am revealed resident 29 seated in her wheelchair in the dining room drinking coffee with other residents. Resident 29 had her hands placed under the table. Surveyor asked resident 29 if she could show her hands to surveyor. Resident 29 lifted her hands up and resident 29 was observed with a brown substance under her nails of both hands.
Observation on 06/05/2024 at 2:54pm revealed resident 29 resting in bed and her fingernails had a brown substance under nails of both hands.
Observation on 06/06/24 at 9:45 am revealed resident 29 seated in her wheelchair in the hallway outside of her room with brown substance under nails of both hands.
In an interview on 06/06/24 at 9:20am with LVN D she stated direct care staff know what kind of care residents need based on their [NAME] and care plan. She stated nail care is the CNA's and nurses' responsibility. She stated if a resident is diabetic the nurses do nail care. She stated resident 29 does not refuse nail care and the reason her nails get dirty is because resident 29 scratches at her pants and also digs her fingers into her brief.
In an interview on 06/06/24 at 9:36am with CNA G he stated staff know what kind of care a resident need based on their [NAME], information passed during report or shift change, common sense, and will ask nurse or therapy. He stated resident 29 tends to dig her fingernails into her brief. He stated CNAs are responsible for fingernail care but not toenails if a resident is diabetic. He stated nail care is done on Sundays.
In an interview on 06/06/24 at 10:20am with DON, she stated staff know what care residents need by looking at the [NAME] and pocket care plans especially for staff that have moved to another hall. She stated they try and not use the pocket care plans. She stated the facility has a lead CNA that floats and two CNA instructors in building. She stated everyone is responsible for nail care. She stated resident 29 scratches and digs at her brief and they clean her nails throughout the day. She stated resident 29 needs nail care throughout the day because she has periods of diarrhea.
In an interview on 06/06/24 1240pm with ADM he stated staff refer to a resident's [NAME] or pocket care plan to find out about a resident's ADLs. He stated staff are also given education and in-services. ADM stated he does role play for in services where he is the resident, and they practice and train for ADLs. He stated he tells staff do not be afraid to ask for help because this protects the resident and staff as well from injury. He stated he tells staff it is better go up in care instead of going down. For example, if a resident is a one person assist and a staff member feels they cannot provide aid by themselves to ask for help. He stated nurses take care of nail care for residents who are diabetic and if the resident is not diabetic the CNAs provide nail care. He stated nails are trimmed as needed.
Review of facility policy dated 05/26/2023 titled Activities of Daily Living reflected the following: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Review of in-services for 2023 and 2024 revealed there were no in-services about nail care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer parenteral fluids consistent with professio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for Resident #6.
The facility failed to assess and properly label Resident #6's peripheral intravenous catheter (PIV)
This failure could place residents at risk of infection, infiltration, and not receiving appropriate PIV care.
Findings include:
Review of Resident #6's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included unspecified dementia, acquired absence of left leg above knee, atherosclerosis (a buildup of fats, cholesterol, and other substances in and on the artery walls), anemia (low levels of healthy red blood cells to carry oxygen throughout the body) and chronic pain.
Review of Resident #6's MDS Assessment, dated 05/09/2024, reflected a BIMS score of 14 which indicted her cognitive function as intact.
Review of Resident #6's Comprehensive Care Plan reflected IV therapy was not addressed. The care plan reflected the resident was at risk for infection and fluid volume deficit.
Observation on 06/04/2024 at 09:45 AM revealed Resident #6 lying in bed with a PIV to her right wrist. A clear dressing was in place over IV site with tape to secure dressing and IV tubing. An empty bag of normal saline was connected to the IV. No date, initials or IV gauge (size) noted on the dressing.
Observation on 06/04/2024 at 11:25 AM revealed Resident #6 sleeping. The IV tubing had been disconnected from the IV and discarded.
Observation on 06/05/2024 at 10:00 AM revealed right wrist PIV still in place. Dressing intact with no label.
In an interview on 06/05/2024 at 11:40 AM, LVN E stated peripheral IV maintenance should be done every shift to include cleaning the site, flushing to ensure patency and applying dressing with date and initials. She stated she was not sure if the current dressing for Resident #6 was dated or initialed. She stated not properly labeling the IV could put the resident at risk for infection.
Observation on 06/06/2024 at 08:20 AM revealed Resident #6 sitting in bed. Right wrist PIV has been removed.
In an interview on 06/06/2024 at 09:15 AM, LVN F stated the standard of practice for IV insertion and care would be to date and initial the IV dressing after insertion. He stated if it was not dated, then staff would not know when it was started or if it was changed.
In an interview on 06/06/2024 at 09:50 AM the DON stated her expectation for IV care would be for the site to be dated, initialed, checked every shift and PRN. She stated the site should be discontinued if not needed. If it needs to stay in, she expected an order in place. She would expect the site to be checked by the nurse on each shift and was upset to find out that was not happening for Resident #6.
Review of facility policy for IV catheter insertion and care, dated July 2016, reflected all IVs should be labeled to include the date and time of catheter insertion, initials, length and gauge of catheter on the label.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 (Resident #65 and Resident #81) of 8 residents reviewed for respiratory care.
A) The facility failed to ensure that Resident #65's oxygen tubing with nasal cannula was changed out every seven days. The facility failed to ensure that Resident #65's Nebulizer tubing and mask, which included the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), was replaced every seven (7) days and bagged. The facility further failed to ensure that the air filter on Resident #65's air concentrator filter was free of dust and debris.
B) The facility failed to ensure that Resident #81's oxygen tubing and nasal cannula was changed out every seven days and failed to date the tubing and failed to ensure that Resident #81's air concentrator filter was free of dust and debris.
These failures could place residents at risk for respiratory compromise and infection.
Findings Included:
A) Review of Resident #65's Face Sheet dated 06/05/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Unspecified Dementia, Moderate (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain), Chronic Respiratory Failure with Hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and Heart Failure (heart does not pump enough blood for your body's needs).
Review of Resident #65's MDS Quarterly Assessment, dated 03/06/2024 revealed Resident #65 had a BIMS Score of 12, which indicated moderate cognitive impairment. Resident #65's MDS indicated for Respiratory Treatments that she was under C1. Oxygen therapy and further indicated under Section I that she had active diagnosis for Pulmonary (relating to lungs).
Review of Resident #65's Comprehensive Care Plan revealed [Resident #65] has potential for ineffective breathing pattern and air way clearance related to chronic lung disease with respiratory failure with an intervention for OXYGEN as ordered with revision date of 03/30/2023.
Review of Resident 65's Order Summary Report dated 06/05/2024 reflected the following start dates / orders:
06/20/2023 for Oxygen 2L NC prn sats<92% and 05/23/2024 for Ipratropium-Albuterol Inhalation Solution0.5-2.5 (3) MG/3ML(Ipratropium-Albuterol) 1 vial inhale orally every 8 hours for SOB/Wheezing.
Further review revealed Resident #65's orders did not reflect any order in reference to care of her oxygen tubing or equipment.
Observation on 06/04/2024 at 8:31 AM, Resident #65 was in her bed receiving oxygen via nasal cannula from an oxygen concentrator at 2L. The tubing was dated in fine print at the connection point with the concentrator which either displayed 5-21-24 or 5-26-24, both of which would have been past the seventh day. The air filter on the back of the concentrator was found to be dirty with built-up particles stuck to it. There was a nebulizer present on the nightstand to the side of Resident #65's bed that had oxygen tubing connected to it that lead to a mask with an in line nebulizing chamber. The mask was exposed to the air, not bagged, resting on paperwork, and was dated 5-26-24.
Interview and observation on 06/04/2024 at 1:47 PM, Resident #65 was in her bed receiving oxygen via nasal cannula. Resident #65's nebulizer mask was now in a plastic bag on the nightstand and the outside of the bag was dated 6/4/24. The mask inside the bag was the same mask dated 5-26-24 that was observed earlier and had not been changed. Resident #65's oxygen tubing at the port of the concentrator now displayed a date of 5-28-24 and it was obvious that the 21 or 26 had been wrote over to place the 28 on the tubing. Resident #65 stated that a staff member did come in her room after the initial observation but stated that no one changed out her tubing / nasal cannula and that she was using the same one she had at 8:31 A.M. Resident #65 had a trash can beside her bed that had a dirty air filter in it and the concentrator now had no filter on the back of it.
B) Review of Resident #81's Face Sheet dated 06/05/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Unspecified Dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain), Chronic Respiratory Failure with Hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and Heart Failure (heart does not pump enough blood for your body's needs).
Review of Resident #81's MDS Quarterly Assessment, dated 04/19/2024 revealed Resident #81 had a BIMS Score of 7, which indicated severe cognitive impairment. Resident #81's MDS indicated for Respiratory Treatments that she was under C1. Oxygen therapy and further indicated under Section I that she had active diagnoses for Pulmonary (relating to lungs).
Review of Resident #81's Comprehensive Care Plan revealed a problem area [Resident #81] has oxygen therapy r/t chronic respiratory failure with an intervention for OXYGEN SETTINGS: O2 via NC @ 2LPM continuously with revision date of 05/03/2024.
Review of Resident #81's Consolidated Orders last reviewed on 05/21/2024 reflected the following start date / order: 04/14/2024 for Oxygen at 2 LPM via NC. Resident #81's orders did not reflect any order in reference to care of her oxygen tubing or equipment.
Observation on 06/04/2024 at 8:12 A.M, Resident #81 was in her bed receiving oxygen via nasal cannula from at concentrator at 2.75 L. Observed that the tubing from the concentrator to her cannula had no date displayed anywhere. The air filter on the back of the concentrator was found to be dirty.
Interview and observation on 06/04/2024 at 2:18 PM, Resident #81 was in her bed receiving oxygen via nasal cannula from a concentrator. Resident #81's concentrator now had a plastic bag attached to it with her name and a date of 6/4/24. Resident #81's oxygen tubing now had a date present on it at the port for the concentrator, which displayed 6/3/24. The filter on the back of the concentrator was found to still be dirty and unchanged. Resident #81 stated a nurse did come in earlier, but that they did not change out her oxygen tubing / nasal cannula that had been in use.
Interview and observation on 06/06/2024 at 11:19 AM, LVN D stated respiratory tubing and mask are to be changed out every seven days and dated. LVN D stated they normally place an orange identification sticker on the tubing, which they were to record the date and time of change on. LVN D stated the nebulizer mask was also to be changed every seven days and have the date recorded on them. LVN D started the concentrator filters are to be cleaned weekly and all oxygen mask and Cannulas are to be in a dated bag when not in use. LVN D stated all oxygen checks / changes are to be performed by the night nurse every Sunday. LVN D stated no one should ever record a date on top of another date because the tubing should be replaced, and a new date recorded. LVN D stated their procedures for oxygen equipment needed to be followed for infection control and to prevent respiratory infections. At 11:24 AM, LVN D entered the room of Resident #65, who was receiving oxygen via nasal cannula. LVN D checked the respiratory equipment for Resident #65 and stated nebulizer mask was past date and should not have been placed in a plastic bag with today's date. LVN D stated a new mask and tubing should have been installed and today's date placed on it before being placed in the bag. LVN D stated the date on the oxygen tubing at Resident #65's concentrator had been recorded over and that whoever did so should not have and should have replaced the tubing with cannula and recorded the new date. At 11:27 AM, LVN D entered the room of Resident #81, who was receiving oxygen via nasal cannula. LVN D checked the respiratory equipment for Resident #81 and stated it was not correct. LVN D stated if the oxygen tubing in fact was changed out on 6/3/24 as recorded that the bag on the concentrator should display the same date. LVN D stated the filter on the concentrator appeared to not have been cleaned in the past seven days.
Interview on 06/06/2024 at 11:50 AM, the DON stated all respiratory tubing needed to be changed and dated every seven days. The DON stated respiratory equipment like mask and Cannulas should be bagged when not in use by the residents. The DON stated a date should never be recorded over and that to do so would not be their standard practice and could result in respiratory issues for the resident. The DON stated all respiratory tubing, mask, and Cannulas are to be changed every Wednesday but that she does allow staff until Sunday if it was not more than seven days. The DON observed evidence obtained in reference to Resident #65 and Resident #81's respiratory equipment and stated it was not within policy, should not have been done, and could lead to a respiratory infection for the resident.
Interview on 06/06/2024 at 12:05 PM, the Administrator stated his expectation was for oxygen tubing / equipment to be replaced and dated every seven days or when soiled if less than seven days, stored in a bag at bedside when not in use, and replaced anytime it was found on the floor. The Administrator stated all oxygen tubing / equipment in to be replaced by a nurse every Wednesday night and that failure to do so could result in the resident having an adverse effect. The Administrator was requested to provide their policy in reference to oxygen equipment / care.
Review of the facility's Oxygen Safety policy dated 01/26/2024, reflected, Policy: It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. Further review revealed that he provided policy did not address respiratory care equipment in reference to dating and change of oxygen tubing, mask, cannulas, bagging of respiratory equipment when not in use, or cleaning of concentrator filters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish an infection prevention and control program that must incl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish an infection prevention and control program that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 (Residents #94 and Resident #28) of 3 residents reviewed for infection control
A) The facility failed to follow the antibiotic stewardship recommendations for Resident #94.
B) The facility failed to follow the antibiotic stewardship recommendations for Resident #28
This deficient practice could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use and increased antibiotic-resistant infections.
Findings include:
A) Review of Resident #94's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include chronic systolic (congestive) heart failure, anemia (low levels of healthy red blood cells to carry oxygen throughout the body), hyperlipidemia (high levels of fat particles in the blood), depression, anxiety, chronic pain, retention of urine, muscle spasms.
Review of Resident #94's MDS Assessment, dated 03/29/2024, reflected a BIMS score of 09 which indicated moderate cognitive impairment.
Review of Resident #94's Comprehensive Care Plan reflected resident was on antibiotic therapy related to Urinary Tract Infection (UTI) prophylaxis, initiated 03/26/2024. Interventions included Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Monitor/document/report PRN adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat).
Monitor/document/report PRN signs/symptoms of secondary infection r//t antibiotic therapy: oral thrush (white coating in mouth, tongue), persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus.
Review of Resident #94 orders, written by NP K, start date of 3/26/2024 for cephalexin oral 250mg with an end date of indefinite. The order reflected an indication for use as UTI prophylaxis.
Review of Resident #94's Medication Administration Record for the months of March, April, May and June of 2024 reflected she has received cephalexin 250mg daily at 0900 (9:00AM) starting on 03/26/2024.
Review of the Antimicrobial Stewardship Recommendation for Resident #94, dated 03/28/2024, reflected a recommendation by the consultant pharmacist to amend the cephalexin order to include an end date and states the prophylactic use of anti-microbials was contra-indicated.
Review of the Consultant Pharmacist's Medication Regimen Review for Resident #94, dated 03/28/2024, reflected a recommendation by the consultant pharmacist to amend the cephalexin order to include an end date and states the prophylactic use of anti-microbials is contra-indicated.
In an interview on 06/06/24 11:00 AM the DON stated the use of antibiotics for UTI prophylaxis was not acceptable and she has spoken with the providers regarding this practice. She stated it was an ongoing issue that has been addressed before and she will continue to communicate with the providers regarding this. She stated the potential consequence of over prescribing could be development of antibiotic resistance and superbugs.
B) Review of Resident #28's face sheet reflected a [AGE] year-old female admitted to the facility 08/16/2022 with the following diagnoses dementia(A group of symptoms that affects memory, thinking and interferes with daily life.), osteoporosis (A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist, or spine.) and Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.).
Review of Resident #28's Quarterly MDS dated [DATE] reflected Resident #28 was assessed to have a 00 BIMS score indicating severe cognitive impairment. Resident #28 was assessed to require substantial/ maximal assistance with all ADLs. Resident #28 was assessed to be incontinent of bladder. Resident #28 was assessed to not be on antibiotics during the assessment period or to have a UTI in the past 30 days.
Review of Resident #28's comprehensive care plan reflected a problem dated 08/16/2022 and revised on 04/25/2024 Resident #28 always has bladder incontinence r/t decreased mobility, muscle weakness, HX of UTI and impaired cognition. Interventions included Monitor/document for signs and symptoms of UTI: pain, burning, blood-tinged urine, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.
Review of Resident #28's nursing progress notes reflected an entry dated 5/30/2024 Caregiver requesting UA, states resident was not acting herself. New order for UTI panel/reflex received.
Review of Resident #28's nursing progress notes reflected an entry dated 05/31/2024 indicating Rocephin 1 gm was administered IM after urine was collected.
Review of Resident #28's urinalysis and UTI panel dated 06/05/2024 reflected Resident #28's UA C&S was negative for infection.
In an interview on 06/06/2024 at 10:00 AM the DON stated the nurses called Resident #28's physician and got orders for the UA C&S. The DON stated Resident #28 should not have been given antibiotics prior to her lab results coming back. She stated she has been having trouble with the physicians not following the antibiotic stewardship policies of the facility. The DON further stated the residents should not be placed on antibiotics unless the PCR test comes back and the resident has a high bacterial load.
Review of a statement dated 05/03/2020 from the facility's Medical Director reflected .As discussed in multiple previous mandatory provider meetings, most recently last month April 2024, has recommended all providers consider getting UpToDate to help with keeping up with the latest guidelines along with the use of policies, procedures, and medical director recommendations. Antibiotic stewardship is of optimal importance in order to collaboratively maintain and align processes for assessing, planning, evaluating, and implementing evidence-based and patient centered antimicrobial stewardship practices, including new drugs, patient care strategies, policies and procedures, treatment guidelines, systems and processes, and antimicrobial stewardship practices integrated into the community. As always, we should all follow evidence-based practice and use all your resources to make the best decision for our patients. To support your stewardship practice, we will work on incorporation and consistency methods to include antibiogram, resident and family information materials, and Loeb and McGeer Criteria for initiation of antibiotics in long-term care residents.
Review of the facility's policy Antibiotic Stewardship Program dated 10/24/2022 reflected It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .a. Antibiotic use protocols: 1.Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR form prior to notifying the physician. Laboratory testing shall be in accordance with current standards of practice. The facility uses the updated McGeer criteria to define infections. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized .Education regarding antibiotic stewardship shall be provided at least annually to facility staff, prescribing practitioners, residents, and families .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sani...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation.
The facility failed to date a box of bananas in the dry storage area which contained a banana that was open and rotted.
The facility failed to ensure that no food products or food product boxes were stored on the floor in the facility's walk-in refrigerator and freezer.
The facility failed to ensure that a food product in the freezer was in a sealed bag to prevent direct exposure to air.
The facility failed to discard of food products that were past indicated use by dates per facility policy.
These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness.
Findings included:
Observation on 06/04/2024 at 6:25 AM, of the facility's walk-in refrigerator revealed the following:
*a bag of lettuce on the floor,
*1 metal tray covered in plastic wrap that was labeled, Cake 5/30/24 to 6/2/24,
*1 covered metal container marked ground beef 5/30/24 10:00 AM use by 6/3/24,
*1 sealable plastic bag with hot dog [NAME] in it that only had a date of 5/28/24, and
*one 16-ounce container of strawberries on the shelf of which one strawberry had visible signs of mold growth on it.
Observation on 06/04/2024 at 6:33 AM, of the facility's walk-in freezer revealed the following:
*two boxes of mild Italian pork sausage on the floor, with boxes stacked on top of them.
* an open box of biscuit dough on a shelf that had an open bag allowing direct air exposure in the freezer to the product.
Observation on 06/04/2024 at 6:38 AM, of the facility dry storage area revealed an undated open box of bananas, one of which was busted open and rotten.
Interview and observation on 06/04/2024 at 10:45 AM, the FSS stated that all items placed in the refrigerator should have the date they are placed in it and then a use by date of no more than four days. The FSS stated in the dry storage area she expected items to be labeled, clearly identified, and date with the received-on date. The FSS stated failure to date food products could result in a lack of knowledge for how long the product has been in the kitchen. The FSS stated no food products or boxes should be stored at any time on the floor of the dry storage area, or the walk-in refrigerator / freezer. The FSS stated storage of food products on the floor could result in possible contamination. The FSS conducted a walk through and stated she discarded the bag of lettuce that was on the floor in the refrigerator due to possible contamination. The FSS stated the boxes found in the freeze should not have been on the floor and were placed more than six inches off the floor. The FSS had discarded all the food product was past the use by date in the refrigerator except for the plastic bag of hot dog [NAME]. The FSS stated they should not have been on the shelf and added there should have been a use by date recorded on the bag. The FSS stated failure to removed expired / out of date food products could result in food borne illness.
Interview on 06/06/2024 at 11:03 AM, DA stated all food products should be dated as soon as they are received. DA stated once opened and placed in the refrigerator they are supposed to record the date opened and then a use by date for three days later when placed in the refrigerator. DA stated failure to label and date items could result in expired food being served leading to possible foodborne illnesses. DA stated no food products should be stored on the floor anywhere in the kitchen to prevent contamination. DA stated items that are placed in the freezer are to be in sealed bags our bags that are tied closed to prevent air exposure. DA stated exposed food products in the freeze could lead to freeze burn resulting in poor taste and loss of nutritional value.
Follow-up interview on 06/06/2024 at 11:08 AM, the FSS stated service of expired food products could lead to contamination and sickness for residents. The FSS stated food exposed in the freezer could result in freezer burn affecting the quality of the food and taste. The FSS stated all staff should be checking for quality and expiration dates but ultimately the responsibility falls on her to ensure that nothing is out of stated or stored improperly.
Interview on 06/06/2024 at 11:12 AM, the Administrator stated his expectation was for all food products to be labeled, dated, and removed from the refrigerator within seventy-two hours if not used. The Administrator stated no food products should be stored on the floor and should always be at least six inches off the ground. The Administrator stated failure to follow these guidelines could lead to bacteria and contamination.
Review of the facility's Food Storage Policy dated 12/01/2011 reflected, Policy: The consultant dietitian will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the state and Federal Food Codes. The following guidelines should be followed. Guidelines: 1. Dry Storage rooms d. To ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. f. Where possible, items are left in the original cartons placed with the date visible. 2. Refrigerators a. All refrigerated foods are stored per state and federal guidelines. b. Fresh meat, poultry, seafood, dairy products and most fresh fruit and vegetable are kept in the refrigerator at an internal temperature <41 F. c. All food is stored on racks or shelves off the floor. e. All refrigerated foods are dated, labeled and tightly sealed, including left overs, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 72 hours. Items that are over 72 hours old are discarded. 3. Freezers c. All foods are stored on racks or shelves off the floor. e. Frozen foods are stored in moisture-proof wrap or containers that are labeled and dated.
Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that CNA be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nurse aides are competent in skills and techniq...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nurse aides are competent in skills and techniques necessary to care for Resident's needs identified through assessments and described in the plan of care.
The facility failed to utilize two caregivers to provide incontinent care for Resident #2 as described in her plan of care. The aide stated in an interview she performed incontinent care by herself for Resident #2, the resident had rolled off the bed and sustained injures on 8/01/23 two days earlier.
This failure could result in falls or injuries for residents who require two person assistance for transfers and repositioning.
Findings included:
Review of the Face Sheet for Resident #2 reflected she was admitted to the facility on [DATE] with diagnosis of: Sequelae of Cerebral Infarction, Chronic Atrial fibrillation, Hemiplegia and Hemiparesis affecting right side , Dementia, Anxiety, Type 2 Diabetes, Congestive Heart Failure (CHF) and Osteoporosis .
Review of the Annual MDS assessment for Resident #2 dated 5/30/23 reflected a BIMS score of 15 indicating normal cognitive functioning. Her functional assessment reflected she required extensive assistance for all ADLs except eating which required set up assistance . She was assessed as always incontinent of bowel and bladder.
Review of the Care Plan for Resident #2 dated 8/03/23 reflected interventions were in place for: post stroke care including physical weakness and deficits, Bilateral Hemiplegia, a High risk for falls, and an actual fall on 8/02/23 with major injury. Interventions for the fall included 2-person assist with repositioning and personal care (dated 8/03/23), Staff education on assisting with proper bed mobility when low air loss mattress is used. Resident #2 had interventions related to pain management and a pathological bone fracture-subchondral insufficiency fracture to the anterior latera tibial plateau r/t Vitamin D deficiency and Osteoporosis (dated 8/02/23).
Review of a progress note for Resident #2 dated 8/01/23 reflected the nurse was notified by the CNA at 4:55 am the resident had rolled off the bed during a brief change. The nurse found the resident laying on the floor on her left side. Blood was noted by the nurse on the floor with skin tears to the left and right forearm. EMS was called for transfer to local emergency room and departed the facility at 5:17 am. The notes reflected hospital staff reported no damage found in a CT of the head and spine. A small 1 centimeter subchondral insufficiency fracture anterior lateral tibial plateau was found on x-ray. Resident #2 returned to facility at 1:35 pm.
Review of the sign up sheet for Resident #2's updated Care Plan post fall dated 08/01/23 reflected CNA S was present for inservice on Resident #2 on 8/01/23.
In an interview and observation on 8/03/23 at 12:05 pm, Resident #2 stated she had a fall two days ago. She stated she did not know how the fall occurred, but she woke up on the floor on her back and could not recall any details. Resident #2 was observed to have a blackened/bruised left eye and a bruise to the front of her left forehead. She stated she was on blood thinners since her heart surgery some time ago. She stated she had one sided weakness from a stroke. Resident #2 stated she had previously stayed at the facility after breaking her hip and insisted on coming back to Towers because she thought care was good.
In an interview on 8/03/23 at 12:56 pm, Resident #2's son stated he was concerned after his mother rolled off the bed on 8/01/23. He stated interventions to remedy the fall risk was to have two persons providing her care and repositioning. He stated when he visited his mother on 8/02/23, he observed one staff member providing care . He stated he was upset about bruising to his mother's face and left eye and a fracture to the left knee bone.
In an interview on 8/03/23 at 12:42 pm, CNA S stated on 8/02/23 she was assigned to the middle hall (300 hall). She stated the aide she was working with went on break and she was answering call lights. She stated she went into Resident Halls room and she requested pericare. She stated she was new and did not know all the resident's names and needs. She stated she did not receive the in-service about Resident #2 needing 2-person care at all times. She stated the son of the resident came in at the end of care, she covered the resident, and the son made no mention of any issues to her. She stated she did Resident #2's care slowly and carefully. No falls occurred and Resident #2 was not injured. She stated the Resident was moderately incontinent of urine and she had since received the in-service care.
In an interview on 8/03/23 at 12:00 pm, LVN B stated he was charge nurse for the 300 hall. He stated Resident #2 was the only person who had experienced a fall on 300 recently. He stated she had bruising to her face and side and was to have two-person assist for all care. He stated fall prevention was in place.
In an interview on 8/03/23 at 12:10 pm, RN H stated she normally worked on Hall 300 with Residents but today she was filling in. She stated most staff work the same halls daily. She stated Resident #2 had fall prevention and the falling star program in place for her safety.
In an interview on 8/03/23 at 12:26 pm, the ADON stated Resident #2 went to the ER on [DATE] and returned a few hours later. She stated an in-service education was held the same day and everyone was aware Resident #2 was to be a two person assist for all care and repositioning. The ADON stated the care plan was updated. She stated there was sufficient staff for a two person assist around the clock. She stated normal staffing was one nurse and 2 aides for each shift.
In an interview on 8/03/23 at 2:50 pm, the Nurse Aide Trainer stated CNA S was present for the in-service on Resident #2's Care on 8/01/23. She stated she performed the in-service herself. She stated she did training for Group A and then group B right after, she stated the timing at change of shift worked out perfectly. She stated the PRN people and part timers have to sign off before they go to their areas.
In an interview on 8/03/23 at 2:55 pm CNA U stated she received the in-service education on providing two-person assistance to Resident #2 for all care.
In an interview on 8/03/23 at 3:05 pm, the ADON stated she expected all staff would provide care as prescribed in each Resident's care plan according to their needs . She acknowledged CNA S had signed the in-service education sheet dated 8/01/23.
In an interview the Administrator stated he was working to resolve the complaints of Resident #2's son. He stated she had sustained a fall on 8/01/23 and was injured. He stated during pericare her low air loss mattress went flat and she rolled off the edge of the bed while one person (CNA T) was providing care. Resident #2 sustained injuries and as a result of the incident her interventions were updated to include that she must have two person assist for care at all times. The Administrator stated he received a report on 8/02/23 that the son entered the facility and one aide was changing his mom. The Administrator stated the aide (CNA S) may not have received the in-service education for Resident #2 as she had recently transferred to the facility. He stated CNA S had admitted she was performing care for Resident #2 by herself. He stated his expectation was all staff would receive the in-service education and provide two person assistance/care to Resident #2.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 12 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $15,239 in fines. Above average for Texas. Some compliance problems on record.
- • Grade D (46/100). Below average facility with significant concerns.
Bottom line: Trust Score of 46/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Towers's CMS Rating?
CMS assigns TOWERS NURSING HOME an overall rating of 3 out of 5 stars, which is considered average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Towers Staffed?
CMS rates TOWERS NURSING HOME's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Towers?
State health inspectors documented 12 deficiencies at TOWERS NURSING HOME during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 10 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Towers?
TOWERS NURSING HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by WELLSENTIAL HEALTH, a chain that manages multiple nursing homes. With 120 certified beds and approximately 114 residents (about 95% occupancy), it is a mid-sized facility located in SMITHVILLE, Texas.
How Does Towers Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, TOWERS NURSING HOME's overall rating (3 stars) is above the state average of 2.8, staff turnover (56%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Towers?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Towers Safe?
Based on CMS inspection data, TOWERS NURSING HOME has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Towers Stick Around?
Staff turnover at TOWERS NURSING HOME is high. At 56%, the facility is 10 percentage points above the Texas average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Towers Ever Fined?
TOWERS NURSING HOME has been fined $15,239 across 1 penalty action. This is below the Texas average of $33,231. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Towers on Any Federal Watch List?
TOWERS NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.