Accel At Willow Bend
Inspection history, citations, penalties and survey trends for this long-term care facility in Plano, Texas.
- Location
- 2620 Communications Parkway, Plano, Texas 75093
- CMS Provider Number
- 676349
- Inspections on file
- 43
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Accel At Willow Bend during CMS and state inspections, most recent first.
Staff failed to follow infection control practices when a medical assistant used a blood pressure cuff on a resident without disinfecting it after wearing it on her own wrist, and when CNAs provided incontinence care to two residents with bowel and bladder needs without performing required hand hygiene before contact, between care steps, and with glove changes. The residents involved had significant medical conditions, including HTN, anemia, diabetes, and severe cognitive impairment, and their care plans required peri care and keeping them clean and dry. In interviews, the staff acknowledged they knew the expectations for disinfecting reusable equipment and performing hand hygiene but stated they forgot, and facility training records showed they had not attended prior in-services on hand washing and device cleaning.
Surveyors found that a main entry door could be unlocked by anyone using a four-digit code that was visibly posted next to the keypad, allowing unmonitored access into the building without alarms or staff notification. A surveyor entered using the posted code and was able to remain in the lobby and adjacent halls for several minutes without encountering staff. Staff interviews revealed that the code had been posted for months on both sides of the door, that the front desk was only staffed during daytime hours, and that no one specifically monitored the door in the evenings or at night. Several staff members, including LVNs and the ADON, reported personal and resident/family concerns about unknown individuals entering at night and the lack of monitoring, while the Administrator acknowledged the practice but did not view it as a true safety concern.
A cognitively impaired resident with dementia, diabetes, and hypertension, care planned to need extensive one-person assistance for transfers due to generalized and unilateral weakness and a prior fall, was observed being transferred between a wheelchair and bed by a CNA without use of a gait belt as required by facility policy. Instead, the CNA held the resident’s arm, pulled on the back of the resident’s pants, and then lifted the resident by placing both arms around the resident while the resident, described as very unsteady and shaky, tried to hold bed and wheelchair supports. The CNA later stated she had been trained on gait belt transfers, knew staff should not lift under the arms, and did not see a gait belt in the room, despite the facility’s written procedure specifying gait/transfer belt use and stand-and-pivot technique for bed-to-chair transfers.
The facility did not develop or accurately complete baseline care plans within 48 hours of admission for three residents, including one who was admitted with psychotropic medication that was not documented on the care plan, and two others who had no baseline care plans at all. Staff interviews revealed confusion over responsibilities and difficulties with a new electronic records system, leading to incomplete or missing care plans for newly admitted residents.
A resident with multiple chronic conditions and complex care needs did not have a comprehensive care plan completed within the required 7 days after the comprehensive assessment. The MDS Coordinator, responsible for care plan completion, overlooked this task, and other staff confirmed the omission, which was not in accordance with facility policy.
Surveyors found that insulin pens on two medication carts were in use without being labeled with the date they were opened, as required by facility policy and manufacturer instructions. Nursing staff and the DON confirmed that it was their responsibility to date insulin pens upon opening, but this was not consistently done, potentially leading to the use of insulin beyond its effective period.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident requiring maximal assistance with bathing and self-care was found with long, discolored fingernails containing residue, despite expressing a preference for clean, short nails. Staff interviews confirmed that nail care responsibilities were not fulfilled, and the facility's ADL policy did not address fingernail care, resulting in a lapse in personal hygiene services.
A resident did not receive the necessary care to maintain or improve range of motion or mobility, and the facility did not ensure that a decline was medically unavoidable.
A resident with severe cognitive impairment and frequent incontinence did not receive proper perineal care after an incontinent episode, as a CNA failed to separate the labia and clean appropriately, and wiped from back to front instead of front to back, contrary to facility policy. This lapse was confirmed by both the CNA and the DON during interviews.
A resident with a G-tube did not receive the physician-ordered water flushes between each medication during administration by an LVN, who administered multiple crushed medications sequentially without the required flushes. The LVN later acknowledged overlooking the order, and the DON confirmed that staff are expected to follow such orders to prevent complications.
A licensed pharmacist did not conduct the required monthly drug regimen review, including reviewing the medical chart, and the facility did not follow its policies for reporting irregularities found during the review.
A medication aide failed to sanitize a blood pressure cuff before and after use when checking the blood pressure of three residents with various medical conditions, including multidrug-resistant organism infection and diabetes. This action was contrary to facility policy, which requires cleaning of non-critical equipment between residents to prevent cross-contamination.
A working call system was not available in each resident's bathroom and bathing area, as required. This deficiency was observed during the survey and no further details about affected residents or their conditions were provided.
A nurse used a syringe with a plunger seal that had fallen to the ground and reused a syringe beyond the 24-hour protocol for a resident with a jejunostomy tube, despite being aware of infection control risks. The facility could not provide a written infection control policy when requested, and staff interviews confirmed knowledge of proper procedures, highlighting lapses in both practice and documentation.
The facility failed to ensure call lights were within reach for three residents, including a male with impaired cognition and muscle weakness, a male with dementia and stroke history, and a female on hospice care. Observations revealed call lights were tangled or on the floor, preventing residents from calling for assistance. Staff acknowledged the importance of accessible call lights, yet did not consistently ensure they were within reach.
A facility failed to provide proper catheter and incontinence care, risking urinary tract infections. A resident's catheter bag was placed above the bladder during a transfer, causing urine backflow. Another resident was left in a saturated brief due to improper care, and a therapist placed a catheter bag on the floor, risking contamination. Staff acknowledged their errors, highlighting training lapses.
The facility failed to ensure controlled drugs were counted and documented at every shift change for Med Aide cart hall 500. LVN S and LVN R did not sign the narcotic sheets after counting, as required by the facility's policy. The DON confirmed the importance of this procedure to prevent drug diversion, although no diversion was detected.
The facility's kitchen failed to meet food safety standards by not discarding expired food, improperly labeling and dating items, and leaving food uncovered. Staff interviews revealed lapses in protocol adherence, with the Dietary Manager citing staffing shortages as a contributing factor.
The facility failed to maintain an effective infection prevention and control program, with staff neglecting to disinfect blood pressure cuffs between residents and not adhering to hand hygiene protocols during care. These actions could lead to cross-contamination and infection spread among residents.
A facility failed to create a comprehensive care plan for a resident with Alzheimer's and anxiety, neglecting to address her resistance to care and eating. Despite known behaviors and preferences, such as using Ensure when meals were refused, these were not documented in the care plan. Staff interviews highlighted inconsistent care approaches due to poor communication and documentation, contrary to facility policy requiring comprehensive care plans.
A resident with intact cognition and a need for supervision in personal hygiene did not receive adequate nail care, resulting in long and chipped fingernails. Despite the facility's policy requiring nail care on shower days and as needed, staff interviews revealed inconsistencies in the execution of this care. The resident did not request assistance due to fear of repercussions, and her nails were only trimmed after the issue was highlighted.
A resident requiring tracheostomy care did not receive appropriate respiratory care due to a nurse's failure to maintain a sterile field. The nurse contaminated her gloves and did not follow proper procedures, risking respiratory infections. Despite training, the nurse did not adhere to the sterile technique required for tracheostomy care.
A resident requiring extensive assistance with ADLs and G-tube feeding was neglected for over 13 hours, with no incontinent care or repositioning provided. The neglect was discovered by the resident's family through video footage and confirmed by staff interviews and record reviews. The incident revealed significant communication and policy adherence issues within the facility.
A resident with extensive care needs was found soaked in urine and bowel movement due to a lack of proper incontinent care during the night shift. Despite being totally dependent on staff for ADLs, the resident was not changed or repositioned, leading to distress and a rash. Staff members failed to report the neglect immediately, resulting in a deficiency for the facility.
A resident with severe cognitive impairment and multiple medical conditions was left without incontinence care for over 13 hours due to the inaction of a CNA and lack of proper communication among staff. The resident was found soaked in urine and with a bowel movement, leading to significant discomfort and potential health risks.
A resident requiring extensive assistance was left without incontinent care for 13 hours, and the staff failed to report the neglect immediately. Interviews revealed that the neglect was known but not communicated or reported promptly, leading to a delay in addressing the issue and investigating the incident.
The facility failed to maintain an infection control program, as staff did not follow proper PPE and hand hygiene protocols for two residents. One staff member improperly donned a face mask in a COVID-19 isolation room, and two staff members did not perform hand hygiene during incontinence care, despite recent training.
Failure to Disinfect Equipment and Perform Hand Hygiene During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper disinfection of reusable equipment and adherence to hand hygiene practices. A male resident with hypertension and anemia, cognitively intact with a BIMS score of 14, had his blood pressure taken by a medical assistant (MA A) using a blood pressure cuff that had just been removed from the assistant’s own wrist. The assistant did not disinfect the cuff before entering the resident’s room and applying it. In interview, the assistant acknowledged she was supposed to use disinfectant wipes to clean the cuff after removing it from her wrist and before applying it to the resident, and stated she had received training on care and disinfection of reusable equipment but could not recall when. The deficiency also includes failures in hand hygiene during incontinence care for two residents with bowel and bladder care needs. One female resident with severe cognitive impairment (BIMS score of 7), hypertension, and diabetes had a care plan identifying risk for bowel and bladder elimination problems and directing peri care after each incontinent episode. A CNA (CNA B) entered this resident’s room to provide incontinence care, put on gloves without washing hands, and cleansed the resident’s abdominal folds and perineal area using wet wipes. After removing a soiled brief, the CNA did not perform hand hygiene or change gloves before applying a clean brief and repositioning the resident. The CNA later stated she knew she was supposed to perform hand hygiene before resident contact, between care, and after glove removal, but said she forgot, and acknowledged that failure to do so could lead to contamination and spread of infection. A third resident, a male with severe cognitive impairment (BIMS score of 0) and hypertension, had a care plan focused on bowel and bladder with interventions to check, change, and keep him clean and dry. During observed incontinence care, another CNA (CNA C) prepared supplies, entered the room, and donned gloves without washing hands. The CNA cleansed the resident’s abdominal area, penis, and Foley catheter, then turned the resident, cleansed the buttocks after a bowel movement, and changed gloves between care without performing hand hygiene. After the resident was clean, the CNA again removed gloves and put on new gloves without hand hygiene before applying a clean brief and cream, and only washed hands after removing gloves at the end of care. In interview, this CNA stated he was supposed to perform hand hygiene before contact and with each glove change, but forgot, and acknowledged that failure to perform hand hygiene during incontinence care could lead to cross contamination and infection. The DON stated her expectation that staff perform hand hygiene before resident contact, between care, and with glove changes, and that reusable equipment be disinfected before and after use, and training records showed the involved staff had not attended prior in-services on these topics.
Unmonitored Public Access Through Posted Entry Code at Main Door
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, secure, and monitored entry environment at Door #1, where a four-digit access code was posted next to the keypad on the outside of the building. During observation, a surveyor used the posted code to unlock Door #1 and enter the facility without any staff presence at the front desk or in the adjacent halls and without any alarm or notification sounding to alert staff of the entry. The surveyor waited approximately 7–10 minutes before locating a staff member in an office behind the front desk, demonstrating that individuals could enter the building unobserved. The facility’s Resident Rights policy, provided in lieu of a physical environment policy, stated that staff would abide by resident rights in accordance with CMS guidance but did not address the specific physical environment or access control procedures. Multiple staff interviews confirmed that the code to Door #1 had been posted on the inside and outside of the door for several months so that staff and visitors could enter without difficulty, and that there was no system in place to reliably monitor who entered through this door when the front desk was not staffed. A staff member reported being very concerned about resident safety, especially after 4 p.m. when no one was stationed at Door #1, and relayed complaints from relatives, including one family member who was worried about the safety of her loved one because the entry code was visible to the public and usable after hours, including near midnight. The social worker reported a resident complaint over the summer about unknown people in the hall at night talking, and stated that there were no staff at the front desk in the evenings and at night, with nurses expected to monitor Door #1 from the nurses’ stations. The Director of Maintenance stated that all doors, including Door #1, had alarms that would sound if someone attempted entry without the code, but acknowledged that once the posted code was entered, there was no alarm or bell to notify staff that someone had come in, and he was unsure how the facility monitored such entries. Nursing staff, including LVNs, stated that no one specifically monitored Door #1 after hours, that they only knew someone had entered if the person came to the nurses’ station, and that they personally felt unsafe because anyone could enter using the posted code. The ADON confirmed that staff were present by Door #1 only during daytime hours and that after that time it was everyone’s responsibility to monitor the door, while acknowledging it was a safety concern that no one monitored Door #1 after hours. The Administrator stated the code had been posted for several months due to staff and family forgetting it, reported no known incidents of harm related to the posted code, and expressed the view that having the code posted and the door unmonitored did not present a true safety concern to residents.
Improper Transfer Technique Without Gait Belt Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer techniques and adequate supervision for a cognitively impaired resident who required assistance with transfers. The resident was an elderly female with dementia, diabetes, and hypertension, severely cognitively impaired with a BIMs score of 3, and care planned to require the assistance of one staff member and extensive assistance for transfers due to generalized and unilateral weakness. Her MDS reflected a history of at least one prior fall without injury, and her care plan interventions included providing an appropriate level of assistance to promote safety during transfers. During interview, the resident reported she had fallen recently and that staff and family had instructed her not to get up by herself, and she acknowledged she was trying to comply by asking for help. On the observed date, a CNA assisted the resident from her wheelchair to the bed and back without using a gait belt, contrary to the facility’s written transfer policy requiring a gait/transfer belt for bed-to-chair transfers. The CNA instead held the resident’s arm, pulled on the back of the resident’s pants, and later placed both arms around the resident to lift her from the bed to the wheelchair while the resident attempted to hold the bed rail and wheelchair arm for support. The resident was described as very unsteady and shaky, and the CNA struggled to complete the transfer. The CNA acknowledged in interview that staff were not supposed to lift residents under their arms because of potential injury, stated she had been trained on gait belt transfers, and reported she did not see a gait belt in the room. The facility’s policy specified use of a snugly applied gait belt at the waist with stand-and-pivot technique, which was not followed during the observed transfers.
Failure to Complete Timely and Accurate Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three out of five residents reviewed for care planning. Specifically, one resident was admitted with a diagnosis of anxiety disorder and prescribed Quetiapine Fumarate, a psychotropic medication, but the baseline care plan did not indicate the presence of psychotropic therapy, despite physician orders and medication administration records confirming its use. Two other residents did not have baseline care plans completed at all upon admission, despite having significant medical conditions such as moderate cognitive impairment and chronic obstructive pulmonary disease. Interviews with facility staff revealed confusion and inconsistency regarding responsibility for completing baseline care plans, with both the MDS Coordinator and nursing staff indicating that nurses were responsible for this task. Staff also reported challenges with a new electronic records system, which contributed to difficulties in timely and accurate completion of care plans. The facility's policy requires baseline care plans to be developed within 48 hours of admission and to include essential healthcare information such as physician orders, but this was not consistently followed for the residents in question.
Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for one resident. Record review showed that the resident, an older male with multiple diagnoses including anxiety disorder, atrial fibrillation, heart failure, diabetes, and asthma, was admitted with several medications and required continuous oxygen. The resident was also developing a pressure ulcer. While a baseline care plan was completed upon admission, there was no evidence of a comprehensive care plan being completed within the required timeframe after the comprehensive assessment. Interviews with facility staff revealed that the MDS Coordinator was responsible for completing the comprehensive care plan but had overlooked this task for the resident in question. The MDS Coordinator acknowledged the omission and described the process typically used to complete care plans, including the use of CAAs, physician notes, and orders. Other staff, including the LVN and DON, confirmed that the comprehensive care plan had not been completed as required and recognized that this failure could impede the resident's treatment. Facility policy requires that a person-centered care plan be developed within seven days after the comprehensive assessment.
Failure to Label Insulin Pens with Open Dates on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to properly label insulin pens with the date they were opened on two medication carts. Specifically, several insulin pens for multiple residents were found in use without an open date, despite instructions on the pens indicating they should be discarded 28 days after opening. Both direct observation and interviews with nursing staff confirmed that it was the nurses' responsibility to label insulin pens with the open date to ensure proper tracking of expiration, but this was not consistently done. The Director of Nursing also acknowledged that insulin pens and vials needed to be dated upon opening due to their limited shelf life after being opened. Record review of the facility's own policy confirmed that insulin products should be labeled with the date when first used. The pharmacy consultant was noted to check the carts monthly, and the DON reported conducting random checks, but these measures did not prevent the observed lapses. The lack of open dates on insulin pens could result in the use of insulin beyond its effective period, as the pens were observed to be in use without proper labeling.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events leading to the deficiency are provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was found that the care plan did not comprehensively cover all identified needs of the resident.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required maximal assistance with bathing and had a self-care deficit was observed to have long, discolored fingernails with brownish residue underneath. The resident, who had a history of cerebrovascular accident and elevated blood pressure, expressed dissatisfaction with the condition of his nails but did not inform staff because they appeared busy. The resident's care plan included assistance with grooming and hygiene, but on the day of observation, his fingernails had not been cleaned or trimmed. Interviews with staff revealed that both CNAs and nurses were responsible for nail care, but the assigned nurse had not noticed the resident's nails and acknowledged the risk of infection and injury. The DON stated that nail care should be performed as needed and during handwashing, with daily observation of nail condition. The facility's policy on ADLs and bathing did not address fingernail care, contributing to the failure to provide necessary services for maintaining the resident's personal hygiene.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care was provided to prevent a decline in these areas unless such decline was medically unavoidable. The report notes that the necessary interventions or services to support or enhance the resident's ROM or mobility were not implemented as required.
Inadequate Perineal Care Provided to Incontinent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was frequently incontinent of bowel and bladder. The resident, who had severe cognitive impairment due to dementia and other medical conditions, required thorough incontinence care as outlined in her care plan and the facility's policy. During an observed episode, the CNA did not separate the resident's labia or clean down the middle, and wiped the resident's buttocks from back to front, contrary to the required front-to-back technique. The resident's brief was also found to be soaked through, indicating a need for prompt and proper care. The facility's policy specifically required staff to separate the labia and wash downward in the center and on each side, using a different wipe for each stroke, and to clean the buttocks in an upward motion towards the back. The CNA acknowledged during an interview that she did not follow these procedures and recognized the importance of proper cleaning. The Director of Nursing confirmed that the observed care did not meet facility standards and that such lapses could place residents at risk for urinary tract infections, skin breakdown, and poor hygiene.
Failure to Follow G-Tube Flush Orders During Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician orders for water flushes during medication administration via a gastrostomy tube (G-tube) for a male resident with a history of traumatic brain dysfunction, respiratory failure, and gastroesophageal reflux. The resident's care plan and physician orders specified that the G-tube should be flushed with 30 cc of water before and after medications, and 15 cc of water between each medication. During observation, the LVN prepared and crushed six medications, administered them sequentially through the G-tube, but did not flush the tube with water between each medication as ordered. Instead, the LVN only performed a flush before the first medication and after the last, omitting the required flushes between each medication. Upon interview, the LVN acknowledged overlooking the physician's orders and admitted not flushing the G-tube as required, which could result in tube clogging. The Director of Nursing (DON) confirmed that staff are expected to follow physician orders for G-tube flushes and that failure to do so could lead to complications. The facility's policy also required irrigation of the feeding tube before, between, and after medication administration, which was not followed in this instance.
Failure to Complete Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its developed policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified based on the surveyor's observation that the required pharmacist review and irregularity reporting were not completed according to established guidelines.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the improper disinfection of reusable medical equipment. Specifically, a medication aide (MA) did not sanitize a blood pressure cuff before or after use when checking the blood pressure of three residents during a morning medication pass. This was observed as the MA moved from one resident to another, using the same blood pressure cuff without cleaning it between uses, despite the facility's policy requiring such equipment to be cleaned between residents. The MA later acknowledged awareness of the requirement but stated she forgot to sanitize the cuff between uses. The residents involved had various medical conditions, including elevated blood pressure, multidrug-resistant organism infection, wound infection, cerebrovascular accident, and type 2 diabetes mellitus. Their cognitive statuses ranged from severely impaired to intact. The facility's policy, revised in March 2025, clearly stated that non-critical items such as blood pressure cuffs must be kept clean, but this protocol was not followed during the observed incident.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The report does not provide additional details about specific residents affected, their medical history, or their condition at the time the deficiency was observed.
Failure to Maintain Infection Control Program and Adherence to Syringe Protocol
Penalty
Summary
The facility failed to establish and maintain an effective Infection Prevention and Control Program, as evidenced by multiple lapses in infection control practices and the absence of a written infection control policy. During a medication administration, a registered nurse knowingly used a syringe with a plunger seal that had fallen to the ground to administer medication to a resident with a jejunostomy tube. The nurse attempted to rinse the contaminated plunger seal with water before use, despite being aware of the infection control risk. The nurse stated that he used the contaminated syringe because it was the only one available and was unsure whether to use facility or hospice-supplied syringes due to confusion about the resident's hospice status. Additionally, the same nurse failed to follow proper syringe protocol by using a syringe for more than 24 hours for medication administration, tube flushing, and placement checks, contrary to facility policy requiring syringes to be changed every 24 hours. The nurse acknowledged the lapse and cited confusion over supply responsibility as a contributing factor. Other staff interviews confirmed that all nurses had received in-service training on infection control and were aware that contaminated or expired syringes should not be used. The facility was unable to provide a written infection control policy when requested by surveyors, despite multiple requests made in person and via email to the administrator and director of nursing. The lack of a written policy, combined with observed lapses in infection control practices, placed residents at risk for the spread of infection through cross-contamination.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for three residents were within reach, which is a critical aspect of accommodating resident needs and preferences. Resident #323, a male with moderately impaired cognition and several medical conditions including chronic kidney disease and muscle weakness, was observed with his call light and bed remote wrapped around the bottom of the bed rail, out of his reach. Despite his contracted hands and partially paralyzed left arm, which made it difficult for him to reach the call light, staff did not consistently ensure it was accessible, leading to his frustration and inability to call for assistance. Similarly, Resident #25, who had a history of dementia, stroke, and other medical issues, was found with his call light hanging from the bed rail, not within his reach. He was unable to locate or use the call light to request help. An LVN confirmed that the call light should always be within reach, yet it was not consistently placed appropriately for Resident #25. Resident #18, a female with severely impaired cognition and on hospice care, was observed with her call light on the floor, obstructed by wheelchair footrests and trash bags. Despite the importance of having the call light accessible, a CNA admitted to leaving it on the floor with plans to return later. The charge nurse and other staff acknowledged the importance of keeping call lights within reach, yet this was not consistently practiced, as evidenced by the observations and interviews conducted during the survey.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for residents with catheters and incontinence, leading to potential risks of urinary tract infections. In one instance, the Staffing Coordinator and a CNA did not maintain the foley catheter drainage bag below a resident's bladder during a mechanical lift transfer. This oversight caused urine to flow back towards the resident's bladder, increasing the risk of infection. Both staff members acknowledged their mistake, with the Staffing Coordinator admitting she was trained to keep the bag below the bladder but failed to do so during the transfer. Another deficiency involved a resident who was not provided timely incontinence care. A CNA placed a wadded-up brief over the resident's penis, which was not standard practice, and failed to return to check and change the resident before the end of her shift. This resulted in the resident being left in a saturated brief, with redness observed on the scrotum and buttocks. The CNA admitted to her error, stating she knew it was wrong but did not have assistance at the time. Additionally, a therapist placed a urine catheter bag on the floor during a transfer, which is against the facility's policy. The therapist acknowledged the mistake, stating she was trained to keep the bag off the floor to prevent cross-contamination. The Director of Nursing confirmed that placing the catheter bag on the floor or above the bladder could lead to urinary tract infections and emphasized the importance of proper catheter care and hand hygiene.
Failure to Document Narcotic Counts at Shift Changes
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that controlled drugs were counted and documented at every shift change for one of the medication carts, specifically Med Aide cart hall 500. This deficiency was identified through interviews and record reviews, which revealed missing signatures on the narcotic count sheet for several dates in July 2024. LVN S and LVN R, who were responsible for the cart, admitted to not signing the narcotic sheets after counting the drugs, which is a critical step to prevent drug diversion. The Director of Nursing (DON) confirmed that the expectation was for nurses to sign the narcotic count sheet at the beginning and end of their shifts after completing the count with the incoming and outgoing nurse. The facility's policy on controlled medication storage, dated September 2007, requires a physical inventory of all Schedule II drugs at each shift change, which was not adhered to in this case. Although no drug diversion was noticed during a medication count, the lack of documentation could potentially lead to such an issue.
Food Safety Lapses in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. Specifically, the facility did not discard expired food items, such as a half-used container of chopped garlic in water with an expiration date that had passed. Additionally, food items in the walk-in refrigerator were not properly labeled or dated, including a white, cream-like substance in a Ziplock bag and hard-boiled eggs that were not securely covered. These lapses were identified during an inspection of the facility's kitchen. Interviews with kitchen staff and management revealed a lack of consistent adherence to food safety protocols. A staff member admitted to forgetting to cover the hard-boiled eggs and was unable to identify the unlabeled food item. The Dietary Manager acknowledged the oversight and attributed it to staffing shortages on the morning of the inspection. The facility's policy requires all food items to be labeled, dated, and covered, but these procedures were not followed, posing a risk of food contamination and potential food-borne illness for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper sanitation and hand hygiene practices. Specifically, medical assistants failed to disinfect blood pressure cuffs between use on different residents. For instance, MA L did not sanitize the blood pressure cuff before and after using it on two residents, despite acknowledging the importance of doing so to prevent the spread of germs. Similarly, MA M also neglected to sanitize the blood pressure cuff between residents, admitting that this oversight could lead to cross-contamination and infection spread. Additionally, the facility's staff did not adhere to proper hand hygiene protocols during resident care. CNA K failed to perform hand hygiene between glove changes while providing incontinence care to a resident, despite being aware of the requirement to wash hands before and after care to prevent infection spread. The Staffing Coordinator also neglected to perform hand hygiene after handling a catheter drainage bag and completing a mechanical lift transfer for a resident, which could lead to cross-contamination. The facility's policies on hand hygiene and disinfecting resident care equipment were not followed, as evidenced by the staff's actions. The Director of Nursing confirmed that staff were trained on these protocols, yet the observed practices did not align with the facility's expectations. These deficiencies in infection control practices could place residents at risk of cross-contamination and infection.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #50, who was admitted with multiple diagnoses including Alzheimer's disease, anxiety disorder, and severely impaired cognition. The care plan did not address the resident's resistance to care and eating, which were significant issues observed and reported by staff and the resident's representative. Despite the resident's known behaviors of resisting meals and care, these were not documented or included in the care plan. Observations and interviews revealed that Resident #50 often resisted eating and care, requiring significant cuing and prompting. The resident's representative had requested specific feeding strategies, such as placing food on the resident's lip and providing Ensure if meals were refused, but these preferences were not reflected in the care plan. Staff interviews indicated a lack of communication and documentation regarding the resident's preferences and behaviors, leading to inconsistent care approaches. The MDS Nurse, responsible for creating care plans, acknowledged that the care plan did not include interventions for the resident's resistance to care or specific food preferences. The facility's policy required comprehensive care plans with measurable objectives and timeframes, but this was not adhered to in Resident #50's case. The deficiency in care planning could potentially impact the resident's psychosocial health and wellbeing, as the care plan did not adequately address her individual needs.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene, specifically nail care. The resident, a female with intact cognition, expressed dissatisfaction with her long fingernails, which she was unable to trim herself. Despite requiring supervision with personal hygiene, the resident did not request assistance due to fear of getting into trouble. Observations revealed that her nails were approximately 0.5 centimeters long and chipped, indicating a lack of proper nail care. Interviews with facility staff, including CNAs, RNs, the DON, and the ADON, revealed inconsistencies in the provision of nail care. Staff members acknowledged that both CNAs and nurses were responsible for nail care, except in cases involving diabetic residents, where only nurses were permitted to perform the task. Despite this, the resident's nails were not trimmed until after the issue was brought to the attention of the staff. The facility's policy required nail care to be performed during shower days and as needed, but this was not adhered to, leading to the deficiency.
Failure to Maintain Sterile Technique in Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring tracheostomy care, as observed during a survey. The resident, a male with severe cognitive impairment and respiratory failure with hypoxia, required tracheostomy care and oxygen therapy. The facility's Licensed Vocational Nurse (LVN) did not maintain a sterile field while performing tracheostomy care and suctioning, which could lead to respiratory infections. Specifically, the LVN contaminated her sterile gloves by touching non-sterile surfaces and did not follow proper procedures for tracheostomy care and suctioning. During the observation, the LVN was seen performing tracheostomy care without maintaining sterility. She contaminated her gloves by handling non-sterile items and did not change gloves or perform hand hygiene when moving from dirty to clean tasks. The LVN also improperly used a trach brush and placed the suction catheter in a plastic bag, which was not part of the standard procedure. These actions were inconsistent with the facility's policy and professional standards of practice for tracheostomy care. Interviews with the LVN, the Director of Nursing (DON), and the facility's Respiratory Therapist (RT) Consultant revealed that the LVN had been trained but failed to adhere to the sterile technique required for tracheostomy care. The RT Consultant noted that the LVN had initially failed a competency test and required additional training. Despite this, the LVN did not follow the correct procedures, posing a risk of respiratory infections to the resident.
Neglect of Resident Over 13-Hour Period
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically neglect, as evidenced by the lack of care provided to a resident over a period of more than 13 hours. The resident, who required extensive assistance with activities of daily living (ADLs) and was dependent on a G-tube for feeding, was not checked on or provided with incontinent care from 9:05 PM on 12/31/23 until 10:22 AM on 1/1/24. This neglect was confirmed through interviews, record reviews, and video footage from a camera placed in the resident's room by the family. The resident's family discovered the neglect when they found the resident's support pillow and chair soaked in urine and reviewed the camera footage, which showed no care being provided during the specified time frame. The resident's medical history included critical illness myopathy, hypertension, pneumonia, diabetes mellitus, aphasia, cerebrovascular attack, respiratory failure, dysphagia, and G-tube feeding dependency. The resident was always incontinent of urine and bowel and required a two-person assist for all ADLs. Despite these needs, the assigned CNAs and LVNs failed to provide the necessary care. CNA A, who was assigned to the resident during the night shift, did not provide any care, citing a previous incident with the resident's family as the reason. However, this decision was not communicated to the charge nurse or other staff members. LVN C, who was the charge nurse during the night shift, also did not check on the resident for incontinent care, assuming the CNA would handle it. The neglect continued into the morning shift, where CNA B did not check on the resident until 10:22 AM, despite the resident being a two-person assist and visibly in need of care. The resident was found soaked in urine and had a small bowel movement, indicating that no care had been provided for an extended period. Interviews with the staff revealed a lack of communication and understanding of the facility's policies on abuse and neglect. The DON and Administrator were not made aware of the incident until days later, highlighting a significant breakdown in the reporting and handling of abuse and neglect allegations within the facility.
Failure to Implement Policies and Procedures to Prevent Neglect
Penalty
Summary
The facility failed to implement written policies and procedures to prevent abuse, neglect, and theft, resulting in a deficiency for one resident. The incident involved a resident who was found soaked in urine and bowel movement, indicating a lack of proper incontinent care. The resident, who required extensive assistance with activities of daily living (ADL) and was totally dependent on staff for transfers and bathing, was not provided the necessary care during the night shift. This failure was reported by multiple staff members, including CNAs and LVNs, who observed the resident's condition and reported it to the Administrator, who serves as the Abuse Coordinator. The resident's medical history included critical illness myopathy, hypertension, pneumonia, diabetes mellitus, aphasia, cerebrovascular attack, respiratory failure, dysphagia, and tube feeding dependency. The resident was always incontinent of urine and bowel and required two-person assistance for all ADL care. Despite these needs, the resident was not changed or repositioned from the night shift until the following morning, leading to a distressed state and a rash in the perineal area. The family members of the resident expressed their concerns and reviewed camera footage, which confirmed the lack of care provided during the night shift. Interviews with staff members revealed a breakdown in communication and adherence to facility policies. CNA A, who was assigned to the resident, did not provide care due to a previous incident with the resident's family and failed to communicate this to the charge nurse. Other staff members, including LVNs and the Staffing Coordinator, acknowledged the neglect but did not report it immediately to the Abuse Coordinator as required by the facility's policy. The DON and Administrator were made aware of the incident after the fact and began investigating the allegations. The facility's failure to ensure proper care and timely reporting of neglect placed the resident at risk for harm and compromised their dignity and comfort.
Failure to Provide Incontinence Care for Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically incontinence care, for over 13 hours. The resident, a male with severe cognitive impairment and multiple medical conditions including critical illness myopathy, hypertension, pneumonia, diabetes mellitus, aphasia, cerebrovascular attack, respiratory failure, dysphagia, and G-tube feeding dependency, was left without incontinence care from 9:05 PM on 12/31/23 to 10:22 AM on 01/01/24. During this period, the resident's clothing and bedding were found soaked in urine, and the resident had a bowel movement that was not attended to, leading to significant discomfort and potential health risks. The deficiency was primarily due to the inaction of CNA A, who was assigned to the resident but failed to provide the necessary care during the night shift. CNA A did not communicate her decision to not care for the resident to the charge nurse, LVN C, or any other staff members. This lack of communication and failure to provide care resulted in the resident being left in a soiled state for an extended period. Additionally, LVN D, who was responsible for the resident during the morning shift, did not physically check the resident for incontinence despite being aware of the resident's needs and the family's concerns. Interviews with various staff members, including LVN D, CNA B, and the Staffing Coordinator, revealed a lack of adherence to the facility's policies on incontinence care and reporting neglect. The DON confirmed that there was no specific facility policy on how often residents should be checked for continence, but expected that dependent residents be changed as needed. The failure to provide timely incontinence care and the lack of proper communication among staff members led to the resident's prolonged discomfort and potential health risks, constituting a clear case of neglect.
Failure to Report Neglect in a Timely Manner
Penalty
Summary
The facility failed to ensure all alleged violations involving neglect were reported immediately, as required by regulations. Specifically, the staff did not report a 13-hour delay in providing incontinent care to a resident who required extensive assistance with activities of daily living. The resident, who had severe cognitive impairment and multiple medical conditions, was left without necessary care, leading to a family member discovering the neglect and reporting it to the staff. Interviews with various staff members revealed that the neglect was not communicated or reported promptly. The charge nurse, LVN, and CNA involved in the resident's care all acknowledged the failure to provide care and the subsequent neglect. However, they did not report the incident to the abuse coordinator immediately, as required by the facility's policy. The staff members admitted to being aware of the neglect but delayed reporting it, citing reasons such as being busy or assuming others would handle the situation. The facility's administration, including the DON and the facility administrator, were not made aware of the incident until days later. The administrator confirmed that the incident was reported to the state regulatory agency only after being notified by the family. The facility's policy on reporting abuse and neglect was not followed, leading to a delay in addressing the neglect and investigating the incident. The failure to report the neglect immediately placed the resident at risk and highlighted a significant lapse in the facility's adherence to regulatory requirements.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two residents. For Resident #3, a staff member (MA BB) did not don the face mask correctly when entering the resident's isolation room. Resident #3, an elderly female with multiple diagnoses including cancer and heart failure, was on droplet precautions due to a positive COVID-19 status. MA BB entered the room with improper PPE, wearing a surgical mask under an N95 mask and without goggles or a face shield, contrary to the facility's policy and recent in-service training on isolation precautions. For Resident #1, the facility failed to ensure proper hand hygiene during incontinence care. Resident #1, a male with severe cognitive impairment and multiple health issues, required extensive assistance with activities of daily living. During an observation, CNA O and ADON B did not perform hand hygiene or change gloves appropriately while providing incontinence care. Both staff members admitted to not following proper hand hygiene protocols, which were confirmed by the DON as necessary to prevent the spread of infection. The facility's policies on COVID-19 PPE and hand hygiene were not adhered to by the staff, leading to potential risks of cross-contamination and infection. The staff involved acknowledged their lapses in following the protocols, despite recent in-service training on infection control measures. The DON confirmed the importance of these procedures in preventing the spread of infection within the facility.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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