Advanced Health & Rehab Center Of Garland
Inspection history, citations, penalties and survey trends for this long-term care facility in Garland, Texas.
- Location
- 1201 Colonel Drive, Garland, Texas 75043
- CMS Provider Number
- 455731
- Inspections on file
- 36
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 16 (3 serious)
Citation history
Health deficiencies cited at Advanced Health & Rehab Center Of Garland during CMS and state inspections, most recent first.
A resident with advanced dementia, severe cognitive impairment, and multiple behavioral symptoms was care planned to be approached calmly, with slow speech, eye contact, and unhurried care. Video evidence from a family-installed camera showed a CNA entering the resident’s room while the resident was lying on the floor, scolding the resident about being on the floor, and twice slapping the resident’s buttocks while insisting he get up and questioning his language. The CNA’s actions and verbal interactions conflicted with the resident’s care plan and the facility’s abuse policy, which defines abuse as the willful infliction of injury, intimidation, or punishment and specifically includes hitting and slapping as physical abuse. Interviews with the DON, Admin, and staff confirmed that hitting a resident is never acceptable, and the incident constituted a failure to ensure the resident’s right to be free from abuse by staff.
A resident with schizoaffective disorder, mild intellectual disability, diabetes, and a history of severe cognitive impairment was assessed as minimal elopement risk and lived on a memory care unit but was sent alone by facility-arranged transport to a vascular appointment. The driver dropped the resident at the clinic door and left, and no staff accompanied the resident despite psychiatric issues and need for supervision with ADLs. After an ultrasound, the resident stated she did not want to wait for results, left the exam area against medical advice, and walked out of the clinic; she then used public transportation, went downtown, and remained missing in the community until located by transit police two days later. Post‑incident, the resident, who was observed to be somewhat confused and unable to recall details or contact information, was placed on the main hall rather than being returned to the memory care unit where she had resided prior to the elopement.
A resident with schizoaffective disorder, DM, mild intellectual disability, severe cognitive impairment, and multiple CAAs triggered for cognitive loss, ADL deficits, and psychotropic drug use had a care plan that addressed adjustment issues, behavior monitoring, DM, psychotropic medications, and ADL self-care, but did not include problems, goals, or interventions for wandering, intellectual disability, or a recent elopement incident. Interdisciplinary conference notes documented the RP’s concerns about safety, the resident’s history of wandering, prior placement on a locked unit with door alarms, and understanding that facility door alarms would alert staff, yet the care plan was not revised to reflect these behaviors or the elopement. Interviews with MDS and nursing leadership confirmed that care plan updates were their responsibility and that failure to update meant the care plan would not reflect current care needs.
A resident on hospice with end‑stage metastatic cancer experienced persistent, severe pain manifested by crying, moaning, thrashing, and screaming during care, while staff failed to provide effective pain management consistent with orders and policy. Although morphine was ordered, nurses repeatedly administered only low doses within a wide PRN range, did not complete or document regular pain assessments or reassessments, and did not document timely notification of hospice or the physician when pain remained uncontrolled. No comprehensive baseline or individualized pain care plan was completed, and staff and hospice altered pain orders in response to a non‑POA friend’s objections to sedation rather than consistently prioritizing the resident’s comfort, resulting in prolonged uncontrolled pain and an immediate jeopardy finding.
A resident with metastatic cancer on hospice care was admitted with documented severe, generalized pain and clear non‑verbal pain indicators, yet the facility failed to complete a baseline care plan within 48 hours that addressed pain management or hospice coordination. The baseline care plan in the EHR was started but left unfinished and contained no pain interventions, despite policy requiring a person‑centered baseline plan for new admissions. Over the following days, the resident was repeatedly observed thrashing, writhing, crying, moaning, grimacing, and screaming during movement and incontinent care, while staff administered PRN morphine that they reported was not effective. CNAs and an LVN described the resident as always crying and in apparent pain, and family members reported that she appeared to be in pain at every visit and that staff did not perform thorough assessments. Multiple nurses, ADONs, the DON, and the Administrator acknowledged that pain should have been included in the baseline care plan, confirmed that it was not completed, and stated that this omission left staff without a defined plan of care for managing the resident’s pain.
A resident with COPD, chronic respiratory failure, heart failure, HTN, impaired vision, ADL deficits, and moderate cognitive impairment was given multiple crushed oral medications mixed in pudding by a medication aide, who then left the medication cup on the bedside table and exited the room without observing ingestion. The resident, who had no documented assessment or authorization for self-administration, later reported that staff left medications when he was busy and that he took them himself, and the aide confirmed she did not witness administration and knew medications should not be left in the room. Facility leadership (ADONs, DON, Administrator) stated that staff were expected to follow the medication pass policy, complete the rights of medication administration, remain with residents until medications were swallowed, and that no residents were permitted to self-administer, consistent with the written policy requiring staff to stay with the patient until medication administration was complete and to document each dose on the MAR.
Staff failed to consistently perform hand hygiene during and between resident care activities, including incontinent care and direct contact, resulting in multiple instances where gloves were not changed or hands were not washed when moving from contaminated to clean areas. These lapses involved CNAs and LVNs providing care to residents with complex medical conditions, despite facility policy and leadership expectations for proper infection control practices.
A resident with multiple complex diagnoses and severe cognitive impairment required a hydraulic lift and two-person assist for all transfers, but the care plan did not include this requirement. On one occasion, a CNA used the hydraulic lift alone to obtain the resident's weight, contrary to facility policy and training. Interviews with the ADON and DON confirmed the omission in the care plan and the necessity of two staff for safe transfers.
A resident with a stage IV sacral pressure ulcer and multiple comorbidities was found with an uncovered wound, despite provider orders and care plan interventions requiring the wound to be dressed and monitored. Staff interviews revealed lapses in communication and responsibility for wound care, and a CNA failed to perform proper hand hygiene during incontinent care. Facility leadership confirmed that these actions did not meet expected standards for wound management and infection control.
A deficiency was identified when a CNA performed a hydraulic lift transfer alone for a resident with severe cognitive and physical impairments, despite facility policy and training requiring two staff for such transfers. The resident's care plan also lacked documentation of the need for hydraulic lift assistance, and interviews with facility leadership confirmed these requirements were not followed.
A resident with a tracheostomy did not receive safe respiratory care when a nurse failed to perform hand hygiene before contact and left respiratory tubing on the floor and zip-tied to a bedside table, contrary to facility policy and infection control standards. Staff interviews confirmed these actions did not meet expectations for safe care.
Four residents with significant mobility and cognitive impairments were found with their call lights out of reach while in bed, despite care plans and facility policy requiring accessibility. Staff interviews confirmed that call lights are expected to be within reach and checked during rounds, but this was not consistently done, leaving residents unable to call for assistance.
A resident with severe cognitive impairment and muscle weakness was found using a bolster mattress on her bed without a physician order or assessment. The care plan identified the resident as a fall risk, but staff confirmed that no order was in place for the equipment, contrary to facility policy requiring physician involvement for restraint use.
A resident with multiple chronic conditions was documented in the MAR as having received all prescribed medications, while progress notes indicated the resident had refused all medications during the same period. An LVN admitted to prematurely coding medications as administered, contrary to facility policy, resulting in inaccurate medication records.
A resident with confusion, agitation, and multiple medical devices was transferred to the ER via private non-medical transport without staff or family supervision, and without adequate clinical documentation or prior notification to the resident's representative. The facility did not update the provider after EMS refused transport, failed to address behavioral concerns in the care plan, and did not ensure the resident was prepared or oriented for transfer in a manner he could understand.
A resident with complex medical needs was admitted without receiving a written admission agreement, consent to treat, notification of rights, or Medicare/Medicaid information. The resident's representative reported not receiving any admission paperwork or required disclosures, and the Business Office Manager confirmed that none of the necessary documentation was completed or provided at the time of admission.
A resident with end stage renal disease missed a scheduled dialysis appointment, and while the Administrator, DON, and Assistant DON were notified, the resident's durable power of attorney for healthcare was not informed as required by facility policy. Staff interviews and record review confirmed that the responsible party was not contacted about the missed treatment.
The facility failed to provide necessary respiratory care for three residents, including one who was readmitted with serious respiratory conditions. This resident did not receive a physician's order for oxygen and was administered oxygen at high levels without proper orders. The resident was found unresponsive and later declared dead, with evidence of inadequate supervision during the night shift. Another resident's tracheostomy tubing was mishandled, and a third resident did not receive consistent oxygen therapy.
A facility failed to manage a resident's trust fund, risking Medicaid eligibility. The resident, with cerebral palsy and other conditions, had a trust fund balance consistently over the Medicaid limit. The BOM and SW did not effectively communicate or act to spend down the funds, despite knowing the risks. The facility's policies on fund management and notification were not followed, leading to the deficiency.
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration and monitoring. A resident with hypertension did not receive her prescribed medication due to undocumented blood pressure readings, resulting in two falls. Another resident with diabetes did not have his blood glucose levels checked or insulin administered as ordered multiple times. Interviews with staff revealed inconsistent documentation and monitoring practices, contributing to the deficiencies.
A long-term care facility failed to document wound care for two residents on multiple occasions, leading to incomplete medical records. One resident missed 29 wound care sessions, while another missed 36. Interviews with staff revealed a lack of communication and oversight in the wound care process, with responsibilities divided between a wound care nurse and a weekend supervisor. The Director of Nursing acknowledged the importance of wound care but was unsure about auditing responsibilities.
A resident with severe cognitive impairment and multiple health issues was discharged home without a completed discharge summary. The facility failed to provide a recapitulation of the resident's stay, a final summary of their status, and a reconciliation of medications, as required by policy. Interviews with staff indicated that the charge nurse was responsible for this task, but it was not completed, potentially affecting the resident's continuity of care.
A resident with multiple medical conditions was ordered a stool culture for C. diff, but the facility failed to complete the lab order. The charge nurse collected the specimen and placed it in the fridge, expecting the lab company to pick it up. However, the lab requisition forms were missing, and the lab company did not collect the specimen. The facility's procedures for handling lab orders were not followed, resulting in a deficiency in care.
A COVID-positive resident with severe cognitive impairment was improperly allowed to leave isolation and dine with other residents, contrary to the facility's 10-day isolation policy. Despite being asymptomatic, the resident's presence in the communal dining area without a mask posed a risk of virus transmission. Staff interviews confirmed the difficulty in enforcing isolation protocols, but the facility's policy required strict adherence to prevent the spread of infection.
Failure to Protect Cognitively Impaired Resident From Physical and Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse by a CNA. The resident was an elderly male with Alzheimer’s disease, major depressive disorder, adjustment disorder, repeated falls, gait and mobility abnormalities, difficulty walking, and a cognitive communication deficit. His MDS showed he was severely cognitively impaired, rarely or never made himself understood or understood others, and had both short- and long-term memory problems. He was dependent for toileting and shower hygiene and required substantial assistance with dressing. His care plan identified multiple dementia-related behaviors, including urinating in inappropriate places, pushing on exit doors, removing clothing after being dressed, sitting on the floor as a refusal mechanism, and resisting care such as showering. The care plan interventions directed staff to approach him calmly, use his name, speak slowly, maintain eye contact, talk while providing care, allow time for responses, and not rush. Despite these identified needs and interventions, a video provided by the resident’s family member showed that a CNA entered the resident’s room while he was lying on the floor next to his bed on his left side and addressed him in a scolding manner. The CNA asked, “Why you do this again, huh?” and told him to “Get up,” then slapped him on his right buttock with her hand. She repeated the question, “why you did this,” and slapped his right buttock again. The resident responded, “Oh shit, lady,” and the CNA continued to question him, telling him, “Come on. No, you are not supposed to do this, come on, sit up. Come on.” When the resident said, “I can’t,” the CNA insisted, “Yes, you can. Why you come on the floor in the first place?” The resident again said, “Oh shit,” and the CNA challenged his language, saying, “Oh shit, why you say oh shit? Give me your hand. So, this place is better than a bed?” When the resident answered, “Yes ma’am,” the CNA replied, “It’s not. Get up. Come on,” took his hand, then walked out of view as the video ended. This conduct, including slapping the resident’s buttocks and verbally chastising him, conflicted with the facility’s own abuse policy, which defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and specifically listed hitting and slapping as physical abuse. The family member reported that the video was recorded on a prior date and stated she had sent multiple videos to facility leadership. She indicated she texted five videos to the Administrator’s personal phone number and had previously sent texts and videos to the Administrator and former ADON, but typically did not receive replies and did not speak to them personally about the video. The Administrator stated she had not seen any such video at the time, reported that the CNA stopped working at the facility not long after starting, and acknowledged that hitting a resident would not be acceptable and that the incident in the video should not have happened. The DON and other staff interviewed described abuse and neglect and agreed that hitting a resident on the bottom would not be alright and that it was never acceptable to hit a resident. The facility’s written policy on abuse, neglect, and exploitation, dated 10/24/22, stated that the facility would make every effort to prevent and prohibit all types of abuse, including physical abuse such as hitting and slapping. Nonetheless, the observed video evidence showed the CNA slapping the resident and speaking to him in a manner inconsistent with his care plan interventions and the facility’s abuse prevention policy, resulting in a cited failure to ensure the resident’s right to be free from abuse.
Elopement After Unsupervised Off‑Site Medical Appointment for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and appropriate placement for a cognitively impaired resident with significant psychiatric and medical conditions, resulting in an elopement from a medical appointment. The resident was a 57‑year‑old female with schizoaffective disorder, bipolar disorder, major depressive disorder, mild intellectual disability, type 2 diabetes mellitus, and chronic venous ulcers. Her admission MDS showed a BIMS score of 7, indicating severe cognitive impairment, and her care plan identified adjustment issues, schizoaffective disorder, diabetes, and a chronic venous stasis ulcer, with a need for supervision and assistance for ADLs such as toileting, bathing, eating, and hygiene. She resided on the memory care unit prior to the incident and had been assessed as minimal risk for elopement on admission and again on an elopement assessment dated shortly after the incident. On the day of the incident, the resident was transported alone by a facility-arranged driver to an off‑site vascular appointment. The driver dropped her at the door of the medical office and left; no staff accompanied her despite her psychiatric diagnoses, mild intellectual disability, diabetes, and prior residence on a secured memory care unit. At the physician’s office, she completed an ultrasound and was placed in a waiting room to await results. Office staff reported that around late morning she stated she did not want to wait, asked for a soda, and then walked out of the office against medical advice. Clinic staff searched the area and contacted campus security and later law enforcement, and the transport driver notified the facility that he could not locate her. The facility’s own investigation documented that she left the appointment AMA and could not be located, and that she was considered missing from that point. The resident remained missing in the community for an extended period until she was located by public transportation police on a train in the early morning hours two days later. When interviewed after her return, she reported that she had taken public transportation downtown, purchased food and a drink, and attempted unsuccessfully to contact a previous SNF, stating she did not have contact information for her responsible party or the current facility. She was described as somewhat confused, with loss for words and inability to recall or respond to questions or details of events while she was gone, and she did not know her locations or contact information. Despite her complex psychiatric history, severe cognitive impairment documented on prior MDS, and diabetes requiring regular monitoring and insulin per sliding scale, the facility had assessed her as minimal elopement risk and did not provide increased supervision or ensure that staff accompanied her to the appointment. Additionally, after the elopement incident, she was not returned to the memory care unit but was instead placed on the main hall, despite her prior placement on the memory care unit before the event.
Failure to Update Care Plan for Wandering, Intellectual Disability, and Elopement
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that addressed all of a resident’s assessed needs, including measurable objectives and services. The resident was a 57-year-old female with diagnoses of schizoaffective disorder, diabetes mellitus, mild intellectual disability, asthma, and a history of MDRO wound infection requiring IV treatment. MDS assessments documented severe cognitive impairment with a BIMS score of 7, mood findings of sometimes socially isolating, ADL dependence requiring supervision or touching assistance, and CAAs triggered for cognitive loss/dementia, ADL functioning/rehab potential, urinary incontinence, falls, nutrition/diet, dehydration, pressure ulcers, and psychotropic drug use. The MDS also reflected evidence of mental illness and intellectual disability. Record review showed that the resident’s care plan, dated 11/20/2025, addressed adjustment issues to admission, behavior problems related to schizoaffective disorder bipolar type, diabetes management, psychotropic medication monitoring, discharge planning, and ADL self-care performance deficits. Interventions included monitoring behavior episodes, documenting behaviors and interventions, approaching the resident calmly, talking during care, allowing time for responses, and not rushing care. However, despite the resident’s diagnoses and cognitive status, the care plan did not include specific problems, goals, or interventions related to her wandering behavior, her intellectual disability, or her most recent elopement incident on 01/05/2026. Care plan conference notes dated 01/09/2026 documented an interdisciplinary meeting with the DON, SW, DOR, DM, AD, Administrator, and the resident’s representative (RP), during which the RP expressed concerns about placement and safety, stated the resident was not believed to be exit seeking and had no history of elopement, and requested that the resident not be “locked up like a prisoner.” The RP indicated willingness for the facility to determine what was best, agreed the resident could be moved to memory care if an unlocked unit did not work, and reported the resident had issues regulating and consistently taking medications. The RP also stated that at the previous placement the resident had been on a locked memory unit with door alarms, believed facility door alarms would alert staff to exits, and stated the resident will wander off and should not have been allowed to go alone to a hospital appointment on 01/05/2026. Interviews with the MDSC and DON confirmed that MDS nurses and nursing staff were responsible for updating care plans with changes, and that if not updated, the care plan would not reflect current treatments and care needs. Despite this, the resident’s care plan remained without entries addressing wandering, intellectual disability, or the recent elopement incident.
Failure to Provide Effective Hospice Pain Management for Terminal Cancer Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management to a hospice resident with end‑stage metastatic cancer to the breast, liver, bone, and intrahepatic bile ducts. On admission for respite care, the resident was confused, disoriented, crying, and restless, and an initial pain assessment documented non‑verbal indicators of pain, including loud moaning or groaning, crying, facial grimacing, tense body language, and a pain score of 6, with an acceptable pain level of 0. The resident was started on morphine sulfate oral solution with an order for 0.25 mL every two hours PRN for shortness of breath and pain, later changed to a routine schedule and then back to PRN with a range dose of 0.25–1.0 mL every hour. Despite these orders, the facility did not complete a finished baseline care plan or comprehensive care plan for the resident, and the existing care plan only addressed impaired communication without specific pain management interventions. From admission through the identified period, the resident exhibited persistent and severe non‑verbal signs of pain, including thrashing and writhing in bed, crying, moaning, groaning, screaming during incontinent care, facial grimacing, clenched jaw, and inability to be consoled or respond to questions. Observations on multiple occasions showed the resident becoming more distressed with movement and care. CNAs reported that the resident was always crying, screaming during changes, restless, and grimacing, and they notified nursing staff of these signs. Family members also reported that the resident had been in pain every time they visited, that she had stage 4 cancer, and that she had not been comfortable since arriving at the facility. One family member stated staff only glanced into the room rather than performing full assessments and expressed that the resident’s pain was not being managed. Nursing staff acknowledged that the resident’s behaviors indicated pain and that the morphine doses being given were not effective. The LVN caring for the resident stated that the current morphine order allowed 0.25–1.0 mL every hour PRN, but he consistently administered only 0.25 mL, later 0.5 mL, despite ongoing severe pain behaviors, and documented these doses only in the narcotic log rather than on the MAR. He reported assessing the resident’s pain every 30–60 minutes but did not chart these assessments, and the EHR contained no pain assessments during this period. The MAR showed no breakthrough or long‑acting pain medications, and there was no documentation that the physician or hospice was notified when the resident displayed uncontrolled pain. The DON and hospice staff confirmed that the resident’s pain was severe and ongoing, that the morphine order had been changed to PRN partly in response to a non‑POA friend’s concerns about sedation and eating, and that staff and hospice had been influenced by this friend’s wishes rather than consistently prioritizing the resident’s comfort. These actions and omissions resulted in the resident experiencing prolonged, uncontrolled pain and led surveyors to identify immediate jeopardy related to pain management. The facility’s own pain management policy required assessment for pain upon admission and with changes in condition, establishment of pain management goals, individualized interventions, ongoing monitoring of response to pharmacologic and non‑pharmacologic measures, and reporting to the physician of patient response to interventions. The hospice coordination policy required a coordinated plan of care, directives for managing pain and uncomfortable symptoms, monitoring and evaluation of the resident’s response to hospice care plans, and immediate communication with hospice and the attending physician regarding significant changes or emergent situations. In this case, the facility did not complete or implement a comprehensive, individualized pain management plan, did not consistently assess and document pain or reassess after interventions, did not fully utilize the ordered morphine range to address uncontrolled pain, and did not document timely escalation to hospice or the physician when pain remained severe. These failures, in the context of the resident’s terminal cancer and clear non‑verbal signs of excruciating pain, constituted the cited deficiency in pain management.
Removal Plan
- Charge Nurse/DON/designee assessed the resident’s pain using an appropriate tool (0-10 scale if able; PAINAD/non-verbal tool if unable) and documented signs/symptoms and current comfort level.
- Facility contacted the hospice nurse and attending/medical provider to report uncontrolled pain episodes and frequency of distress behaviors.
- Facility obtained clarified, complete medication orders from prescriber/hospice that include clear administration parameters (e.g., which dose to give under which conditions) and documented these orders per policy.
- Facility updated the care plan to reflect end-of-life comfort needs, pain assessment frequency, medication administration/reassessment expectations, and hospice coordination.
- Facility implemented enhanced monitoring until pain was controlled, including pain checks and comfort rounds at least hourly, with reassessment after each intervention and documentation of effectiveness.
- DON/designee ran a list of all residents on hospice and all residents with active opioid PRN range orders and/or recent pain complaints.
- For each identified resident, a licensed nurse/designee audited for complete parameters on PRN/range orders (no range without direction), pain assessment and reassessment documentation after PRN administration, evidence of provider/hospice notification for uncontrolled pain, and care plan alignment with pain management needs.
- Any orders lacking parameters were held for clarification; the facility contacted the provider/hospice promptly and residents were assessed and managed per hospice/provider direction.
- Facility implemented a requirement to not accept or implement range/variable dose opioid orders without written parameters from prescriber/hospice (dose selection criteria, frequency limits, reassessment expectations, and hold criteria).
- Orders missing parameters triggered an automatic provider/hospice clarification call and documented follow-up.
- Facility implemented an uncontrolled pain escalation pathway requiring staff to notify hospice/provider when pain is not relieved or distress behaviors persist, using defined escalation triggers (e.g., repeated PRN use, persistent severe pain behaviors, frequent crying/screaming).
- For hospice residents, facility implemented use of a Hospice Symptom Escalation Call Log to document time of call, who was contacted, response received, and new orders.
- Facility implemented documentation standards requiring pain documentation every shift and with any complaint/behavior suggestive of pain, before PRN administration (baseline), reassessment after medication/intervention within policy timeframe, documentation of effectiveness, and documentation of escalation if ineffective.
- Facility provided staff education/competency training for all licensed nurses (and individualized education for those who missed the in-service) on pain assessment including non-verbal tools, end-of-life comfort care expectations and SNF/hospice coordination, PRN opioid documentation and reassessment standards, and clarifying incomplete orders/range dose parameters, with sign-in sheets and a post-test prior to assuming duties.
- Facility implemented audits/monitoring using a Pain Management & Hospice Coordination Audit tool to monitor PRN opioid/range order parameters, pain assessment documentation, reassessment after each PRN, hospice/provider notification when pain uncontrolled, and care plan alignment with pain/hospice involvement.
- Facility set audit frequency to weekly for 4 weeks, then monthly for 2 months, then quarterly, with DON/ADON/designee and unit managers responsible for follow-up and results reviewed in QAPI with trends/actions documented.
- QAPI committee provided oversight to review audit results, identify patterns (e.g., missing parameters, missed reassessments, delays calling hospice/provider), and implement additional actions (targeted re-education, disciplinary action if warranted, EMR prompts, staffing workflow changes).
Failure to Complete Baseline Pain Management Care Plan for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission that addressed a hospice resident’s significant pain management needs. The resident, a middle‑aged female with metastatic malignant neoplasms of the right breast, liver, intrahepatic bile ducts, and bone, as well as chronic pain and depression, was admitted for respite care and then remained at the facility. Record review showed that the resident’s baseline care plan had been started but not completed, and it contained no information about her pain or hospice services. The facility’s own policy required person‑centered baseline care plans to be developed and implemented within 48 hours of admission, including measurable objectives to meet the resident’s medical, nursing, mental, and psychosocial needs. Clinical documentation and observations showed that the resident had ongoing, severe pain that was not effectively addressed in a care plan. An initial pain assessment documented non‑verbal indicators of pain, including occasional labored breathing, repeated troubled calling out, loud moaning or groaning, crying, facial grimacing, tense body language, and a pain score of 6 with generalized body pain, while the resident’s acceptable pain level was recorded as 0. Progress notes from admission described the resident as confused, disoriented, crying, restless, and unable to control her body, with hospice already involved and the facility physician agreeing to continue hospice orders. Despite this, there was no completed baseline care plan outlining pain management interventions or coordination with hospice services. Surveyor observations and staff and family interviews further demonstrated that the resident exhibited persistent signs of severe pain over multiple days without a guiding baseline care plan. On multiple observations, the resident was seen thrashing, writhing, moaning, crying, grimacing, and screaming during movement and incontinent care, with symptoms worsening on touch or repositioning. Nursing staff reported that the resident “was always crying,” that morphine given as needed every 1–2 hours did not appear effective, and that she would only sleep briefly before waking and resuming moaning and crying. CNAs described frequent crying, screaming, restlessness, and grimacing, and reported uncertainty about the source of pain and the effectiveness or timing of medications. Family members stated the resident had been in pain during each visit, believed her pain was not being managed, and reported that staff often only glanced into the room rather than performing full assessments. Multiple nurses, ADONs, the DON, and the Administrator all acknowledged in interviews that pain should have been included in the baseline care plan, that the resident’s baseline care plan was not completed, and that its absence meant staff did not have a defined plan of care or interventions for managing the resident’s pain. The facility’s leadership and nursing staff confirmed that the baseline care plan for this resident was not triggered or completed when she was admitted for respite care and that pain management was not care planned despite her known metastatic cancer and documented severe pain. Staff interviews consistently indicated that baseline care plans are supposed to be completed on admission by the admitting nurse, that pain must be included when present, and that these plans guide staff on how to care for residents, including when and how to address pain. In this case, the lack of a completed baseline care plan with pain interventions and hospice coordination resulted in staff relying on PRN medications without a structured, person‑centered plan, while the resident continued to display ongoing, excruciating pain over the period reviewed.
Unattended Bedside Medications Left by Medication Aide
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administering of medications when a medication aide left a resident’s medications unattended at the bedside. The resident was an older male with COPD, chronic respiratory failure with hypercapnia, muscle weakness, heart failure, hypertension, impaired visual function, ADL self-care deficits, and moderate cognitive impairment (BIMS score of 7). His care plan reflected he required assistance with feeding, was on a mechanical soft diet with thin liquids, and used antidepressant/anxiety medications. There was no assessment documented for self-administration of medications or competency to manage his own medications. On the morning in question, the resident had multiple scheduled medications, including antihypertensives with hold parameters, GI medications, constipation medication, vitamin C, and ferrous sulfate. The MAR for that day showed he received vitamin C, famotidine, protonix, ferrous sulfate, and sennosides-docusate sodium, and that all blood pressure medications were held due to vital signs being out of range. During the morning med pass, the medication aide crushed the ordered medications, mixed them with pudding, and placed the medication cup on the resident’s bedside table, informing him that his medications were there and then leaving the room without remaining to observe administration. Subsequent observation showed the medication cup remained on the bedside table after the aide left, and the resident stated he was going to take the medications. Later, the cup was no longer present, and the resident reported that staff left medications on the table when he was busy and that he took them himself; he confirmed staff did not watch him take his medications that day. The medication aide acknowledged leaving the medications in front of the resident at his request, admitted she did not see him take them, and stated she knew she was not supposed to leave medications in the room. Facility leadership, including the ADONs, DON, and Administrator, each stated that staff were expected to follow the medication administration policy, complete the rights of medication administration, remain with residents until medications were swallowed, and never leave medications unattended, and they identified that no residents in the facility were authorized to self-administer medications. The facility’s written Medication Administration: Medication Pass policy required staff to remain with the patient until administration of medications was complete and to document each medication administered on the MAR.
Failure to Ensure Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not performing proper hand hygiene during resident care. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) were observed providing incontinent care and other direct resident contact without changing gloves or performing hand hygiene when moving from contaminated to clean areas. For example, during incontinent care for a male resident with multiple diagnoses including heart failure, dementia, and a stage IV pressure ulcer, a CNA did not change gloves or perform hand hygiene before handling a clean brief, despite having contaminated gloves. The CNA later acknowledged the lapse, attributing it to the absence of visible contamination on the gloves. In another instance, a CNA and an LVN provided incontinent care to a male resident with cerebrovascular disease and hemiplegia, touching clean items such as briefs, linens, and a bedside remote with contaminated gloves before eventually removing gloves and performing hand hygiene. Both staff members admitted to not following proper hand hygiene protocols during the care episode. Additionally, an LVN was observed entering a resident's room and making direct contact with the resident's mouth and secretions without performing hand hygiene after using the computer at the nurse's station. The LVN acknowledged the failure to perform hand hygiene but did not provide a reason for the omission. Further observations revealed an LVN repeatedly failed to perform hand hygiene before donning gloves and making contact with three different residents after handling items such as the facility computer, medication cart, and keys. The LVN did not consider hand hygiene necessary before resident contact in these situations. Facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator, all stated that their expectation was for staff to perform hand hygiene prior to donning gloves and before any resident contact, in accordance with facility policy. The facility's hand hygiene policy requires staff to wash hands after removing gloves, between resident contact, after handling contaminated objects, and before performing resident care procedures.
Failure to Develop and Implement Comprehensive Care Plan for Resident Requiring Hydraulic Lift
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes to address a resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan did not include any focus, goal, or intervention related to the resident's requirement for a hydraulic lift and transfer device, despite the resident being bedbound and dependent on staff for all transfers. The resident's diagnoses included cerebrovascular disease, right-sided hemiplegia, peripheral vascular disease, dementia, major depressive disorder, and bipolar disorder, and he was severely cognitively impaired and required a wheelchair for mobility. On one occasion, a CNA obtained the resident's weight using a hydraulic lift and transfer device without the required assistance of a second staff member. The CNA stated she proceeded alone because her assigned coworker was late and nurses were busy, acknowledging that this was not the correct procedure and that she had been trained to always use two staff members for such transfers. Facility policy and the CNA's skills validation checklist both required two staff members for all hydraulic lift operations to ensure safety. Interviews with the ADON and DON confirmed that the resident had long required a hydraulic lift for all transfers and that two staff members were always required for its use. Both acknowledged that the resident's care plan should have included specific instructions regarding hydraulic lift and transfer care, and that it was the DON's responsibility to ensure all resident care needs were accurately reflected in the care plan. The failure to include these details in the care plan and to follow established procedures led to the deficiency.
Failure to Maintain Pressure Ulcer Dressing and Adhere to Infection Control Practices
Penalty
Summary
A resident with multiple complex medical conditions, including stage IV sacral pressure ulcer, Alzheimer's disease, vascular dementia, and a syndrome causing frequent bowel movements, was admitted from an acute care hospital and was receiving hospice care. Provider orders specified daily wound care for the stage IV pressure ulcer, including cleansing and application of topical medications, with instructions to keep the dressing clean, dry, and intact. The resident's care plan also emphasized the need for wound care per order, monitoring and replacing dressings as needed, and reporting any issues with the dressing to nursing staff. During observation, the resident was found in bed with a large, uncovered sacral wound exposing muscle, tendon, and bone. Interviews with staff revealed that the wound had been left uncovered for an extended period, and there was confusion and lack of communication among CNAs, hospice aides, and nursing staff regarding responsibility for checking and reporting on the wound's status. The hospice aide reported that the wound was already uncovered during morning care and was unable to locate nursing staff to report the issue. CNAs admitted to not checking the sacral area during rounds and not reporting the uncovered wound, despite being trained to do so. Additionally, during incontinent care, a CNA failed to perform proper hand hygiene and glove changes when moving from contaminated to clean areas, contrary to facility policy and infection control standards. Facility leadership, including the ADON, DON, and Administrator, confirmed that their expectation was for wounds to be covered at all times and for staff to follow hand hygiene protocols, but these standards were not met in this instance. Facility policies reviewed also required adherence to hand hygiene and pressure injury prevention practices, which were not followed in the care of this resident.
Failure to Provide Adequate Supervision During Hydraulic Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) used a hydraulic lift to transfer a resident without the required assistance of a second staff member. The resident involved was a male with significant medical conditions, including cerebrovascular disease, right-sided hemiplegia, peripheral vascular disease, dementia, major depressive disorder, and bipolar disorder. He was bedbound, severely cognitively impaired, and dependent on staff for all activities of daily living, including transfers, which required the use of a hydraulic lift and two staff members for safety. On the day of the incident, the CNA proceeded to obtain the resident's weight alone using the lift because her assigned partner was late and other staff were unavailable, despite being trained and aware of the policy requiring two staff for such transfers. Further review revealed that the resident's comprehensive care plan did not include specific interventions or instructions regarding the use of a hydraulic lift and transfer assistance, even though this was necessary for his care. Interviews with facility leadership, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed that two staff are required for all hydraulic lift transfers and that the resident's care plan should have reflected this need. The facility's policy and CNA training materials also specified the two-person requirement for mechanical lift use.
Failure to Provide Safe Respiratory Care and Adhere to Infection Control Practices
Penalty
Summary
A resident with a history of cerebral infarction, venous thrombosis, embolism, and a tracheostomy was not provided safe and appropriate respiratory care as required by the comprehensive care plan and professional standards. During observation, a nurse entered the resident's room from the nurse's station without performing hand hygiene, then cleaned the resident's mouth of secretions without donning gloves or washing hands. The resident's tracheostomy corrugated tubing was found on the floor next to the bed and was also zip-tied to the bedside table, contrary to facility policy and infection control standards. The resident was fully dependent on staff for all personal care and unable to communicate due to cognitive impairment. Interviews with the nurse, ADON, DON, and Administrator confirmed that the tubing should not have been on the floor or zip-tied to the bedside table, and that hand hygiene should have been performed prior to resident contact. Facility policies reviewed also required hand hygiene before resident care and specified proper handling of respiratory equipment. The failure to follow these procedures was directly observed and acknowledged by staff, constituting a deficiency in providing safe and sufficient respiratory care.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the resident call system was accessible to allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or a centralized staff area. Observations on a specific date revealed that four residents had their call lights positioned out of reach while they were lying in bed. For example, one resident's call light was found on the floor under a fall mat, another's was at the foot of the bed, and two others had their call lights hanging over the headboard or bottom bed frame, all out of reach. Record reviews for these residents showed that they had significant medical conditions such as muscle weakness, unsteadiness on their feet, and a history of falls. Their care plans specifically included interventions to ensure the call light was within reach due to their fall risk and need for assistance. Despite these documented needs, the call lights were not accessible at the time of observation. Interviews with CNAs and nursing staff confirmed that call lights are supposed to be within reach of residents and that staff are expected to check this during rounds. Staff acknowledged that sometimes call lights are not repositioned after care is provided, which can leave residents unable to contact staff if they need help. The facility's policy also requires call lights to be accessible at all times, but this was not consistently followed for the residents observed.
Failure to Obtain Physician Order for Use of Bolster Mattress as Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. Specifically, a resident with severe cognitive impairment, muscle weakness, and a history of unsteadiness was observed lying on a bolster mattress on her bed. The resident's care plan identified her as a fall risk and included interventions such as a fall mat and keeping the bed in a low position, but there was no physician order or assessment for the use of the bolster mattress. Record review confirmed the absence of a physician order for the bolster mattress, and interviews with facility staff, including the ADON and Administrator, acknowledged that an order should have been obtained for the equipment. The facility's policy requires that restraints only be used when warranted by medical symptoms and with appropriate physician involvement, which was not followed in this instance.
Failure to Accurately Document Medication Refusals
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, vascular dementia, and other chronic conditions was not properly documented as refusing medication. The resident was prescribed multiple medications, including psychotropics and treatments for chronic illnesses. According to the medication administration report, the resident was documented as having received all prescribed medications during a specific period, while progress notes indicated that the resident had refused all medications during that same timeframe. The LVN responsible for administering the medications admitted to prematurely coding the medications as administered because they had already been pulled from the medication cart, despite the resident refusing to take them. The LVN documented the refusals in the progress notes but did not accurately reflect this in the medication administration record (MAR). This discrepancy was confirmed by interviews with the ADON and another LVN, both of whom stated that medication administration should only be documented after witnessing the resident take the medication, and refusals should be properly coded in the MAR. Facility policy required accurate and timely documentation of medication administration, including verifying medications against physician orders and documenting immediately after administration. The failure to accurately document medication refusals in the MAR resulted in a discrepancy between the MAR and progress notes, which could lead to a lack of awareness regarding the resident's actual medication intake.
Failure to Ensure Safe and Informed Transfer of Resident with Behavioral Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate transfer of a resident who was experiencing behavioral issues, including agitation and attempts to remove his g-tube, ostomy, and catheter. Despite the resident's confusion, inability to speak English, and need for one-to-one supervision to prevent device removal, the facility arranged for a private non-medical transport to take him to the emergency room after EMS declined to transport, determining it was not a medical emergency. The resident was sent without a staff escort or family member, and upon arrival at the ER, he was left unsupervised in the waiting area, with only a face sheet and medication list provided to the hospital. No clinical documentation or detailed report about his condition or the reason for transfer was sent with him. The facility did not notify or coordinate with the resident's representative (RP) prior to the transfer, which prevented the RP from selecting a preferred hospital or being present to supervise and interpret for the resident. The RP was only notified after the resident was already en route, and the hospital staff expressed concern and frustration upon the resident's arrival without proper documentation or supervision. The resident's inability to communicate and his ongoing agitation further complicated his care upon arrival at the ER. Additionally, the facility failed to update the medical provider (MD/NP) after EMS refused to transport the resident, and did not consider or implement alternative interventions such as PRN medications or physical restraints (e.g., abdominal binder) to address the resident's behaviors prior to transfer. The care plan did not address behavioral concerns, and staff interviews revealed a lack of clear communication and decision-making regarding the resident's needs and the appropriate method of transfer. The facility's actions did not meet regulatory requirements for safe transfer, communication of clinical information, or preparation and orientation of the resident in a manner he could understand.
Failure to Provide Required Admission Documentation and Disclosures
Penalty
Summary
The facility failed to establish and implement an admissions policy for one resident, as evidenced by the lack of a written admission agreement, consent to treat, resident rights notification, Medicare/Medicaid information, and disclosure of services and charges at the time of admission. The resident, a 71-year-old male with multiple complex medical conditions including a recent intracerebral hemorrhage, anxiety disorder, colostomy, urinary retention with catheter, and gastrostomy, was admitted from the hospital for a planned stay. Despite these needs, neither the resident nor his representative received any of the required admission documentation or information upon arrival. Interviews and record reviews revealed that the resident's representative was not provided with an admission packet, was not informed of the resident's rights, and did not receive any required disclosures or facility protocols. The representative reported that all communication regarding the admission occurred between the facility and the hospital, with no direct engagement or paperwork provided to the family. The facility attempted to obtain verbal consents and later requested the resident's social security information for billing, but the representative refused due to concerns about the admission and subsequent transfer to the emergency room. The Business Office Manager (BOM) confirmed responsibility for admission documentation and acknowledged that none of the required forms or consents were completed for this resident. The BOM stated that admission documentation typically begins on the day of admission and can be completed electronically, but in this case, there was no evidence that the resident or representative was notified or provided with the necessary documents. The facility's admission packet, which includes multiple forms and disclosures required by state and federal regulations, was not given to the resident or representative at the time of admission.
Failure to Notify Resident Representative of Missed Dialysis Appointment
Penalty
Summary
The facility failed to immediately notify a resident's durable power of attorney for healthcare when the resident missed a scheduled dialysis appointment. The resident, an 84-year-old male with diagnoses including Type 2 Diabetes Mellitus and end stage renal disease, was care planned to attend dialysis three times weekly and was at risk for complications if appointments were missed. Documentation showed that the resident did not attend a scheduled dialysis session, and subsequent efforts to reschedule and arrange transportation were unsuccessful. Progress notes indicated that the nursing staff notified the Administrator, DON, and Assistant DON about the missed dialysis and the inability to secure transportation, but there was no documentation that the resident's representative was informed. Interviews with staff confirmed that while internal notifications were made, the family or responsible party was not contacted regarding the missed treatment. The durable power of attorney for healthcare also confirmed she was not notified of the missed dialysis session. Facility policy required that the resident's physician and family be notified about refusals of care, service, or treatment. Despite this, the responsible party was not informed when the resident missed dialysis, as confirmed by both staff interviews and record review. This omission occurred even though the resident was moderately cognitively impaired and had a designated healthcare representative.
Failure in Respiratory Care and Monitoring
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice, the resident's care plan, and the residents' choice for three residents reviewed for respiratory care. One resident, who was readmitted to the facility after an acute care hospital stay with diagnoses including Acute on Chronic Respiratory Failure with Hypoxia, COPD, and CHF, did not receive a physician's order for oxygen administration upon readmission. The resident was administered oxygen at levels ranging from 7 to 10 liters per minute without proper orders, and there was a failure to accurately assess for a respiratory change of condition when the resident requested to return to the hospital. The resident was found unresponsive and later declared dead, with evidence suggesting inadequate supervision and monitoring during the night shift. Another resident's tracheostomy tubing was observed resting on the floor, indicating a failure in safe handling and infection control practices. Additionally, a third resident did not receive consistent oxygen therapy as required. These deficiencies placed residents at risk of not receiving adequate respiratory care, potentially leading to difficulty breathing, health decline, or worsening of symptoms. The report includes detailed observations and interviews that highlight the facility's failure to adhere to care plans and professional standards, resulting in significant lapses in respiratory care. The facility was found to be out of compliance, with an Immediate Jeopardy identified and later removed, although the facility remained at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Failure to Manage Resident's Trust Fund Appropriately
Penalty
Summary
The facility failed to properly manage and account for the personal funds of a resident, identified as Resident #3, who was under their fiduciary care. Resident #3, a male with cerebral palsy, diabetes, hyperlipidemia, and impulse disorder, had a trust fund managed by the facility. Despite having no legal guardian or power of attorney, the facility did not ensure that his trust fund account was spent down to avoid exceeding the Medicaid resource limit, which could jeopardize his Medicaid benefits. The resident's account consistently held a balance over $5,500, with no deductions made, and the facility did not adequately notify him of the need to spend down his funds. Interviews with the Business Office Manager (BOM) and Social Worker (SW) revealed a lack of effective communication and action regarding the resident's financial situation. The BOM admitted to not providing a formal notification to Resident #3 about his over-resourced status, despite being aware of the risk of losing Medicaid eligibility. The SW attempted to assist the resident in spending down his funds but faced challenges due to the resident's limited understanding and lack of interest in purchasing items. The facility's policy required notification when a resident's account approached the Medicaid resource limit, but this was not properly executed. The facility's administration, including the Director of Nursing (DON) and Administrator (ADM), acknowledged the importance of maintaining the resident's resource limit to ensure continued Medicaid coverage. However, there was a lack of clarity and oversight in the process of managing the resident's trust fund and ensuring compliance with Medicaid requirements. The facility's failure to reconcile the trust fund monthly and notify the resident appropriately contributed to the deficiency, placing the resident at risk of losing essential benefits.
Deficiencies in Medication Administration and Monitoring
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration and monitoring. Resident #7, who has a history of essential hypertension and Alzheimer's disease, was not administered her prescribed Metoprolol Tartrate on three occasions in August 2024. The facility did not document blood pressure readings to justify withholding the medication, despite the resident's care plan indicating the need for antihypertensive medication. During this period, Resident #7 experienced two unwitnessed falls, although no injuries were reported. Resident #9, diagnosed with Alzheimer's disease and Type 2 Diabetes Mellitus, did not have his blood glucose levels checked or his sliding scale insulin administered as ordered 28 times in August 2024. The MAR lacked documentation of blood glucose readings or insulin administration, which was necessary to manage his diabetes effectively. The absence of documentation and administration of insulin could have impacted the resident's health, given his fluctuating blood glucose levels during the month. Interviews with facility staff, including LVNs and the DON, revealed a lack of consistent documentation and monitoring of medication administration. Staff acknowledged the importance of documenting medication administration and vital signs to ensure compliance with physician orders and to identify any trends or issues. The facility's policy on medication administration and documentation was not followed, as evidenced by the incomplete MARs and lack of recorded vitals, contributing to the deficiencies identified in the survey.
Incomplete Documentation of Wound Care in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically regarding the documentation of wound care. For one resident, the facility did not document wound care on 29 occasions in August 2024. This resident had multiple wounds, including a stage 4 pressure ulcer and other non-pressure wounds, which required regular wound care as per physician's orders. The treatment administration records (TAR) for this resident were left blank on several dates, and there was no documentation in the clinical chart or nursing progress notes explaining why the wound care was not performed. Similarly, for another resident, the facility failed to document wound care on 36 occasions in August 2024. This resident also had multiple wounds, including a stage 4 pressure ulcer and other non-pressure wounds, necessitating regular wound care. The TAR for this resident was also left blank on numerous dates, with no documentation in the clinical chart or nursing progress notes to indicate why the wound care was not completed. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the wound care nurse, and the Director of Nursing (DON), revealed inconsistencies in the wound care process. The wound care nurse was responsible for weekday wound care, while a weekend supervisor handled weekends. However, there was a lack of communication and oversight, leading to missed wound care sessions. The DON and Assistant Director of Nursing (ADON) acknowledged the importance of following wound care orders to prevent infection and ensure proper healing, but there was uncertainty about who was responsible for auditing the TARs to ensure compliance.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident who had a planned discharge home. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and a reconciliation of all pre-discharge medications with the resident's post-discharge medications. This deficiency was identified for one of the two residents reviewed for discharge planning. The resident in question was an elderly female with severe cognitive impairment, who had been admitted to the facility with multiple health issues including aphasia, dysphagia, hemiplegia, diabetes, and hypertension. She was on a feeding tube and had a history of unplanned weight loss. Despite these complex medical needs, the facility did not complete the necessary discharge documentation when the resident was discharged home with home health services. Interviews with facility staff, including LVNs and the DON, revealed that the charge nurse was responsible for completing the discharge summary. However, this was not done for the resident in question. The facility's policy required a comprehensive discharge summary to ensure continuity of care, but this was not adhered to, potentially impacting the resident's transition back home.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide or obtain timely laboratory services for a resident, leading to a deficiency in care. The resident, an elderly male with multiple medical conditions including sepsis, dementia, and pressure injuries, was ordered a stool culture for C. diff by his physician due to a strong odor during bowel movements. However, the facility did not complete the lab order, as there was no evidence of lab collection or results for C. diff from the specified dates. The charge nurse, who was responsible for collecting the specimen, stated that he placed the stool sample in the fridge and expected the lab company to collect it during their routine visit. However, the lab requisition forms were missing, and the lab company did not pick up the specimen. The nurse believed the specimen was collected after his shift, but the lab company and facility could not determine why the lab was not completed. The Director of Nursing (DON) explained the expected procedure for handling lab orders, which included collecting the specimen, sending a requisition form to the lab company, and documenting the process. Despite these protocols, the specimen was not processed, and the facility's policy on diagnostic services was not followed, resulting in a failure to meet the resident's needs for timely laboratory services.
Failure to Isolate COVID-Positive Resident
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper isolation of a COVID-positive resident. The resident, who was on day 7 of a 10-day isolation period, was observed in the communal dining room without a mask, sitting near other residents who were also unmasked. This action was contrary to the facility's COVID policy, which required the resident to remain isolated for the full 10-day period to prevent the transmission of the virus. The resident in question was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 00, and had multiple diagnoses including Alzheimer's disease, hypertension, depression, anxiety, and dysphagia. Despite being asymptomatic, the resident was still required to adhere to isolation protocols. However, the facility's records did not reflect any interventions specific to her COVID-positive status, and there was no documentation of a negative test result that would have justified her presence in the dining room. Interviews with facility staff, including LVNs and the DON, revealed a lack of adherence to the established COVID isolation protocols. Staff acknowledged the difficulty in keeping residents isolated, particularly those with cognitive impairments, but confirmed that the protocol required a 10-day isolation period regardless of symptoms. The facility's policy mandated isolation and the use of PPE for staff and residents, yet these measures were not effectively implemented, leading to the potential risk of virus transmission among residents.
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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