Afton Oaks Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 7514 Kingsley St, Houston, Texas 77087
- CMS Provider Number
- 455682
- Inspections on file
- 39
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 13 (8 serious)
Citation history
Health deficiencies cited at Afton Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with paraplegia, generalized muscle weakness, contractures, dysphagia, cognitive communication deficit, and a need for extensive ADL assistance was care planned and assessed as requiring supervision and two-person assist for bed mobility, transfers, toileting, dressing, and personal hygiene. During personal care, a CMA provided care alone, despite the documented two-person assist requirement, and the resident became agitated and fell from the bed to the floor, landing face down and sustaining an upper lip laceration that required stitches. Interviews and records confirmed that the resident’s need for two-person assistance was documented in the MDS, care plan, and Kardex, and that this requirement was not followed at the time of the incident.
A resident with significant cognitive impairment and a history of wandering eloped from the facility after staff failed to provide adequate supervision and did not ensure required monitoring devices were in place. The resident exited the building without a wander guard, was not identified by staff as leaving, and was later found outside by a staff member and police. Facility policies for monitoring and door alarms were not effectively implemented, resulting in the resident's unsupervised exit.
A resident with multiple complex medical conditions, including ESRD, sepsis, and numerous wounds, did not receive ordered IV antibiotics, wound care, or pain management upon admission. Facility staff failed to notify the physician of missed medications, missed hemodialysis, and incomplete wound care, and did not document pain assessments or administer pain medication prior to wound treatments. These failures led to the resident's transfer to the hospital with sepsis and subsequent bilateral amputations.
Two residents experienced neglect due to the facility's failure to initiate timely wound care, administer prescribed IV antibiotics, and notify physicians of missed treatments and changes in condition. One resident did not receive wound care for several days after admission, while another with multiple wounds and end-stage renal disease did not receive necessary antibiotics, wound treatments, or pain management, and missed a scheduled hemodialysis session without physician notification. Staff interviews revealed confusion about responsibilities and a lack of comprehensive clinical review for new admissions.
Two residents with multiple pressure ulcers and complex wounds did not receive timely wound care or treatment orders upon admission. Wound care orders, wound consults, and necessary medications were delayed for several days, and staff interviews revealed confusion about responsibilities and a lack of follow-up to ensure prompt care. These failures resulted in significant delays in wound management and treatment.
A resident with multiple severe wounds and cognitive impairment did not receive appropriate pain assessment or management during wound care. Staff failed to assess pain, did not administer ordered pain medication, and did not stop procedures when the resident showed signs of distress. There was no care plan for pain, and staff were unclear about pain management responsibilities and documentation, resulting in unmanaged pain during treatments.
A resident with end-stage renal disease did not receive prescribed hemodialysis for four days due to an elevated heart rate and subsequent failures in staff communication, documentation, and physician notification. The breakdown in following facility policy and lack of timely intervention led to a missed critical treatment and placed the resident at risk.
A resident with severe wounds, sepsis, and on dialysis did not receive ordered IV antibiotics for several days after admission due to failures in order entry, communication, and medication administration. Staff did not ensure timely IV access or notify providers about missed doses, and the resident's complex condition and nonverbal status further complicated care. This resulted in a significant medication error as the facility did not follow physician orders or its own medication administration policies.
Two halls were found to have significant deficiencies in maintaining a safe, clean, and homelike environment. On one hall, persistent foul odors from two residents' rooms, due to refusal of care and wound treatment, spread throughout the area despite increased cleaning efforts. On another hall, ongoing construction exposed residents and staff to dust and noise, with incomplete barriers and no clear communication or protective measures, resulting in missed wound care visits for two residents. Staff and residents were not adequately informed or protected during these events.
The facility did not maintain a safe and comfortable environment on two halls, with persistent foul odors from two residents who refused care on one hall and unsafe renovation practices on another, including inadequate communication, lack of protective equipment, and barriers that prevented wound care for two residents. Additionally, a dining room door was improperly propped open for an extended period, and staff were unclear about interventions to address these issues.
The facility did not maintain an effective pest control program, resulting in live flies being observed in a hallway and in the rooms of two residents, both of whom had significant medical needs and required assistance with daily activities. Despite ongoing pest control treatments, flies continued to be present in resident care areas, indicating a deficiency in the facility's pest management practices.
A resident who was legally blind and cognitively intact was not consulted about designating a responsible party at admission, resulting in a family member being listed without consent. This led to an unauthorized insurance change and a delay in necessary eye surgery. Staff interviews confirmed the resident was capable of making his own decisions and should have been consulted, but the process failed to include his input.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. The report notes that the environment posed risks and staff oversight was insufficient, but does not specify the hazards or individuals involved.
Staff failed to ensure that medications, including Latanoprost eye drops and Humalog KwikPen insulin, were properly labeled with open and expiration dates or removed when expired on two medication carts. Multiple residents' medications lacked required labeling, and an expired medication was not removed as per facility policy, as confirmed by observations, record reviews, and staff interviews.
A resident with quadriplegia and anxiety disorder received duplicate Buspirone orders, leading to administration of the medication both two and three times daily due to failure to discontinue the previous order. Staff interviews confirmed the duplicate orders and acknowledged the error, with facility policy requiring daily review of new physician orders for accuracy.
Surveyors found that the facility failed to maintain food service safety standards, including leaving dirty dishes with leftover food in the dining room overnight, allowing grease buildup on kitchen vent hood rails, and not properly labeling or dating food items in the refrigerator and freezer. Expired food was also found in the dry goods pantry. Staff interviews confirmed these practices were not in line with facility policy.
A resident with multiple chronic conditions was discharged from hospice services, but the facility did not complete a Significant Change MDS assessment or update the care plan within the required 14-day period. The MDS nurse, who was new to the role, was unaware of the discharge until after the deadline had passed, resulting in the assessment being completed late and the care plan remaining outdated.
A resident with diagnoses of bipolar disorder and schizoaffective disorder was admitted and readmitted to the facility, with documentation confirming mental illness on her records and care plan. Despite these findings, the required PASARR Level II (PE) screening was not completed, as confirmed by the MDS coordinator and review of the clinical record.
A resident with multiple chronic conditions was admitted without a completed baseline care plan within the required 48-hour timeframe. The baseline care plan document was left blank, and the comprehensive care plan was not started until after the deadline. Staff interviews revealed confusion about which nurse was responsible for initiating the care plan, and the resident's admission MDS was also incomplete.
A resident with multiple chronic conditions was discharged from hospice and began receiving therapy, but the care plan was not updated to reflect this change. Staff interviews revealed a lack of awareness and communication regarding the resident's status change, resulting in the care plan continuing to indicate hospice care despite the resident's new therapy regimen.
A resident with quadriplegia and anxiety disorder received duplicate orders for Buspirone, with both twice-daily and three-times-daily regimens being administered concurrently. The consultant pharmacist did not identify or report this irregularity during the monthly drug regimen review, and staff interviews confirmed the duplicate orders were not discontinued as required. The issue was discovered through record review and staff interviews, revealing a lapse in medication review and reporting processes.
A resident with advanced dementia and a history of wandering accessed and ingested hand sanitizer that was not properly secured, leading to hospitalization. The resident's care plan identified her as at risk for unsafe wandering and required staff redirection, but hand sanitizer was left accessible on medication carts. Staff interviews confirmed the resident's known behaviors and the unsecured sanitizer, resulting in a failure to prevent the accident.
A resident with significant physical and cognitive impairments did not receive scheduled showers on multiple occasions, despite requiring substantial assistance for ADLs. Interviews with the resident and staff confirmed that the resident did not refuse care, and documentation was lacking for the missed showers. Staffing shortages and lack of follow-up contributed to the failure to provide necessary hygiene services.
A resident with advanced dementia and a history of wandering was found with a bottle of hand sanitizer, appearing to drink from it, and was later hospitalized after being found hard to awaken. Staff interviews and documentation revealed that hand sanitizer was not always secured, and the incident was not thoroughly investigated or reported as neglect to the state agency, despite facility policy requiring such actions.
A resident experienced significant weight loss and was prescribed Ozempic for diabetes, but the facility failed to update the care plan to address these issues. The resident's care plan did not reflect the weight loss or the medication's side effects, despite the resident being cognitively aware and requiring assistance with daily activities. Interviews with staff revealed a lack of experience and oversight in updating care plans.
The facility failed to administer medications as ordered for two residents, leading to blanks in the MARs without documentation of reasons. A resident did not receive his inhaler and supplement, while another missed a dose of Carvedilol. Interviews with staff confirmed the expectation for complete documentation, highlighting a lapse in following the facility's medication administration policy.
A resident with cognitive and physical impairments did not receive proper incontinent care, as CNAs failed to clean the perineal area thoroughly, increasing the risk of UTIs. Despite the facility's training programs, the CNAs did not follow the correct procedures, and the facility could not provide a documented perineal care policy.
A CNA in a long-term care facility failed to perform hand hygiene after removing soiled gloves during incontinence care for a cognitively impaired resident. Despite recent training, the CNA left the room without sanitizing her hands, risking cross-contamination. The facility's infection control policy emphasizes hand hygiene as crucial for preventing infection spread, but this protocol was not followed.
A resident reported missing personal property, including important identification and financial cards, but the facility failed to adequately follow up or assist in replacing the items. Despite reporting the incident to the state and police, the facility did not complete the grievance process, leaving the resident unable to replace all missing items, affecting his ability to renew his citizenship.
Failure to Follow Two-Person Assist Requirements Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents. A male resident with diagnoses including immobility syndrome (paraplegic), generalized muscle weakness, cognitive communication deficit, contractures, dysphagia (oral phase), hyperlipidemia, and a need for assistance with personal care was admitted on an unspecified date. His MDS assessment showed he required supervision and two-person assistance with bed mobility, transfers, toileting, dressing, and personal hygiene, and his care plan documented that he was at risk for falls and required two-person assistance with all ADLs except eating. On the date of the incident, a CMA (CMA-A) was providing personal care to this resident. According to CMA-A’s signed statement, the resident became agitated during care, so she stopped to calm him. After he calmed down, she resumed care, but the resident became agitated again, and as she was wiping him, he fell from the bed to the floor, landing face down and on his left side. CMA-A reported observing blood and calling for help. The facility’s Provider Investigation Report later documented that CMA-A had provided care to the resident alone, despite the care plan requirement for two-person assistance, and that the resident rolled out of bed onto the floor during this episode of care. As a result of the fall, the resident sustained a laceration to his upper lip. Hospital records documented a diagnosis of a fall with an upper lip laceration, and the resident received stitches to treat the injury. A progress note recorded that he returned to the facility with one stitch to his upper lip following the fall. During interviews, the Administrator and ADON stated that the resident was supposed to receive two-person assistance for care, that this requirement was reflected in the Kardex and care plan, and that CMA-A did not follow these directions when providing care at the time of the fall.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent a resident from eloping. The resident involved had significant cognitive impairment, as indicated by a BIMS score of six out of fifteen, and diagnoses including Parkinson's Disease with dyskinesia, dementia with agitation, and a traumatic brain injury. The care plan identified the resident as an elopement risk, with interventions such as a wander guard and monitoring per shift, but these were not effectively implemented at the time of the incident. On the day of the incident, the resident was observed in the lobby, pacing, and later left the facility at an unknown time. Multiple staff interviews revealed that the resident exited the building without a wander guard in place and was not identified by staff as leaving. The resident was later found outside the facility by a staff member and a police officer, having crossed a street and nearly reached a freeway. Staff were unable to determine which door the resident used to exit, and it was noted that someone would have had to unlock the door for the resident to leave, but no staff could confirm who did so or how the resident was able to exit undetected. Facility policy required the use of door alarms, monitoring devices, and regular checks of wander guard devices, but these measures were not followed or were ineffective in this case. Staff interviews confirmed that the resident did not have a wander guard on at the time of elopement, and the required monitoring and documentation were not completed. The failure to supervise and monitor the resident according to the care plan and facility policy resulted in the resident's unsupervised exit from the facility.
Failure to Notify Physician and Administer Critical Treatments
Penalty
Summary
The facility failed to immediately notify the resident's physician and representative of significant changes in the resident's condition, as well as failures in administering ordered treatments and medications. Specifically, a resident with a history of cerebral infarction, sepsis due to E. coli, end-stage renal disease (ESRD) requiring hemodialysis, multiple pressure ulcers, and a recent hospital stay for sepsis was admitted with orders for IV antibiotics (Zosyn), wound care, and pain management. Upon admission, the facility did not administer the ordered IV antibiotic Zosyn from admission through several days, nor did they notify the physician of this failure. Additionally, wound care orders for the resident's 14 wounds were not entered or implemented in a timely manner, and the physician was not informed of these omissions. The resident also missed a scheduled hemodialysis treatment due to an elevated heart rate, but the physician was not notified of the missed treatment or the change in condition. Documentation and interviews revealed confusion among nursing staff regarding roles and responsibilities for wound care and medication reconciliation, leading to delays in treatment initiation. The resident did not receive any pain medication prior to wound care treatments, and no pain assessments were documented, despite the presence of multiple severe wounds. The only pain medication ordered was oral acetaminophen, which was not administered, and the resident was gastrostomy status, making oral administration inappropriate. Interviews with staff, including the admitting nurse, treatment nurses, DON, and medical director, confirmed a lack of communication and clinical review following the resident's admission. The medical director and nurse practitioners were not informed of missed medications, missed dialysis, or incomplete wound care, and there was no evidence of a care plan for pain management. Observations of wound care procedures showed the resident exhibiting signs of pain without appropriate pain management. These failures were identified as an Immediate Jeopardy situation, as they resulted in the resident being transferred to the hospital with sepsis and ultimately undergoing bilateral above-knee amputations due to necrotic tissue and lack of blood flow.
Failure to Provide Timely Wound Care, Medication Administration, and Physician Notification
Penalty
Summary
The facility failed to protect two residents from neglect by not ensuring timely and appropriate medical care and communication with physicians. One resident was admitted with a pressure ulcer but did not have wound care orders or treatment initiated until several days after admission. Documentation shows that the wound was identified upon admission, but no orders for wound care or wound consult were entered until nearly a week later, resulting in a delay in treatment. Interviews with nursing staff and administration confirmed that wound care should have been initiated within 24 hours of admission, and the lack of documentation indicated that the treatment did not occur as required. Another resident with multiple complex medical conditions, including end-stage renal disease, sepsis, and numerous wounds, was admitted without all necessary medication and treatment orders being entered or implemented. This resident did not receive prescribed IV antibiotics (Zosyn) or wound care treatments for several days after admission. Additionally, the facility failed to notify the resident's physician when the resident missed a scheduled hemodialysis session and when wound care orders were not implemented. The resident also did not receive adequate pain management, as only PRN oral acetaminophen was ordered, which was not appropriate for a resident with a gastrostomy tube, and no pain assessments were documented prior to wound care procedures. Interviews with facility staff revealed confusion and lack of clarity regarding roles and responsibilities for wound care and admission processes. There was no evidence of a comprehensive clinical review of new admissions to ensure all necessary orders and treatments were in place. The failures in communication, documentation, and timely implementation of physician orders led to significant lapses in care for both residents, as confirmed by staff interviews and record reviews.
Failure to Provide Timely Pressure Ulcer Care and Treatment Orders
Penalty
Summary
The facility failed to provide necessary and timely pressure ulcer care for two residents, resulting in delayed treatment and lack of appropriate wound management. One resident was admitted with a stage 2 pressure ulcer and additional wounds, but did not have wound care orders or treatments initiated until several days after admission. Documentation shows that from the time of admission, there were no wound care orders, no wound consult, and no wound care documented on the Medication Administration Record (MAR) until nearly a week later. Facility staff, including the ADON, DON, and Administrator, confirmed that wound care orders should be in place upon admission or within 24 hours, and acknowledged that the lack of orders and treatment placed the resident at risk for wound deterioration and infection. Another resident was admitted with multiple complex wounds, including two stage 4 pressure ulcers, several unstageable wounds, venous and arterial ulcers, and a diabetic foot ulcer. The initial skin assessment identified these wounds, but orders for wound care and a wound consult were not entered or implemented until several days after admission. Additionally, the resident was prescribed IV antibiotics for wound infection, but the medication was not administered until several days after admission. Interviews with nursing staff and practitioners revealed confusion and lack of clarity regarding responsibility for entering and implementing wound care orders, as well as a lack of communication and follow-up to ensure that all necessary treatments were started promptly. Observations and interviews further revealed that there was no consistent process for clinical review of new admissions to ensure accuracy and completeness of wound care orders and treatments. Staff members were unclear about their roles and responsibilities in the wound care process, and there was no timely follow-up to identify and correct errors or omissions in the admission process. As a result, both residents experienced significant delays in receiving appropriate wound care and treatment, as documented by the lack of orders, delayed administration of medications, and missed wound consults.
Failure to Provide Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple severe wounds, resulting in a deficiency identified by surveyors. The resident, a female with a history of cerebral infarction, sepsis, end-stage renal disease requiring dialysis, and multiple stage four pressure ulcers and arterial wounds, was admitted with significant medical complexity and was nonverbal with severe cognitive impairment. Despite her extensive wounds and high risk for pain, there was no care plan for pain, and her pain was not assessed or managed according to professional standards or her needs. Observations revealed that during wound care procedures, the resident exhibited clear signs of pain, such as wincing, deep breathing, and tears, particularly when bandages were removed and wounds were treated. Staff failed to assess her pain prior to wound care, did not provide timely or appropriate pain medication, and did not stop procedures to reassess or address her pain when she showed distress. Documentation showed that although there were orders for acetaminophen, these were not administered, and staff were unclear about pain assessment tools and procedures. Interviews with nursing staff indicated confusion about responsibilities for pain management, lack of documentation, and a failure to communicate or follow up on the resident's pain needs. The attending physician and wound care doctor were not notified of the resident's pain, and no additional pain management interventions were implemented until after the surveyor's intervention. The facility's own policy required assessment and management of pain, including for nonverbal residents using the PAINAD tool, but this was not followed. The deficiency was identified as Immediate Jeopardy due to the failure to provide pain management consistent with professional standards, the resident's care plan, and her goals and preferences, resulting in unmanaged pain during daily wound care treatments.
Removal Plan
- The treatment where the resident was experiencing pain was stopped until adequate pain relief could be achieved.
- Primary care provider was contacted by the director of nurses and Tylenol order changed to Extra Strength 650 mg every 8 hours scheduled and an additional dose prior to wound care.
- 100% review of residents receiving wound care for PRN pain medication orders that may be given prior to wound care was completed by Regional Compliance nurse/DON/Designee.
- Residents identified requiring wound care received new orders/order clarifications to ensure adequate pain management prior to wound care from audit completed.
- Resident identified in the audit has an allergy to acetaminophen.
- Care plans for facility residents with wounds were updated by Regional Compliance Nurse and DON with interventions to monitor, assess, and report pain during care, including wound care, and what to do if pain management is not effective.
- Regional Compliance Nurse provided in-service to DON/ADON regarding pain management during care and procedures following facility's policy for enforcement, requiring no change in company policy as the policy was effective but not being followed.
- Communication with medical provider for any resident that is experiencing uncontrolled pain during care and/or procedures using the SBAR as communication tool.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool.
- All nurses (LVN/RNs), including PRN nurses, who are not in serviced will not be allowed to provide resident care until training has been completed.
- The Medical Director was notified by the Administrator regarding the immediate jeopardy citation.
- An Ad-hoc QAPI meeting was held by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will observe wound care to ensure any residents that is receiving wound care receive effective pain management during the procedure.
- DON/Designee will review order listing report in point click care (facility electronic medical record) to see any new wound care orders and ensure that pain management orders are in place.
Failure to Provide and Document Hemodialysis Services as Ordered
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, dependent on hemodialysis, did not receive her prescribed dialysis treatment for a period of four days. The resident, who was severely cognitively impaired and fully dependent on staff for activities of daily living, was admitted with multiple complex medical conditions, including a central line for dialysis access. On the scheduled dialysis day, the resident was unable to receive treatment due to an elevated heart rate, and although the nephrologist and facility nurse attempted interventions, the dialysis session was not completed. Following the missed dialysis session, there was a breakdown in communication and documentation among facility staff. The charge nurse did not clearly document the missed dialysis or the resident's change in condition in the 24-hour report or other required communication tools. The nurse also failed to ensure that the physician or nurse practitioner was adequately notified regarding the missed dialysis and did not follow up on orders for medication administration or alternative interventions. Other staff members, including the DON and ADON, were unaware of the missed treatment until after the fact, and there was no evidence that the resident's care plan or medical record was updated to reflect the missed dialysis or any follow-up actions. The facility's policies required prompt notification of a physician in the event of a change in status or missed treatment, as well as thorough documentation of all communication and interventions. These procedures were not followed, resulting in the resident missing dialysis for four consecutive days. The failure to provide dialysis as ordered and to communicate and document the missed treatment placed the resident at risk for delayed treatment and actual harm, as identified by surveyors.
Removal Plan
- Review all facility residents receiving dialysis to identify any other residents receiving dialysis treatments.
- Assess all facility residents ordered to receive hemodialysis treatments to ensure no other residents missed hemodialysis treatments.
- Regional Compliance Nurse provides in-service to DON, ADON, and Administrator regarding Change of Condition (when to Report to MD/NP/PA and follow-up communication), Abuse/Neglect, and Dialysis (facility's dialysis policy in-serviced for enforcement).
- DON/ADON will in-service facility staff by phone and/or in person regarding facility policy on Abuse/Neglect. Facility staff, including PRN staff, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding Change of Condition to include when to Report to MD/NP/PA. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RN) by phone and/or in person regarding facility's dialysis policy. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR).
- Notify the Medical Director regarding the immediate jeopardy citation.
- Hold an Ad-hoc QAPI meeting by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will monitor changes of condition to ensure changes of condition have been reported to the MD and followed up.
- DON/Designee will monitor Dialysis residents to ensure that residents did not miss any dialysis or had any incomplete dialysis session, if dialysis sessions were missed or incomplete that an SBAR was completed, and was the resident monitored.
Failure to Administer Prescribed IV Antibiotic Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including sepsis due to E. coli, severe wounds, and dependence on renal dialysis, was admitted to the facility. Upon admission, the resident had physician orders for IV antibiotic therapy (Piperacillin-Tazobactam/Zosyn) to treat infections related to wounds, urinary tract, and pneumonia. Despite these orders, the resident did not receive the prescribed IV antibiotic from the time of admission for several days. Record reviews showed that the medication was not administered as ordered, and there was no documentation of administration for multiple scheduled doses. Additionally, there was confusion regarding IV access, with delays in arranging for a midline catheter and issues with the pharmacy dispensing the correct antibiotic dosage. Interviews with facility staff revealed that the admitting nurse did not ensure all admission orders were entered before the end of her shift, and there was a lack of timely communication with the medical provider regarding the inability to administer the antibiotic. The medical director and nurse practitioners were not notified of the missed doses or the issues with medication availability and IV access. The wound care physician was also unaware that the resident had not received the ordered antibiotic therapy. Progress notes indicated that the resident had no IV access for the antibiotic, and there was a delay in obtaining the correct medication from the pharmacy. The facility's policy required medications to be administered as prescribed and for staff to notify providers of any issues, but these procedures were not followed. The resident's condition was further complicated by extensive wounds, including stage four pressure ulcers and necrotic tissue, and she was nonverbal and dependent on staff for all care. Observations documented the severity of her wounds and her lack of response to painful procedures, likely due to her cognitive and physical impairments. The failure to administer the prescribed IV antibiotic as ordered was identified as a significant medication error, and the facility was cited for not ensuring residents were free from such errors.
Removal Plan
- SBAR/Change of condition assessment completed with notification of provider and responsible party regarding the missed IV antibiotics.
- Correct dosage of IV antibiotics have been obtained by facility and are being administered as ordered.
- 100% audit completed of facility residents to identify any residents with IV antibiotics. No additional residents identified as receiving IV antibiotics.
- 100% audit completed of facility residents to identify any missed medications and/or treatments. Providers for residents identified as missing medications/treatments were notified and medication error documentation completed on facility residents identified as missing medications/treatments.
- Regional Compliance Nurse provided in-service to DON, ADON, and Administrator regarding: admission Process to include reconciling treatment and medication orders.
- Medication Administration policy in-serviced for enforcement (no revision of policy required, as policy is effective but not being followed).
- DON/ADON will in-service facility staff by phone and/or in person regarding facility policy on Abuse/Neglect. Facility staff, including PRN staff, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding the admission Process to include reconciling treatment orders and medication orders. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RN) by phone and/or in person regarding Medication Administration. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- The Medical Director was notified by Administrator regarding the immediate jeopardy citation.
- An Ad-hoc QAPI meeting was held by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will monitor admission Process daily to ensure any new admissions and readmissions had reconciled treatment and medication orders.
- Nursing administration designee will complete admission checklist audit to ensure medication reconciliation has been double checked from what was ordered versus what the facility staff enters into the facility's electronic record.
- DON/Designee will monitor Medication & Treatment Administration Records daily to ensure all medications & treatments were signed out, administered, and available by utilizing the Missed Med Report during morning clinical meeting.
Failure to Maintain Safe, Clean, and Homelike Environment During Odor and Construction Issues
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on two of its four halls, specifically Hall 300 and Hall 400. On Hall 300, persistent foul odors of urine, feces, and body odor were observed, particularly emanating from the room of two residents with significant wound care needs and a history of refusing care such as bathing, grooming, and wound treatment. Multiple interviews with staff, residents, and family members confirmed that the odor was longstanding, noticeable throughout the hallway, and had not been effectively addressed by increased cleaning or the use of odor neutralizers. Housekeeping staff reported cleaning the affected rooms twice daily and using multiple bottles of odor neutralizer per week, but these efforts did not resolve the issue. Residents and family members expressed dissatisfaction with the living conditions, describing the environment as unpleasant and not reflective of a homelike setting. On Hall 400, the facility failed to ensure that ongoing construction and renovation activities did not negatively impact residents' comfort and access to care. During the renovation, a section of the hallway was closed off with plastic sheeting, and workers were observed spraying texturizer on the ceilings while wearing N95 or respirator masks. The area was filled with dust and noise, and residents remained in their rooms behind incomplete plastic barriers, with no clear communication or protective measures provided to them or the staff. Staff members were unaware of the nature of the work or the need for personal protective equipment, and residents were not given the option to move or provided with masks. The construction activities resulted in at least two residents missing scheduled wound care visits, as the wound care physician was unable to access their rooms due to the barriers. The report details that the facility administration did not provide adequate notice or information to staff or residents regarding the renovation activities, and there was a lack of signage indicating the type of work being performed. Staff interviews revealed confusion and concern about the safety of the environment, and residents reported increased discomfort, including noise, dust, and respiratory symptoms. The administration acknowledged the renovations but was unable to specify the materials being used or the necessary precautions. The facility also failed to provide a policy for maintaining a homelike environment when requested by surveyors.
Failure to Maintain Safe, Sanitary, and Comfortable Environment During Odor and Renovation Issues
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment on two of four halls, specifically Hall 300 and Hall 400. On Hall 300, persistent foul odors were observed, described as urine, bowel movement, and body odor, emanating from a specific resident room and spreading into the hallway and other rooms. Multiple staff, residents, and family members confirmed the ongoing odor issue, with some stating it had been present for an extended period. The source of the odor was attributed to two residents who consistently refused care, including bathing, wound care, and incontinence care. Despite additional cleaning and the use of odor neutralizers, the problem persisted, and staff were unclear about any effective interventions being implemented by facility management. On Hall 400, the facility failed to ensure that construction and renovation activities were conducted safely and with proper communication. Residents and staff were not informed in advance about the nature of the work, which involved spraying a texturizer on ceilings, creating dust and loud noise. Plastic barriers were erected, but they did not fully seal resident rooms, allowing dust and sprayed material to enter. Some residents were confined to their rooms without being offered masks or the option to relocate, and staff were not provided with information or appropriate personal protective equipment. The construction activities also resulted in at least two residents not receiving scheduled wound care, as the wound care physician was unable to access their rooms due to the barriers. Additionally, the facility failed to maintain the physical environment in the dining area, where a door was propped open with a zip tie and an extension cord was zip tied to the door hinges, preventing the door from closing. This situation had persisted for approximately two months, and staff were aware of the issue but had not addressed it. Throughout the report, staff interviews revealed a lack of communication and awareness regarding environmental safety and infection control practices during renovations, as well as ongoing issues with odor management and resident care refusals.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live flies in one of the hallways (Hall 300) and in the rooms of two residents. Observations revealed approximately 16 flies in Hall 300, as well as multiple live flies on the blankets and walls in the rooms of two residents. Both residents reported seeing flies in their rooms frequently, with one resident attributing the presence of flies to towels used by staff to wipe tables. Record reviews indicated that one resident was cognitively intact and had multiple pressure ulcers, requiring varying levels of assistance with daily activities. The other resident had moderately impaired cognition, multiple pressure ulcers, chronic venous ulcers, and required substantial assistance with personal care. The presence of flies was directly observed during interviews and room inspections, confirming the ongoing pest issue in these areas. Facility records showed that pest control services were being provided, with treatments for various pests including flies, roaches, and ants. However, the frequency and scope of treatments appeared insufficient to prevent the recurrence of flies, as evidenced by the continued presence of pests in resident care areas. The facility's pest control policy focused on maintaining an insect and vermin-free environment, but the observed conditions demonstrated a failure to achieve this standard.
Failure to Ensure Resident's Right to Designate a Representative
Penalty
Summary
The facility failed to ensure that a resident was given the right to designate a representative or responsible party at the time of admission, despite the resident being alert, oriented, and cognitively intact. The resident, who was legally blind due to bilateral retinal detachment, was admitted with the ability to make his own decisions, as evidenced by a BIMS score of 15 and documentation of being alert and oriented. However, there was no documentation or evidence that the resident was consulted about his wishes regarding the designation of a responsible party during the admission process or at the 72-hour care plan meeting. As a result of this omission, a family member was listed as the responsible party without the resident's explicit consent. This led to confusion and a grievance when the resident discovered his health insurance had been changed without his knowledge, resulting in a delay of a scheduled eye surgery. The resident and the alleged responsible party both denied authorizing the insurance change, and the responsible party stated he was only next of kin and not authorized to make decisions on the resident's behalf. Multiple staff interviews confirmed that the resident was capable of making his own decisions and should have been consulted about the responsible party designation at admission. Facility staff, including the admissions coordinator, business office manager, MDS coordinator, and social worker, acknowledged that the resident was not asked about his preferences for a responsible party, and that this was a violation of resident rights. The facility's policy required that residents be allowed to exercise their rights without interference, and staff interviews confirmed that the process for establishing a responsible party did not include direct consultation with the resident, despite his capacity to make such decisions.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents and that staff did not provide sufficient oversight to mitigate these hazards. Specific details regarding the nature of the hazards, the supervision provided, or the residents affected were not included in the report.
Failure to Label and Remove Expired or Undated Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper labeling and removal of expired or undated medications on two out of three medication carts reviewed. Specifically, Latanoprost ophthalmic solution, used to treat glaucoma, was not labeled with an expiration date for three residents, and an expired bottle was not removed from the cart for another resident. Additionally, a Humalog KwikPen (insulin lispro) was found on a medication cart without an open date, despite manufacturer instructions requiring it to be discarded 28 days after removal from refrigeration. Observations revealed that multiple bottles of Latanoprost for several residents lacked open dates, and one bottle remained on the cart past its recommended use-by date. The Humalog KwikPen for a resident with diabetes was also undated after being placed on the medication cart, contrary to storage guidelines. These findings were corroborated by record reviews, which confirmed the medication orders and the absence of required labeling. Interviews with facility staff, including the ADON, DON, and the facility pharmacist, indicated that responsibility for medication cart oversight was shared among staff and managers, with periodic audits conducted. The facility's own policy required immediate removal of outdated medications and proper labeling with open and expiration dates, but these procedures were not consistently followed, resulting in the identified deficiencies.
Failure to Discontinue Duplicate Buspirone Orders Resulting in Excessive Dosing
Penalty
Summary
A deficiency occurred when a resident with quadriplegia and generalized anxiety disorder received duplicate orders for Buspirone 5 mg, resulting in the medication being administered both two times a day and three times a day over a period of time. Record reviews showed that both orders were active and being administered concurrently, with documentation on the Medication Administration Records (MAR) confirming that the resident received both regimens. The issue was identified when a nurse placed a call to the physician to clarify the Buspirone orders, and the duplicate order was subsequently discontinued. Interviews with facility staff, including an LPN, medication aide, ADON, DON, and the Administrator, revealed that the previous Buspirone order should have been discontinued when the new order was entered, but this did not occur. Staff acknowledged the presence of duplicate orders and the risk of medication errors, with the facility's policy indicating that new physician orders are to be reviewed for accuracy during daily clinical meetings. At the time of observation, the resident was alert and showed no signs of distress, and did not report any concerns regarding his medications.
Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations. The dining room was found to have dirty dishes with leftover food left overnight, and gnats were seen flying around the dishes while residents were present waiting for coffee. Additionally, there was a buildup of grease along the vent hood rails in the kitchen. In the kitchen's refrigerator and freezer, several food items, including a large bowl of salad and fruit, were found undated and unlabeled. Tuna salad was found with a date range, but other items such as cookies were discovered without proper identification and were discarded. In the dry goods pantry, a container of creamy peanut butter was found to be expired. Interviews with dietary staff confirmed that the vent hood was supposed to be cleaned and that all food items removed from their original containers should be labeled and dated with the date opened and a use-by date. The facility's own policies require that all food preparation and storage areas be maintained in a clean and sanitary condition and that food be stored and labeled according to FDA Food Code standards. These observations and staff statements indicate that the facility did not adhere to its own policies or professional standards for food safety and sanitation.
Failure to Timely Complete Significant Change MDS After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days after a resident was discharged from hospice services, as required. The resident in question had multiple diagnoses, including Alzheimer's disease, dementia, hypertension, osteoarthritis, anxiety disorder, COPD, bipolar disorder, muscle weakness, and abnormal posture. The resident was admitted to hospice services and later discharged due to medical stability, but the facility did not update the MDS or the comprehensive care plan to reflect this significant change in condition within the required timeframe. Interviews with facility staff revealed that the MDS nurse was new to the position and was still learning the process, and only recently became aware of the resident's discharge from hospice. The care plan continued to indicate the resident was receiving hospice care, and the Significant Change MDS was completed more than 14 days after the resident's discharge from hospice. The facility's policy and the RAI manual guidelines both require timely completion of the MDS following a significant change in a resident's status.
Failure to Complete PASARR Level II Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of mental illness received a required PASARR Level II (PE) screening. The resident, a female with diagnoses including bipolar disorder and schizoaffective disorder, was admitted and later readmitted to the facility. Her records, including the face sheet, PASARR Level I screening, MDS assessment, and care plan, all indicated the presence of mental illness. Despite this, there was no evidence in the clinical record that a PASARR Level II evaluation had been completed for her. Interviews with the facility's MDS coordinator confirmed that the PASARR Level II assessment was not performed. The coordinator acknowledged responsibility for completing PASARR screenings and stated that she would have checked for the Level II assessment if she had been present during the resident's comprehensive assessment. The facility's policy requires that a PASARR be completed for all patients with mental illness, and a Level II assessment is specifically required for those with new mental health diagnoses upon readmission, but this process was not followed for the resident in question.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours of admission, as required. The resident, a male with diagnoses including acute on chronic systolic heart failure, chronic kidney disease, and chronic obstructive pulmonary disease, was admitted with physician orders and an incomplete baseline care plan document. Review of the care plan revealed that no information was completed on the baseline care plan form, and the comprehensive care plan was not initiated until after the 48-hour window had passed. Interviews with facility staff revealed confusion regarding responsibility for initiating the baseline care plan. The DON stated that the admission nurse was responsible, while an LVN indicated that RNs should complete the care plan but was unsure who was responsible for the resident in question. The DON later clarified that either an RN or LVN could open the baseline care plan. Additionally, the resident's admission MDS was incomplete, with the BIMS section left blank. The facility's policy referenced the CMS guidelines for the care area assessment process.
Failure to Update Care Plan After Discharge from Hospice
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after a significant change in a resident's status. Specifically, a resident with multiple diagnoses, including Alzheimer's disease, dementia, hypertension, osteoarthritis, anxiety disorder, COPD, bipolar disorder, muscle weakness, and abnormal posture, was discharged from hospice services after being deemed medically stable. Despite this change, the resident's care plan continued to reflect hospice care and was not updated to reflect the discharge and the initiation of therapy services. Interviews with facility staff revealed that the MDS nurse was unaware of the resident's discharge from hospice until the week of the survey and had not updated the care plan accordingly. The interim DON confirmed that care plans should accurately reflect the resident's current condition. The facility's policy referenced the RAI manual for care plan accuracy, but no specific care plan policy was provided during the survey.
Failure to Identify and Report Duplicate Medication Orders
Penalty
Summary
The facility failed to ensure that a licensed pharmacist accurately identified and reported drug regimen irregularities for a resident with multiple medication orders. Specifically, a male resident with quadriplegia and generalized anxiety disorder had two active orders for Buspirone 5 mg: one to be administered twice daily and another three times daily, both without end dates. Medication administration records showed that both orders were being followed concurrently, resulting in duplicate administration of the same medication. Despite the presence of duplicate orders, the consultant pharmacist's monthly drug regimen review did not identify or report this irregularity. The pharmacist stated that only the three times daily order was documented in her notes and denied awareness of the twice daily order, even though both were present in the facility's electronic medical record and being administered. Interviews with nursing staff and medication aides confirmed the existence of duplicate orders and acknowledged that the previous order should have been discontinued when the new one was entered. The facility's policies required new physician orders to be reviewed for accuracy during daily clinical meetings, but the duplicate orders for Buspirone were not identified or addressed until after the issue was brought to attention. The resident was alert and showed no signs of distress at the time of observation, and staff interviews indicated a lack of ongoing training regarding medication management for some personnel. The deficiency was identified through record review and staff interviews, highlighting a lapse in the facility's medication review and reporting processes.
Failure to Prevent Resident Access to Hazardous Substance Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with significant cognitive impairment. The resident, diagnosed with late-stage Alzheimer’s disease, bipolar disorder, type 2 diabetes, and acute kidney failure, had a history of wandering and poor safety awareness. Her care plan identified her as at risk for elopement and wandering, requiring a wander guard and staff redirection when she entered unsafe areas or other residents’ rooms. Despite these interventions, the resident was able to access and ingest hand sanitizer, which was not secured as required. On the day of the incident, the resident was observed with a bottle of hand sanitizer up to her mouth and sanitizer on her shirt, suggesting ingestion. Staff immediately intervened, removed the sanitizer, and monitored her for adverse effects. The resident was later found in the lobby, hard to awaken, and was subsequently sent to the hospital for evaluation. Hospital records indicated a small amount of alcohol in her system, but not at a harmful level. Interviews with staff revealed that hand sanitizer was typically kept on top of or inside medication carts, but not always secured, and that the resident was known to wander and seek out items in her environment. The facility’s failure to secure hazardous materials such as hand sanitizer and to provide adequate supervision allowed the resident to access and potentially ingest a dangerous substance. Staff interviews confirmed that hand sanitizer was accessible on medication carts and that the resident’s wandering behavior was well known. The care plan interventions for supervision and redirection were not sufficient to prevent the incident, resulting in the resident’s hospitalization.
Failure to Provide Scheduled Showers and Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADLs) independently received the necessary assistance to maintain good hygiene. Specifically, one resident with chronic obstructive pulmonary disease, sequelae of cerebral infarction, type 2 diabetes mellitus, hemiplegia, hemiparesis, and muscle weakness, and who required substantial/maximal assistance for bathing, did not receive scheduled showers on three documented occasions. The resident's care plan indicated scheduled showers on Mondays, Wednesdays, and Fridays during the 6a-2pm shift, but there was no documentation of showers being provided on the specified dates. The resident's medical record and care plan confirmed his need for assistance and outlined interventions to maintain hygiene. Interviews with the resident, CNAs, RN, DON, and Administrator revealed that the resident did not refuse showers and enjoyed being clean. Staff interviews indicated that showers were sometimes missed due to staffing shortages and that refusals were to be reported to nursing staff. The DON acknowledged receiving complaints about missed showers and stated that refusals should be care planned. The Administrator was not aware of missed showers but confirmed that a schedule was in place and that staff were expected to follow up on incomplete ADLs. The lack of documentation and missed showers resulted in the resident not receiving necessary services to maintain good hygiene as required.
Failure to Investigate and Report Potential Neglect After Resident Accessed Hand Sanitizer
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate and report an incident involving a resident with late-stage Alzheimer’s disease, diabetes, acute kidney failure, and bipolar disorder. The resident, who was at risk for wandering and had a history of entering other residents’ rooms, was found with a bottle of hand sanitizer, appearing to drink from it. Staff observed hand sanitizer on her shirt and the bottle upturned at her mouth. The resident was later found in the lobby, hard to awaken, and was subsequently sent to the hospital for evaluation. Hospital records indicated a chief complaint of drug overdose, but laboratory results showed no significant ethanol in her system. The facility’s documentation revealed that the hand sanitizer was typically kept on or near medication carts, sometimes not secured as required. Staff interviews confirmed that hand sanitizer was accessible and not always stored in locked areas, despite the presence of cognitively impaired residents. The incident was not witnessed directly, but staff assumed ingestion based on the resident’s behavior and physical evidence. The resident’s care plan identified her as a wander risk with poor safety awareness, and interventions included redirecting her and monitoring her use of a wander guard. Despite the incident, the facility did not report the event as neglect to the state agency, citing the lack of harm as the reason. The facility’s abuse and neglect policy required reporting and investigation of all alleged violations, but the administrator and DON determined that reporting was unnecessary. The investigation was incomplete, with unsigned statements and a lack of clear documentation regarding the source of the hand sanitizer and the exact circumstances of the incident. The failure to report and thoroughly investigate the incident constituted a deficiency, as it did not comply with regulatory requirements for addressing alleged violations of abuse and neglect.
Failure to Update Care Plan for Resident's Weight Loss and Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's significant weight loss and the use of the medication Ozempic, which was prescribed for diabetes management. The resident experienced a 15-pound weight loss over two months, and the care plan did not reflect this change or the potential side effects of Ozempic, such as decreased appetite. The resident, a cognitively aware male with multiple diagnoses including diabetes and anxiety, was on a mechanically altered diet and required assistance with activities of daily living. Despite the resident's weight loss and the known side effects of Ozempic, the care plan only included general nutritional goals and interventions without specific measures to address the actual weight loss or the medication's impact. The resident's weight log showed a consistent decrease in weight, yet the care plan remained unchanged. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that the care plan was not updated to reflect the resident's weight loss and medication use. The MDS Coordinator admitted to being new in the position and acknowledged the oversight in updating the care plan. The DON confirmed the need for the care plan to be updated and recognized the inexperience of the MDS nurses in their roles. The facility lacked a specific policy for care planning, relying instead on the RAI manual for guidance.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in deficiencies in medication administration. Resident #3, a cognitively aware male with multiple diagnoses including chronic obstructive pulmonary disease and diabetes, was not administered his Proair inhaler and house supplement as ordered by his physician. The medication administration record (MAR) for February and March 2025 showed blanks for several doses of these medications, with no documentation in the nurse's notes explaining the omissions. During an interview, Resident #3 reported issues with receiving his Clonazepam medication as ordered, which had only been corrected recently. Resident #5, a cognitively intact male with conditions such as hypertension and heart failure, was not administered his Carvedilol oral tablet as ordered. The MAR for March 2025 showed a blank for the 8:00 pm dose on a specific date, with no documentation in the progress notes explaining why the medication was not given. Interviews with nursing staff, including LVNs and the Director of Nursing (DON), confirmed that there should be no blanks on the MARs, and any medication not given should be documented with reasons. The facility's policy and procedure on the standard of practice require compliance with physician's orders for medications. The lack of documentation and failure to administer medications as ordered could lead to residents not receiving necessary treatments, potentially affecting their health and recovery. The DON acknowledged the issue and indicated plans to in-service the staff to address these documentation and administration deficiencies.
Inadequate Incontinent Care Poses UTI Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infections. During an observation, two CNAs did not properly clean the resident's perineal area, specifically failing to spread the labia and clean the urinary meatus. This oversight was acknowledged by one of the CNAs, who attributed the lapse to nervousness and admitted to not having undergone competency checks for incontinent care at the facility. The resident involved was an elderly female with cognitive communication deficits, bipolar disorder, and weakness, requiring substantial assistance with personal hygiene and dressing. Her care plan indicated she was always incontinent of bowel and bladder, with a goal to prevent skin breakdown due to incontinence. Despite the facility's policy and in-service training on perineal care, the CNAs did not adhere to the proper procedures, and the facility was unable to provide a documented policy on perineal care upon request.
Infection Control Lapse Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not perform hand hygiene after removing soiled gloves. This incident occurred during incontinence care for a resident who was cognitively impaired and required substantial assistance with daily activities. The resident was always incontinent of both bowel and bladder, necessitating frequent incontinence care to prevent skin breakdown. During the care, CNA A removed soiled gloves and left the resident's room without sanitizing or washing her hands, which could lead to cross-contamination and the spread of infection. Interviews with the CNA and the Director of Nursing (DON) revealed that the CNA acknowledged forgetting to sanitize her hands and recognized the risk of cross-contamination. The DON confirmed that staff were expected to sanitize their hands before entering a room, after touching a dirty area, and between glove changes during incontinence care. The facility's infection control policy emphasized the importance of hand hygiene as a primary means to prevent infection spread. Despite having completed recent in-service training on infection control, the CNA did not adhere to these protocols, highlighting a lapse in the facility's infection control practices.
Failure to Resolve Resident's Grievance Regarding Missing Property
Penalty
Summary
The facility failed to promptly resolve grievances for a resident who reported missing personal property, including a wallet containing important identification and financial cards. The resident, who was moderately cognitively impaired and required assistance with daily activities, reported the loss of his wallet, which included his social security card, green card, cash app card, bank card, $10.00, and food stamp card. Despite the resident's report, the facility did not adequately follow up to ensure the items were found or replaced, nor did they assist the resident in replacing the missing items. The facility's grievance process was not completed as required. Although the administrator reported the incident to the state and police and conducted interviews with staff, there was no further investigation or assistance provided to the resident. The social worker acknowledged that the grievance process could have been more thorough, and the resident confirmed that he was unable to replace all his missing items, specifically his social security and green card, which affected his ability to renew his citizenship. The business office manager indicated that the resident's identification documents were copied and uploaded to his files upon admission, but when the surveyor requested these documents, the administrator refused to provide them. The facility's policy on filing grievances and complaints states that they will assist residents in filing grievances without fear of reprisal, but in this case, the facility did not adequately support the resident in resolving his grievance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
