Arlington Residence And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Texas.
- Location
- 405 Duncan Perry Rd, Arlington, Texas 76011
- CMS Provider Number
- 455872
- Inspections on file
- 56
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Arlington Residence And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was discharged to another facility without a completed discharge summary, as required by facility policy. While some documentation such as the face sheet and medication orders was provided, essential elements like the reason for discharge, medication reconciliation, and a final summary of the resident's status were missing. Staff interviews revealed inconsistent practices and uncertainty about discharge documentation responsibilities.
A resident with severe cognitive impairment eloped from a facility twice due to inadequate supervision and environmental hazards. Despite being in a secure unit, the resident broke a window and left the facility, being found by police hours later. On a second occasion, the resident scaled a fence after breaking another window. Staff were aware of the resident's elopement risk but failed to prevent these incidents.
The facility failed to maintain an adequate emergency water supply, leaving 68 residents at risk. Observations revealed no emergency water on site, and interviews with the Dietary Manager and Administrator showed a lack of awareness and responsibility for water storage. The Chief Nursing Officer confirmed the need for a three-day supply, which was not met, as the facility lacked the required 519 gallons of water for residents and employees.
The facility failed to provide adequate training on dementia and ANE for several CNAs and LVNs, as required by policy. Training transcripts lacked documentation of completed trainings, and there was no monitoring system to ensure compliance. The HR Manager and DON acknowledged the absence of a system to track training completion, which could lead to potential harm due to untrained staff.
The facility failed to conduct EMR/NAR checks for a CNA prior to employment, as required by their Abuse Prevention Program. This oversight was discovered during a review of employment registry screenings, revealing that the HR Manager did not complete the necessary checks before the CNA's hire date. The Administrator confirmed the checks were not monitored, potentially placing residents at risk.
Three residents in an LTC facility did not receive scheduled showers, impacting their hygiene and dignity. A resident with quadriplegia was not bathed due to a lack of clean linens, while another with total paralysis had stained linens and unkempt hair. A third resident refused bed baths when clean linens were unavailable. Staff interviews revealed documentation and communication issues regarding shower refusals.
The facility failed to provide organized activities for residents in a secure unit, as observed over several days. Despite a scheduled activities calendar, no activities were conducted, and residents were left with minimal engagement. Staff interviews confirmed the absence of activities, and the Activity Director cited challenges in managing activities on and off the unit.
The facility failed to verify the certification status of two CNAs, allowing them to provide care without current certifications. The HR Manager did not complete the required EMR/NAR checks upon hire or annually, leading to expired certifications for CNA D and CNA E. Interviews revealed a lack of oversight and awareness of certification requirements, potentially risking resident safety.
A resident with chest pain did not receive her prescribed Ranolazine 1000 mg ER on multiple occasions due to a failure in the facility's pharmaceutical services. The medication aide ordered the medication twice, but it was not delivered, and the issue was not communicated to management in a timely manner. The facility's policy for ordering medication was not followed, leading to missed doses and a breakdown in communication among staff.
The facility failed to maintain kitchen sanitation standards, with dust and fuzz on air vents and grease buildup on the stove backsplash. Staff interviews revealed confusion over cleaning responsibilities, with the stove last cleaned a month ago and vents not cleaned for three months, contrary to the facility's sanitation policy and the Federal Food Code 2022.
The facility failed to maintain essential laundry equipment, resulting in a backlog of laundry and unclean linens for residents. A resident reported having stained sheets for six days and a lack of clean towels for showering. The facility operated with only one residential washing machine, as the commercial machine was broken. The Administrator acknowledged the issue and had requested a new machine from corporate.
The facility failed to provide privacy curtains for several resident rooms, compromising visual privacy. Observations showed missing curtains and window blind slats in multiple rooms. The HR Manager acknowledged responsibility but noted the floor tech responsible for curtains had quit. The Administrator confirmed no specific policy on privacy curtains, but they were covered under Resident Dignity policies.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as stained ceiling tiles, a precarious HVAC vent, inadequate clean linens, and a broken room door. These deficiencies affected residents' comfort and safety, with staff and management aware of the issues but unable to resolve them due to various constraints.
A facility failed to ensure a resident was free from physical restraints unless needed for medical treatment. The resident, with severe cognitive impairment, had half bedrails in place without a care plan, safety assessment, or consent. Staff interviews revealed the bedrails were not used for mobility, contrary to the physician's order. The DON was unaware of the bedrail type, and the facility's policy on side rails was not followed.
A resident with severe cognitive impairment and multiple health conditions was sent to the hospital, yet her EMR inaccurately showed vital signs and medication refusals documented by LVNs. One LVN was not present, and the other admitted to documenting without verifying the resident's presence. The DON confirmed the resident had passed away at the hospital, highlighting a failure in maintaining accurate records.
A resident was issued an immediate discharge from a facility due to non-compliance with the smoking policy, but the facility failed to provide the required written notification to the resident and the Ombudsman. The resident, who had intact cognition and multiple medical conditions, was sent to a hospital for low sodium and was ready for discharge shortly after. However, the facility refused to readmit the resident, leaving them without a place to go and without proper discharge planning.
A resident with a history of elopement risk managed to leave a secured unit in an LTC facility due to a malfunctioning door alarm. The resident exited through a back door that did not sound an alarm, allowing him to leave unnoticed initially. Staff later found and returned the resident safely, but the incident revealed a significant lapse in safety measures.
The facility failed to serve pureed bread to residents on a pureed diet during a lunch meal. A dietary staff member forgot to prepare the bread, and the DM did not ensure all meal components were served. This oversight affected residents requiring a pureed diet, including one with dementia and malnutrition, as the facility did not follow its policy to meet residents' nutritional needs.
The facility failed to maintain an effective pest control program, leading to the presence of bugs in a resident's room and a dining area. Multiple residents and staff reported frequent sightings of bugs, including cockroaches, throughout the facility. Despite regular visits from a pest control company, the issue persisted, as documented in maintenance logs.
Two incidents at the facility resulted in violations of resident rights and dignity. In the first case, a staff member recorded a resident with his cell phone while the resident was agitated, violating privacy policies. The resident had cognitive impairments and a history of behavioral issues. In the second case, a CNA removed a resident's cell phone to prevent him from calling 911 during a care episode, which was against the resident's rights. The resident had multiple sclerosis and cognitive deficits. Both incidents reflect a failure to respect residents' rights to dignity and communication.
The facility failed to ensure Cook C wore a beard restraint while preparing and serving food, as observed during a lunch meal service. Cook C, with facial hair, was seen using a blender and plating meals without a beard restraint, contrary to the facility's policy and the Federal Food Code. Interviews revealed a lack of awareness and availability of beard restraints in the kitchen.
A resident with moderate cognitive impairment and a history of Alzheimer's was not provided necessary grooming services, resulting in unwanted facial hair. Despite the resident's desire for hair removal, staff did not offer or attempt to shave her chin, and there was no documentation of care refusal. Interviews with facility staff revealed a lack of awareness and action regarding the resident's grooming needs, contrary to the facility's policy requiring daily grooming.
The facility did not update the daily nurse staffing information on one occasion, as required by policy. Observations showed that the staffing information was not updated for the current day, and interviews revealed that the DON, responsible for the update, did not return to the facility. The ADON acknowledged the oversight, and the Administrator confirmed the requirement for daily updates.
A resident with schizoaffective disorder and other health issues was not re-admitted to the facility after being transferred to a behavioral health hospital. Despite the discharge assessment indicating a return was anticipated, the facility did not complete necessary paperwork or communicate effectively with the hospital. The DON and Administrator cited safety concerns and property damage as reasons for not allowing the resident to return.
A resident's urinary catheter was found on the floor, contrary to infection control protocols. The resident, with a complex medical history, was unaware of the catheter's position. The LVN repositioned the catheter after surveyor prompting. The DON and Administrator confirmed the expectation for proper catheter positioning, aligning with facility policy.
A resident in a LTC facility was unable to use a non-functional call light system, impacting her ability to request assistance. Despite being cognitively intact and requiring a wheelchair, she had to self-propel to the nurse's station for help. The LVN was unaware of the issue, and the maintenance log showed no record of the malfunction. The Corporate Maintenance Director and Administrator both emphasized the importance of a functioning call light system, which was not adhered to as per facility policy.
The facility failed to provide adequate supervision and assistive devices to prevent accidents for three residents. One resident experienced a fall resulting in a sacrum fracture, another eloped from a secured unit due to a malfunctioning door, and a third sustained burns from accessing a microwave in an unlocked staff break room.
Failure to Complete Required Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to complete a required discharge summary for a resident who was discharged to another healthcare facility. Record review showed that while the resident's face sheet, medication orders, and belongings were provided at discharge, there was no comprehensive discharge summary in the clinical records. The available documentation, including the Summary Episode Note, did not address key elements such as the reason for discharge, date of discharge, reconciled medications sent to the new facility, personal belongings disposition, or physician signature. Additionally, the resident's care plan did not address discharge goals. Interviews with facility staff revealed inconsistent understanding and implementation of discharge documentation procedures. The nurse responsible for the discharge documented the transfer in progress notes and provided some information to the receiving facility, but did not complete a full discharge summary as required by facility policy. The DON and Administrator both indicated uncertainty or changes in policy regarding who was responsible for completing the discharge summary, and the process was not followed for this resident. The facility's own policy required a comprehensive discharge summary to be completed by the interdisciplinary team, but this was not done.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and provide adequate supervision to prevent elopement for a resident with severe cognitive impairment. The resident, who had a history of elopement and was diagnosed with dementia, managed to leave the facility on two separate occasions. On the first occasion, the resident broke a window in his room and was found by the police after being missing for several hours. The facility's secure unit was not adequately monitored, and the resident's risk of elopement was not sufficiently mitigated. The resident was placed in a secure unit due to his risk of wandering and elopement, yet the interventions in place were insufficient. Despite being on enhanced supervision, the resident was able to break a window and exit the facility. Staff interviews revealed that the resident was known to pack his belongings and stand by exit doors, indicating a desire to leave, but he was usually redirected back to his room. However, on the day of the incident, the staff failed to prevent his elopement. On a subsequent occasion, the resident again managed to elope by breaking a window and scaling a newly constructed fence. The fence was improperly constructed with rails on the inside, facilitating the resident's escape. Staff witnessed the resident climbing the fence but were unable to reach him in time. The facility's failure to provide adequate supervision and secure the environment placed the resident at risk of harm and serious injury.
Inadequate Emergency Water Supply Puts Residents at Risk
Penalty
Summary
The facility failed to ensure an adequate emergency water supply was available, placing 68 residents at risk. During an observation, it was found that the facility had no emergency water on hand. Interviews with the Dietary Manager and the Administrator revealed a lack of awareness and responsibility regarding the storage and management of emergency water supplies. The Dietary Manager admitted to never ordering or being informed about emergency water storage, while the Administrator acknowledged the absence of a policy and the need for corporate guidance. The Chief Nursing Officer confirmed the necessity of having at least one gallon of water per resident for three days, which was not met. The facility's policies indicated a requirement for a three-day supply of water, but this was not adhered to. The record review showed discrepancies in the understanding and implementation of emergency water requirements, with the facility lacking the necessary 519 gallons of water for residents and employees. This oversight could lead to dehydration and other health complications for residents.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for eight out of eleven staff members reviewed for training. Specifically, the facility did not provide training on dementia and abuse, neglect, and exploitation (ANE) for CNAs A, B, C, D, E, and LVNs G and H. The training transcripts for these staff members did not indicate when the last ANE or dementia training had been completed, which is a requirement according to the facility's policy. Interviews with the HR Manager and the Director of Nursing (DON) revealed that there was no monitoring system in place to ensure that required trainings were completed and documented in the staff's employee files. The HR Manager stated that all required trainings were to be completed every two years and that staff were directed to complete their trainings online, with completion certificates to be submitted to the DON. However, the DON admitted that some in-service trainings were conducted in person but could not be located during the survey. The Administrator also confirmed the lack of a monitoring system to ensure trainings were completed, acknowledging the potential for harm when staff are not properly trained. The facility's policy requires nursing staff to participate in a competency-based staff development and training program, which includes preventing abuse, neglect, and exploitation, as well as dementia management.
Failure to Conduct EMR/NAR Checks for CNA Prior to Employment
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency was identified during a review of the employment registry screenings for one of the eight employees, specifically CNA D. The facility did not ensure that a search of the EMR/NAR was completed for CNA D prior to employment and before providing direct patient care. This oversight could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The HR Manager, who began working at the facility in March 2024, acknowledged that no EMR/NAR checks were completed for CNA D before her hire date of July 7, 2023, nor was an annual EMR/NAR check conducted. The HR Manager stated that it was her responsibility to complete these checks both upon hire and annually. The Administrator confirmed that EMR/NAR checks were supposed to be completed by the HR Manager and that it was his responsibility to monitor their completion. The facility's current, undated Abuse Prevention Program outlines the requirement for conducting employee background checks to prevent employing individuals with a history of abuse, neglect, exploitation, or misappropriation of property.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, three residents, identified as Residents #29, #48, and #57, did not receive showers as scheduled. This deficiency was observed through record reviews, interviews, and direct observations, which revealed that these residents were not provided with adequate bathing services, leading to poor hygiene and potential risks to their health and dignity. Resident #29, a female with quadriplegia and other significant medical conditions, was dependent on staff for bathing. Her care plan did not address bathing or showering, and records showed she did not receive showers or bed baths during a specified period, with no documented refusals. Interviews revealed that she was told by staff that there were no clean linens or towels available, and she expressed feelings of diminished self-esteem due to the lack of personal care. Resident #48, a male with total paralysis due to multiple sclerosis, was also dependent on staff for ADLs. His care plan was not individualized, and he had a pressure ulcer. Observations noted that his bed linens were stained, and he had not been bathed recently, as confirmed by his statements. Similarly, Resident #57, a male with multiple health issues, required substantial assistance with bathing. He refused bed baths when clean linens were unavailable, citing the futility of washing only to return to a dirty bed. Interviews with staff, including CNAs, LVNs, and the DON, highlighted inconsistencies in documentation and communication regarding shower refusals and the importance of maintaining hygiene for infection control and resident dignity.
Lack of Activities in Secure Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of residents in a secure unit. Observations over several days revealed that no organized activities were conducted as per the facility's activities calendar. On multiple occasions, residents were seen in the dining room with the TV on, but no structured activities were taking place. Staff interviews confirmed that activities listed on the calendar were not being executed, and the Activity Director admitted to difficulties in managing activities both on and off the unit. The facility's policy on activity programs states that activities should be available daily and tailored to individual resident needs. However, the Activity Director acknowledged that none of the scheduled activities were conducted during the observed days, and only minimal engagement, such as painting nails, was attempted. The Administrator was unaware of the complete lack of activities and recognized the importance of activities in preventing resident boredom and potential behavioral issues.
Failure to Verify CNA Certification Status
Penalty
Summary
The facility failed to ensure that two certified nurse aides (CNAs), identified as CNA D and CNA E, had current nurse aide certifications while employed and actively providing care to residents. The facility did not complete the required EMR/NAR checks upon hire or annually for these CNAs. CNA D's personnel file showed no evidence of a completed EMR/NAR check, and CNA E's certification had expired without renewal. The HR Manager, who was responsible for conducting these checks, was unaware of the requirement to update both CNA and MA certifications annually until informed by regional management. The HR Manager had instructed CNA D to renew her certification, but it was not done, and CNA E was under the impression that renewing her MA certification would automatically renew her CNA certification. Interviews with the HR Manager, Director of Nursing (DON), and the Administrator revealed a lack of monitoring and oversight in ensuring that certifications were current. The HR Manager acknowledged her responsibility to conduct annual EMR/ENR checks but stated that it was also the staff's responsibility to keep their certifications current. The DON and Administrator confirmed that the HR Manager was responsible for these checks and that the failure to maintain active certifications could lead to potential harm to residents, including falls, fractures, and incorrect procedures. The facility's policy required all nursing staff to meet specific competency requirements as defined by state law, which was not adhered to in this case.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of Ranolazine 1000 mg ER for chest pain. The resident, a female with a diagnosis of chest pain and moderate cognition, did not receive her prescribed medication on several occasions. The medication was not administered on the evenings of February 3rd and 4th, and the mornings of February 4th and 5th, as documented in the Medication Administration Record (MAR). The medication aide (MA) responsible for administering the medication was aware of the shortage and had ordered the medication from the pharmacy twice, but it was not delivered. The MA failed to notify management about the missing medication, although she informed the nurse. The charge nurse was not made aware of the issue until February 5th, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were also not informed until later. The facility's policy required medication to be ordered when seven tablets remained, but this was not adhered to, leading to the missed doses. Interviews with facility staff, including the MA, charge nurse, ADON, DON, and the pharmacist consultant, revealed a breakdown in communication and procedure adherence. The pharmacist consultant noted that the facility should have followed up with the pharmacy within 24 hours of ordering and notified the doctor for a substitute medication. The physician assistant was not aware of the issue until February 5th and instructed the facility to hold the medication until it was available. The facility's failure to ensure timely medication refills and communication with the pharmacy and physician led to the resident missing critical doses of her medication.
Deficiency in Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain kitchen sanitation standards, as observed during a survey. Specifically, three air conditioning vents over the food preparation area and two vents by the dishwasher were found to have accumulated fuzz and dust. Additionally, the stove backsplash was observed to have a buildup of grease. These conditions were noted on two consecutive days, with food being prepared in the kitchen during the second observation. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities. A staff member was unsure who was responsible for cleaning the stove backsplash and could not recall the last cleaning. The Dietary Manager indicated that kitchen staff, particularly cooks, were responsible for cleaning the stove, which was last cleaned about a month ago. The Maintenance Supervisor was uncertain about who should clean the air vents, which had not been cleaned for approximately three months. The facility's sanitation policy and the Federal Food Code 2022 require that food service areas and equipment be maintained in a clean and sanitary manner, free from dust, grease, and other contaminants.
Failure to Maintain Essential Laundry Equipment
Penalty
Summary
The facility failed to maintain essential equipment, specifically a laundry washing machine, in safe operating condition. This deficiency was observed when Resident #37 was found with large brown stains on his bed sheets, which had been unchanged for about six days. The resident also reported being unable to shower due to a lack of clean towels. The facility's laundry area was found to have only one operational residential washing machine, as the commercial washing machine was broken with parts removed and placed on top of it. Interviews with the Laundry Aide and Laundry Supervisor revealed that the facility had been operating with only one residential washing machine for about a month, leading to a backlog of laundry. The Administrator acknowledged the insufficiency of one residential washing machine for the facility's needs and stated that he had requested a new machine from corporate multiple times. The Administrator also mentioned that the facility had sent laundry out for cleaning on a few occasions. The facility's Quality of Life-Homelike Environment policy emphasizes providing residents with a clean and comfortable environment, which was not upheld due to the equipment failure.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure that each bed had ceiling-suspended curtains to provide total visual privacy for residents in several rooms. Observations revealed that multiple rooms lacked privacy curtains at the end of the beds, and some rooms had no privacy curtains at all. Additionally, there were missing slats in the window blinds in one of the rooms. This lack of privacy curtains was noted in rooms #110, #117, #118, #120, #122, #127, and #144, which could compromise the residents' privacy. Interviews conducted with the HR Manager and the Administrator highlighted that the responsibility for changing out the curtains fell to a floor technician who had recently quit and had not been replaced. The HR Manager acknowledged her ultimate responsibility for ensuring privacy curtains were in place. The Administrator confirmed that there was no specific policy addressing privacy curtains, but they were considered under the broader policy of Resident Dignity. The facility's undated policy on Quality of Life-Dignity emphasized respecting residents' private space and property, including knocking before entering rooms and not handling personal belongings without permission.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In one instance, ceiling tiles above a resident's bed were stained and had not been replaced for over a month, despite the resident notifying the nursing staff. Additionally, a ceiling HVAC vent in another resident's room was found to be hanging precariously due to a missing screw, posing a potential safety hazard. The facility also failed to provide adequate clean linens for residents, as observed in the case of a resident whose sheets had not been changed for approximately six days due to a shortage of clean linen. The laundry facilities were found to be lacking in clean linens, and the laundry supervisor acknowledged the shortage, attributing it to staff discarding dirty linens and the facility having only one functioning residential washing machine. The administrator was aware of the linen shortage but had not been able to secure a commercial washing machine due to budget constraints. Furthermore, the facility did not ensure that room doors were in proper working condition, as seen in the case of a resident whose door did not latch and remained open unless blocked by a wheelchair. This issue had persisted for a couple of months, and although the maintenance director was aware of the problem, it had not been addressed. The facility's policy on providing a homelike environment was not adhered to, as residents were not provided with a clean, sanitary, and orderly environment, nor with clean bed and bath linens in good condition.
Failure to Properly Assess and Care Plan for Bedrail Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment. Specifically, the facility did not care plan for the use of half bedrails for a resident who was at risk for falls and had severe cognitive impairment. The resident's care plan did not address the use of bedrails, and there was no assessment for bedrail safety or consent for their use from the resident's responsible party. The resident had a physician order for bedrails for mobility, but observations indicated that the resident did not use the bedrails for mobility and was unable to follow requests to reposition herself using them. Interviews with facility staff revealed that the resident did not use the bedrails for mobility and would only grab onto them when being turned for incontinent care. The Director of Nursing (DON) was unaware that the resident's bedrails were half rails instead of mobility bars and stated that bedrails should only be used for mobility, not to keep the resident in bed. The facility's policy on the proper use of side rails was not followed, as it requires an assessment for the use of side rails, consent from the resident or legal representative, and inclusion in the resident's care plan.
Inaccurate Medical Record Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to a deficiency in accordance with accepted professional standards. The resident, a female with severe cognitive impairment and multiple health conditions including congestive heart failure, diabetes, and chronic kidney disease, was sent to the hospital following a fall. Despite the resident's absence from the facility, her electronic medical records (EMR) inaccurately reflected vital signs and medication refusals, which were documented by two Licensed Vocational Nurses (LVNs). Interviews revealed that LVN B, who was not present on the day in question, had her password saved on the computer, allowing another nurse to document under her credentials. LVN A, who was working that day, admitted to documenting the resident's medication refusals and vitals without verifying the resident's presence in the facility. The Director of Nursing (DON) confirmed that the resident had passed away at the hospital earlier that day, making it impossible for the documented events to have occurred at the facility. The facility's documentation practices were called into question, as the DON and Assistant Director of Nursing (ADON) acknowledged that nurses may have been careless with password security and documentation accuracy. The facility's policy required that all services and changes in a resident's condition be accurately documented by licensed personnel, but this was not adhered to, resulting in the deficiency.
Failure to Notify Resident and Ombudsman of Immediate Discharge
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the Office of the State Long-Term Care Ombudsman of an immediate discharge, as required by regulations. The resident, who had a history of non-compliance with the facility's smoking policy, was issued a 30-day discharge notice due to this non-compliance. However, the facility later decided to issue an immediate discharge notice without providing the required written notification to the resident and the Ombudsman. The resident, who had intact cognition as indicated by a BIMS score of 15, was admitted to the facility with multiple diagnoses, including a fibroblastic disorder, Type II diabetes, muscle weakness, a personality disorder, and an acquired absence of the right leg below the knee. Despite the resident's refusal to adhere to the smoking policy, the facility's documentation did not show that the resident or the Ombudsman received a written copy of the immediate discharge notice. Interviews with the DON and the Ombudsman revealed that the Ombudsman was not aware of the immediate discharge notice, and the resident was not provided with the necessary documentation. The resident was sent to a local hospital due to critical lab results for low sodium and was ready for discharge a few days later. However, the facility refused to readmit the resident, citing the 30-day discharge notice. This left the resident without a place to go, as the facility did not assist in finding alternative placement. The facility's failure to provide proper notification and assistance with discharge planning placed the resident at risk of not having access to advocacy services and discharge options.
Resident Elopement Due to Faulty Door Alarm
Penalty
Summary
The facility failed to ensure adequate supervision and functioning assistive devices to prevent accidents, specifically for a resident who eloped from a secured unit. The resident, who had a history of elopement risk and cognitive impairment, managed to exit the facility through a back door that was not properly secured. The door alarm did not sound, allowing the resident to leave the premises unnoticed initially. The resident, who had been admitted to the secured unit due to his risk of wandering and elopement, was able to leave the facility because the back door was not functioning correctly. Staff interviews revealed that the door alarm did not activate, and the door was found wide open. The resident was eventually found by staff and returned to the facility without injury, but the incident highlighted a significant lapse in the facility's safety measures. The deficiency was identified as past noncompliance, with the immediate jeopardy situation beginning and ending over a two-day period. The facility's failure to maintain a secure environment and provide adequate supervision placed the resident at risk of harm, severe injury, or even death. The incident underscored the importance of ensuring that all exit doors are properly secured and alarms are functioning to prevent similar occurrences.
Failure to Serve Pureed Bread to Residents on Pureed Diet
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents requiring a pureed diet during the lunch meal on September 10, 2024. Specifically, pureed bread was not served to eight residents who required it, including a resident with non-Alzheimer's dementia and malnutrition. This oversight was identified through observation, interviews, and record reviews, which revealed that the dietary staff did not follow the menu that was supposed to meet the nutritional needs of the residents. The deficiency occurred because the dietary staff member responsible for preparing the pureed bread forgot to make it, and the Dietary Manager (DM) did not verify that all meal components were prepared and served. The DM acknowledged that the omission of meal components could lead to missing nutritional values in residents' diets. The facility's policy requires that menus meet the nutritional needs of residents, but this was not followed, resulting in a failure to provide the necessary dietary components to residents on a pureed diet.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of small brown bugs in one resident's room and a dining area. Observations and interviews revealed that multiple residents and staff members noticed bugs throughout the facility, including cockroaches and other insects. Resident #3 reported finding bugs in his room every night, which crawled into his shoes, while Resident #7 observed bugs daily and claimed that staff did not address the issue. On-site observations confirmed the presence of bugs in Resident #6's room and the Sunflower hallway. Interviews with staff, including CNAs, LVNs, and the Maintenance Director, indicated that bugs were frequently seen in various areas of the facility. Staff members reported these sightings to the maintenance department, which logged them in a maintenance book. The Maintenance Director acknowledged the pest issue and stated that a pest control company visited regularly. However, the problem persisted, as evidenced by the maintenance request logs that documented pest control requests and sightings over several months. The facility's policy required immediate communication of pest sightings to management and documentation in the maintenance work order binder.
Violation of Resident Rights and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, leading to a deficiency in the care provided to two residents. The first incident involved the Maintenance Director recording a resident with his personal cell phone while the resident was yelling and cursing at the staff. The resident, who had a history of stroke, hemiplegia, and traumatic brain injury, was cognitively impaired and used a wheelchair for mobility. The Maintenance Director claimed he recorded the incident to show management how the resident treated him, but he was unaware that recording residents was against policy. The Administrator confirmed that the Maintenance Director had been trained on managing residents with behaviors and acknowledged that recording the resident was a violation of the resident's rights. The second incident involved a CNA taking away a resident's cell phone when the resident attempted to call 911. This resident had multiple sclerosis, cognitive communication deficit, and muscle weakness, with a moderately impaired cognition. The resident had a history of refusing care and being verbally and physically aggressive. During an episode where the resident was being changed, he became upset and attempted to call 911, prompting the CNA to take his phone away. The CNA stated she was following the DON's orders, although the DON later denied instructing staff to remove the resident's phone. The phone was eventually returned to the resident, but the incident was recognized as a violation of the resident's rights. Both incidents highlight the facility's failure to uphold residents' rights to dignity, self-determination, and communication. The actions of the Maintenance Director and the CNA, whether intentional or due to misunderstanding, resulted in breaches of privacy and autonomy for the residents involved. The facility's policies on electronic devices and resident rights were not adhered to, leading to these deficiencies in care.
Failure to Use Beard Restraints in Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the actions of Cook C, who did not wear a beard restraint while in the food preparation area and during the lunch meal service. On the specified date, Cook C was seen with facial hair on his chin and was not wearing a beard restraint while using a blender to prepare pureed meat for lunch. Later, during the lunch meal service, Cook C was observed plating meals for residents without a beard restraint, which could potentially lead to food contamination. Interviews conducted with the Dietary Manager (DM) and Cook C revealed a lack of awareness and availability of beard restraints in the kitchen. The DM admitted to not having heard of beard restraints before and confirmed that none were available for staff with facial hair. The facility's policy on preventing foodborne illness requires the use of hair nets or caps and beard restraints to prevent hair from contacting exposed food. This policy aligns with the Federal Food Code 2022, which mandates the use of effective hair restraints where appropriate.
Failure to Provide Necessary Grooming Services
Penalty
Summary
The facility failed to provide necessary grooming services to a female resident with moderate cognitive impairment, as evidenced by the presence of unwanted facial hair. The resident, who had a history of Alzheimer's, myopathies, Type 2 diabetes with neuropathy, and other conditions, required assistance with activities of daily living (ADLs) such as personal hygiene. Despite the resident expressing a desire to have her facial hair removed, staff did not offer or attempt to shave her chin, and there was no documentation of any refusal of care by the resident. Interviews with facility staff, including a CNA, LVN, and the ADON, revealed a lack of awareness and action regarding the resident's grooming needs. The CNA, who had been caring for the resident for two weeks, did not notice the facial hair and had not attempted to shave it. The LVN and ADON were also unaware of the issue, and there was no documentation of grooming refusals in the resident's records. The facility's policy required residents to be groomed daily, but this was not adhered to in the case of this resident, leading to a deficiency in maintaining her dignity and self-esteem.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily, as required by their policy. On 08/29/24, observations at multiple times throughout the day revealed that the staffing information posted near the facility's entrance was dated 08/28/24, indicating that it had not been updated for the current day. This oversight was confirmed through interviews with the Assistant Director of Nursing (ADON) and the Administrator, who both acknowledged the lapse in updating the staffing information. The ADON stated that the Director of Nursing (DON) was responsible for updating the daily staffing post, but the DON had left the facility at the end of her shift on 08/28/24 and did not return the following day. The ADON admitted that she might have been responsible for updating the post in the absence of the DON but had not done so. The Administrator confirmed that the staffing posting should be updated daily and was unaware of why it was not updated for 08/29/24. The facility's policy requires that the number of nursing personnel responsible for direct care be posted within two hours of each shift's start, but this was not adhered to on the day in question.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization or therapeutic leave, violating the bed-hold policy. The resident, a male with schizoaffective disorder, heart failure, hyperlipidemia, mild cognitive impairment, and hypertension, was initially admitted to the secure unit of the facility. He was transferred to a behavioral health hospital following an incident where he expressed suicidal ideation and self-harm. Despite the discharge assessment indicating a return was anticipated, the facility did not re-admit him. The resident's care plan included interventions for behavioral problems, but there was no documentation of his transfer to the hospital or a discharge summary. Interviews with facility staff revealed that the resident exhibited unusual behaviors, such as pacing and attempting to intimidate others. After the incident, emergency services transferred him to the hospital, but the facility did not complete the necessary paperwork or communicate effectively with the behavioral health hospital regarding his return. The Director of Nursing (DON) and the Administrator both indicated that the resident would not be allowed to return due to safety concerns and property damage. The Administrator stated that residents are considered discharged once sent to a hospital, and no discharge documents were sent with the resident. The behavioral health hospital's Program Director confirmed that the facility did not provide the necessary documentation or communication, placing the resident at risk of an unsafe discharge.
Infection Control Deficiency: Urinary Catheter Positioning
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program, as evidenced by the improper positioning of a urinary catheter for a resident. The resident, who was admitted to the facility from an acute care hospital, had a urinary catheter that was observed to be on the floor. This was noted during an observation and interview with the resident, who was unaware of the catheter's position and its significance in infection control. The resident's medical history included encephalopathy, heart disease, hypertension, cerebrovascular disease, hemiplegia following cerebral infarction, and dementia. The resident's nurse, LVN B, confirmed the catheter's position on the floor and repositioned it after being prompted by the surveyor. The Director of Nursing (DON) and the facility Administrator both acknowledged the expectation that urinary catheters should not touch the floor and should be frequently checked by nursing staff. The facility's policy on catheter care also specified that the catheter bag should be positioned below the bladder level and not touch the floor, indicating a lapse in adherence to established protocols.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that a functional call light system was available for a resident, which compromised the resident's ability to call for staff assistance. The resident, who was cognitively intact and required a wheelchair for mobility, reported that her call light had not been working for an unspecified period. This issue forced her to self-propel to the nurse's station for assistance, which she found inconvenient. The resident's care plan included the need to call for assistance when in pain, highlighting the importance of a functional call light system for her care. During the investigation, it was confirmed that the call light in the resident's room was not functioning, as it did not signal at the nurse's station. The Licensed Vocational Nurse (LVN) interviewed was unaware of the malfunction and could not provide a maintenance log for review. The Corporate Maintenance Director stated that he was not aware of the issue and emphasized the importance of a functioning call light system. The facility's Administrator acknowledged the deficiency and stated that staff should conduct daily rounds to check call light functionality. The facility's maintenance log showed no record of the call light issue, and the facility's policy required prompt reporting and repair of defective call lights.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for three residents. Resident #1, a male with severe cognitive impairment and multiple physical disabilities, experienced an unwitnessed fall resulting in a non-displaced sacrum ring fracture. The fall occurred when a CNA left the resident alone during incontinence care to retrieve more wipes, despite the resident's known impulsiveness and need for constant supervision during such activities. The CNA was later terminated for negligence, and the facility acknowledged that the CNA should have called for assistance instead of leaving the resident alone. Resident #2, a male with severe cognitive impairment and a history of elopement, managed to leave the facility's secured unit without triggering any alarms. The resident was found by a housekeeper outside the facility and brought back. The incident revealed that the back door of the secured unit was not functioning properly, as it did not lock or set off an alarm when the resident exited. The facility's maintenance logs showed that the door had been checked regularly, but the malfunction was not identified until after the elopement. Resident #3, a male with moderate cognitive impairment, sustained burns on his left foot's first and second toes after accessing a microwave in an unlocked staff break room. The resident's care plan noted a risk for skin breakdown, and the burns were treated with various dressings over time. The incident highlighted the facility's failure to secure areas containing potential hazards, such as the staff break room, to prevent residents from accessing dangerous equipment like microwaves.
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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
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.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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