Austin Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 11406 Rustic Rock Drive, Austin, Texas 78750
- CMS Provider Number
- 455799
- Inspections on file
- 49
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Austin Wellness & Rehabilitation during CMS and state inspections, most recent first.
A resident with intact cognition and multiple complex conditions (CAD, ESRD, HF, HTN, DM, PVD, GERD, pneumonia, COPD, hyperlipidemia, depression, PTSD, anemia, and pain) had active diagnoses and medications documented on the face sheet, MDS, and MAR, but the comprehensive care plan contained no care plans for any of these conditions. The resident reported dissatisfaction with nursing care, including medications not always being given on time. The MDSC stated he was responsible for care plans and believed he had completed this resident’s plan, but record review showed it was incomplete. Nursing staff reported they did not use care plans, instead relying on the Kardex, 24-hour report, and IDT notes, and some were unaware of the relevance of care plans or person-centered care planning and reported no in-service training on care plans. The facility’s policy required an IDT-developed, person-centered care plan with measurable objectives and timetables for each resident’s medical, nursing, mental, and psychosocial needs, which was not implemented for this resident.
A resident with intact cognition and multiple complex diagnoses, including CAD, ESRD, HF, HTN, DM, COPD, depression, PTSD, and pain, had a quarterly MDS completed, but the facility failed to develop a comprehensive care plan within 7 days as required. Record review showed that only a smoking-policy noncompliance care plan was in place, with no plans addressing the resident’s medical, nursing, mental health, or psychosocial needs. The resident reported dissatisfaction with nursing care, including medications not always being given on time and a missing personal item. The remote MDSC believed the care plan had been completed on time but acknowledged responsibility for care plans, while the new DON was unaware of the missing comprehensive plan, and the ADM stated that prior care plans were not transferred or updated after the recent MDS, leaving the resident’s conditions unreflected in the current care plan.
A resident with multiple comorbidities, including prior CVA with hemiplegia, chronic pain, depression, morbid obesity, and altered mental status, had ongoing refusals of showers and incontinence care that were not incorporated into the comprehensive care plan. The DON stated that ADL participation and refusals should be reflected and updated in the care plan, but could not explain why this resident’s refusals and related risks, goals, and interventions for skin assessment and infection risk were not added. The ADM reported he had previously asked the DON to care plan the resident’s refusals and did not do so himself, and he was unaware of how the DON monitored care plan revisions. Record review confirmed that the resident’s care plan, while containing ADL self-care performance goals, lacked updates addressing the repeated refusals of care and associated skin and UTI risk.
Surveyors found a medication cart unlocked and unattended near the nurse’s station while an RN was inside the station and out of view of the cart, and another RN walked past without securing it. Residents were walking by the cart, which contained prescribed medications, OTC drugs, narcotics, and injectable antibiotics. The RN, DON, and administrator all acknowledged that facility policy requires medication carts to be locked when not in use and that only authorized staff should have access, but they could not explain why the cart had been left unlocked.
A resident with a history of trauma and psychiatric diagnoses reported being sexually molested by a staff member during the night. The DON initiated an internal assessment and suspended the accused aide, but law enforcement was not notified, and the resident was not offered the opportunity to speak with police. Staff interviews revealed inconsistencies in the investigation, and the facility did not provide evidence of a thorough investigation or timely reporting of results to the state survey agency, as required by policy.
A resident with multiple complex medical conditions did not have a comprehensive care plan addressing key needs such as pain management, pressure ulcer risk, ADL assistance, incontinence, medication management, hospice care, oxygen therapy, DNR status, fall risk, and elopement risk. Only two care areas were documented, despite clinical assessments and physician orders indicating broader needs. Staff interviews revealed confusion about care plan responsibilities, and facility policy requirements for comprehensive, updated care plans were not followed.
A strong urine odor was observed throughout the facility, with multiple residents and staff confirming the persistent foul smell in various areas. Residents with conditions such as Hepatitis A, bipolar disorder, depression, cerebral infarction, epilepsy, and malnutrition reported discomfort and frequent complaints about the odor. Staff interviews confirmed awareness of the issue, and facility policies requiring a sanitary environment were not upheld.
Staff did not complete serving meals to all residents at one table before moving to the next, and failed to set up or assist with meals for several residents with cognitive and physical impairments. Some residents were left with meal trays unprepared or received minimal feeding assistance, with no alternatives or supplements offered when they refused food. These actions did not align with facility policy and resulted in a lack of respect for resident dignity and rights during dining.
Several residents with complex medical conditions had missing, conflicting, or incomplete documentation of their advance directives across admission face sheets, care plans, and medical records. Staff interviews revealed no clear process or designated responsibility for ensuring accurate entry and maintenance of advance directive information, leading to inconsistencies and omissions despite facility policy requirements.
The facility did not ensure that food and drink were palatable, attractive, and served at an appetizing temperature, as observed during a meal where pureed foods were unappealing and lacked proper seasoning, and silverware was wet. Additionally, food preferences were not obtained or documented for three residents with complex medical needs, leading to dissatisfaction and reports of inadequate meal service. Staff interviews confirmed that required procedures for documenting preferences were not followed.
Surveyors identified multiple deficiencies in kitchen operations, including improper hand hygiene, lack of hair restraints and beard guards, failure to label and date food items, improper food storage, and inadequate cleaning practices. Staff were observed wearing jewelry and artificial nails without gloves, and cleaning logs and temperature records were not maintained. Interviews revealed inconsistent staff training and understanding of infection control and food safety protocols.
Staff failed to follow infection control protocols, including hand hygiene between resident contacts and disinfection of reusable medical equipment, during meal service and vital sign checks. Multiple staff members, including CNAs, an LVN, and a medication aide, did not sanitize hands or equipment as required, despite facility policies and recent training. Residents involved had various medical and cognitive conditions, and leadership confirmed expectations for proper infection control were not met.
A resident with severe physical and cognitive impairments was not consistently provided with an accessible call device, leaving him unable to request assistance and without water within reach on multiple occasions. Staff confirmed the resident could not use standard call lights and that alternative devices were not reliably available, resulting in unmet needs for care and hydration.
Two residents were admitted without baseline care plans developed within 48 hours, resulting in missing instructions for person-centered care. One resident with severe cognitive impairment and behavioral issues did not have care plan interventions for wandering or agitation, while another with dementia and muscle weakness lacked care plan details for personal grooming needs. Staff interviews revealed confusion about care plan responsibilities, and no care plan policy was provided.
Two residents with severe physical and cognitive impairments did not receive individualized or group activities as required by their care plans. Despite being dependent on staff for all activities and having documented needs for 1:1 engagement, there was no evidence or documentation that such activities were provided. Staff interviews and observations confirmed the lack of participation in activities, and facility leadership was unaware of consistent activity documentation or provision for these residents.
A resident experiencing weight loss was not consistently weighed weekly as required by facility policy and dietitian recommendations. Staff interviews revealed lapses in communication and follow-through, resulting in the resident not receiving prescribed dietary supplements and assistance. The failure to monitor and address the resident's nutritional status was confirmed through record review and staff interviews.
Two residents did not have their controlled medications accurately documented on narcotic count sheets, as required by facility policy. An LPN administered Tramadol and Alprazolam to these residents but failed to complete the necessary documentation, resulting in discrepancies between the medication records and the actual pill counts observed in the medication cart. These deficiencies were confirmed through record review, observation, and staff interviews.
A long-term care facility failed to implement an effective infection prevention and control program, resulting in inadequate use of PPE during high-contact care for residents with wounds and medical devices. Staff were not properly trained on Enhanced Barrier Precautions (EBP), and there was a lack of signage and PPE availability. This deficiency placed residents at risk of infection.
The facility failed to designate a qualified Infection Preventionist for its infection control program. The ADON was responsible but lacked certification, while the Administrator and DON, who were certified, were not involved in infection control activities. The ADON completed the necessary training only after a state surveyor's inquiry, highlighting a compliance gap.
A resident with severe cognitive impairment and a history of myalgia and knee pain was found with long, dirty fingernails, indicating a failure in providing necessary grooming and personal care. The resident had not had her nails trimmed since admission and expressed a desire for assistance, which was not offered. The ADON acknowledged the importance of nail care and the facility's policies emphasized maintaining residents' well-being, but these were not followed, resulting in the deficiency.
The facility failed to develop baseline care plans within 48 hours for three residents with moderate cognitive impairment and complex medical conditions. Interviews revealed a lack of oversight and accountability, with no designated individual ensuring timely completion of these plans, potentially affecting residents' health.
A resident with moderate cognitive impairment and a diagnosis of sepsis did not receive her prescribed Ertapenem Sodium Injection Solution as documented. The facility failed to document the administration of the antibiotic on a specific date, and staff interviews revealed inconsistencies in medication administration and documentation practices. The facility's policy requires immediate documentation of medication administration, which was not followed in this case.
Two residents with cognitive impairments and high fall risks experienced frequent falls without appropriate interventions. Despite multiple falls, care plans were not updated, and necessary assessments were not conducted. The facility's staff failed to adhere to fall prevention policies, leading to an Immediate Jeopardy situation.
Two residents in the facility experienced multiple falls without proper follow-up assessments or updates to their care plans. One resident, with a history of COPD and TBI, had several unwitnessed falls, resulting in significant injuries, but lacked consistent neurological checks and care plan updates. Another resident, with intellectual disabilities and unsteadiness, also suffered major injuries from falls, yet her care plan was not revised, and necessary assessments were not conducted.
A facility failed to document nursing progress notes for a resident with Alzheimer's, hypertension, seizures, and diabetes, resulting in a deficiency. The resident's medical record lacked documentation since admission, which was against the facility's policy requiring concise and accurate nursing documentation by the end of each shift. The DON stated that such a lapse was unacceptable and could lead to errors in care.
A facility failed to implement PASRR recommendations for a resident with multiple diagnoses, including epilepsy and quadriplegia, who was identified as PASRR positive for developmental disabilities. The care plan required specialized PT, OT, and ST services, but the facility did not ensure timely referrals. Staff interviews revealed a lack of awareness of the resident's PASRR status and required services, with the administrator stating that referrals were made later. This oversight could risk residents' functional ADLs.
The facility failed to maintain a safe temperature in the main dining room and community TV area, with temperatures reaching up to 93°F. Residents reported discomfort and exhaustion due to the heat, and activities were moved to cooler areas. The air conditioning system had a history of malfunctions, and a new unit was purchased but not yet installed.
The facility failed to label insulin medications with open dates, affecting three residents. Insulin pens in a medication cart were found without open dates, risking the administration of expired medications. Interviews revealed a lack of awareness and adherence to the facility's policy, which requires labeling and disposal of insulin after 28 days if opened.
A resident with a history of traumatic brain injury and multiple falls was admitted to an LTC facility, but the care plan failed to address fall prevention. Despite ongoing falls, the care plan only included goals for elopement and antidepressant medication. Observations showed the resident's room was not set up to prevent falls, and staff interviews revealed a lack of awareness and training regarding fall precautions. The facility's DON and Administrator acknowledged deficiencies in the care plan and communication.
A resident with a history of traumatic brain injury and moderate cognitive impairment experienced repeated falls due to inadequate supervision and ineffective interventions. The care plan initially failed to address fall prevention, and staff were not consistently aware of necessary precautions. Despite multiple falls, the facility did not implement effective systemic changes, leading to an immediate jeopardy situation.
The facility failed to review and revise comprehensive care plans for five residents after their quarterly MDS assessments, potentially risking unmet needs. Residents with severe cognitive impairments and complex medical histories had outdated care plans. Interviews revealed a lack of clarity and responsibility among staff, including the ADM, SW, DON, and MDS Coordinator, regarding care plan management.
A facility failed to implement PASRR recommendations for a resident requiring specialized OT and PT services, despite agreement during an IDT meeting. The resident, with a history of spina bifida and other conditions, did not receive the necessary therapy services until months later. Interviews revealed confusion among staff about the PASRR process and responsibilities, with the MDS nurse responsible for service requests no longer at the facility and the current MDS nurse working remotely. The administrator admitted to the lack of a procedure for timely PASRR service requests.
The facility failed to ensure that two residents received their scheduled showers, leading to deficiencies in personal hygiene and grooming. Both residents missed multiple scheduled showers, and there was no documentation of refusals or reasons for missed showers. Staff interviews revealed issues with towel availability and inconsistent documentation practices.
The facility failed to provide a resident with the correct mechanical soft diet with pureed meats, as required by the physician's order. Observations revealed that dietary cards were not used consistently, leading to the resident receiving inappropriate food textures. Staff interviews confirmed that the issue had been ongoing for several months due to a change in ownership and lack of proper implementation of diet cards.
A resident with multiple medical conditions eloped from the facility and was found injured 1.5 miles away. The facility failed to evaluate the resident's elopement risk and did not have a care plan in place. The emergency exit door had a security flaw, and staff were unaware of the resident's absence until informed by the family.
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents and one hallway. Observations revealed sticky floors in residents' rooms and a hallway with a foul odor. Housekeeping staff confirmed inconsistent cleaning practices and a lack of night-time coverage, leading to frequent complaints from residents and families.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan for Medically Complex Resident
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple complex medical conditions. The resident, an older adult male with intact cognition (BIMS score of 14), had active diagnoses including coronary artery disease, end-stage renal disease, heart failure, hypertension, diabetes mellitus, peripheral vascular disease, GERD, pneumonia, COPD, hyperlipidemia, depression, PTSD, anemia, and pain. His face sheet, MDS, and MAR confirmed these active conditions and corresponding medications, yet review of his comprehensive care plan initiated in early March showed no care plans addressing any of these active complex medical conditions. During interviews, the resident reported dissatisfaction with nursing care, stating that staff were not doing their job properly, that medications were sometimes not given on time, and that he and his family were looking for another facility. He also reported a missing watch that he suspected was taken by staff. The MDS coordinator stated he was responsible for initiating, updating, and completing care plans, received information on residents’ conditions during daily IDT meetings, and believed he had completed the resident’s care plan after the MDS assessment in early February, but the record review showed otherwise. Additional staff interviews revealed that nurses were not using or relying on care plans in practice. One RN working PRN stated she used the Kardex for resident care, had never referred to care plans, and was unaware of their relevance, noting she had never received in-service training on care plans. Another RN reported she did not rely on care plans, instead using the 24-hour report and other assessment tools, and stated she was unfamiliar with person-centered care plans or how to implement interventions listed in them, instead basing daily care on IDT meeting notes. An LVN stated she had worked with the resident and had not noticed the absence of care plans for his conditions, acknowledged that care plans are important for goals and interventions, and reported she had never received in-services on care plans. The DON and ADM both stated that care plans are essential and integral to nursing care, and the facility’s written policy required a comprehensive, culturally competent, trauma-informed person-centered care plan with measurable objectives and timetables for each resident’s medical, nursing, mental, and psychosocial needs, which was not in place for this resident.
Failure to Complete Comprehensive Care Plan Following Quarterly MDS
Penalty
Summary
The facility failed to develop and complete a comprehensive, person-centered care plan within 7 days of the comprehensive assessment for one resident, as required by facility policy. Record review showed that the resident, an adult male with multiple complex medical diagnoses including coronary artery disease, end-stage renal disease, heart failure, hypertension, diabetes mellitus, peripheral vascular disease, GERD, pneumonia, COPD, hyperlipidemia, depression, PTSD, anemia, and pain, had a quarterly MDS assessment completed on 02/05/26 with a BIMS score of 14, indicating intact cognition. Despite this, the only care plan in place as of 03/05/26 addressed the resident’s noncompliance with facility smoking policies, and there were no care plans addressing his medical, nursing, mental health, or other psychosocial needs. During interviews, the resident reported dissatisfaction with nursing care, stating that staff were not doing their jobs properly, that medications were sometimes not given on time, and that a personal item (a watch) had gone missing, which he suspected was taken by staff. The MDSC, who worked remotely and was responsible for initiating, updating, and completing care plans, stated he believed he had completed the care plan within the required 7-day timeframe and acknowledged that care plans are integral to nursing care and must be timely. The DON, who was new to the facility, stated she was unaware that there was no proper care plan for the resident based on the quarterly MDS and agreed that the missing care plan related to the resident’s medical conditions was a concern. The ADM stated that the resident had prior care plans before a period out of the facility and that the MDSC failed to transfer and update those care plans after the recent quarterly MDS, suggesting a possible system glitch, and confirmed that the resident’s conditions were not reflected in the current care plan.
Failure to Update Care Plan for Repeated Care Refusals and Skin Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and update a complete, measurable care plan that reflected a resident’s refusals of showers and incontinence care, including associated skin assessments and interventions to reduce the risk of skin breakdown. Interview with the DON revealed she had been trained on completing care plans and stated that residents’ participation in ADLs and refusals of care should be included on the care plan and updated when new problem areas are identified. She acknowledged that Resident #1’s care plan did not contain risk, goals, or interventions related to the resident’s refusals of showers and changing briefs, and she stated she did not know why the care plan was not updated. She further stated that if something was not on the care plan, it could affect the quality of care and that not updating this resident’s care plan could increase the risk for skin breakdown and infection (UTI). The ADM reported he was trained on care plans and that they should be person-centered, and that frequent refusals of services should be included so staff would know the resident refused. He stated the IDT was responsible for entering information into the care plan and that the DON monitored care plans for accuracy, although he did not know how she monitored revisions. The ADM reported that he had asked the DON to care plan this resident’s refusals back in September 2025 and did not care plan it himself. Record review showed that Resident #1, an 80-year-old female with diagnoses including cerebral infarction, chronic pain, depression, morbid obesity, altered mental status, hemiplegia, and hemiparesis, had a comprehensive care plan with ADL self-care performance goals, but the plan lacked revisions to address her ongoing refusals of showers and changing briefs, and the related skin and infection risk.
Unlocked Medication Cart Left Unattended With Medications Accessible
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications on a medication cart were securely stored and inaccessible to unauthorized individuals. During an observation of the nurse’s station, Medication Cart #1 (MC #1) was found unlocked and unattended while an RN sat inside the nurse’s station, out of view of the cart. Another RN walked past the unlocked cart and entered the nurse’s station without locking it. Residents were observed walking by the unlocked cart, which contained prescribed creams, prescribed drugs, over-the-counter medications, narcotics, and injectable antibiotics. The facility’s written policy required that all medications and biologicals be securely stored in a locked cabinet or cart inaccessible to residents and visitors, and that only authorized staff have access to keys or codes for medication storage areas. In interviews, the RN assigned to the cart stated she had been trained on medication storage and acknowledged that the policy required the medication cart to be locked any time staff stepped away from it, and that the nurse using the cart was responsible for locking it. She also stated that all staff were expected to monitor and lock any cart found unlocked, and acknowledged that a resident might get into the medications if the cart was left unattended and unlocked. The DON confirmed she had been trained on medication storage and reiterated that medication carts must be locked when not in use or when the nurse is not present, and that medication aides and nurses passing medications are responsible for locking the carts. The administrator, though not clinical, also stated his expectation that carts be locked when not in use and confirmed that any staff member could lock an unattended cart. Both the DON and the administrator stated they did not know why the RN left MC #1 unlocked.
Failure to Thoroughly Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse made by a resident and did not report the results of the investigation to the state survey agency within five working days, as required. The incident involved a female resident with a history of trauma, major depressive disorder, borderline personality disorder, and unspecified psychosis, who reported that a tall black man entered her room during the night and touched her vaginal area. The resident had a BIMS score indicating no cognitive impairment and was her own responsible party. Upon being informed of the allegation, the DON instructed a staff nurse to perform a complete skin survey and suspended the aide assigned to the resident's hall pending investigation. Statements were collected from staff, and the incident was reported to the state agency (HHSC), but there was no evidence that law enforcement was notified or that the resident was offered the opportunity to speak with police. Interviews and record reviews revealed inconsistencies in the investigation process. The resident described the incident in detail to multiple staff members, including the DON, RN, NP, and social worker, and expressed that she wanted to make a police report but was not given the opportunity. Staff assessments found no physical evidence of injury or penetration, and the resident later clarified that she was sexually molested, not raped. The staff involved in the investigation, including the DON and Administrator, indicated that they did not notify law enforcement because the resident did not explicitly request it or because they did not believe the allegation due to the resident's history of making false accusations. The facility's policy required immediate reporting of abuse allegations to law enforcement, but this step was omitted. The investigation documentation showed that safety checks were performed on other residents in the hall, and the accused staff member was suspended. However, the facility did not provide evidence that all alleged violations were thoroughly investigated or that the results were reported to the state survey agency within the required timeframe. The Administrator acknowledged that he was unaware of the requirement to notify law enforcement and deferred the investigation to the DON in his absence. The lack of a thorough investigation and failure to notify law enforcement constituted a deficiency in the facility's response to the abuse allegation.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. The care plan did not address several critical areas, including pain management, risk for pressure ulcer development, assistance needed for activities of daily living (ADLs), bowel and bladder incontinence, medications for disease management, hospice care, the reason for oxygen therapy, DNR status, fall risk, and elopement risk. Despite the resident's significant medical history—including COPD, diabetes, pneumonia, hypertension, bipolar disorder, depression, chronic kidney disease, benign prostatic hyperplasia, low back pain, jaw pain, age-related decline, and asthma—only two care areas were documented: pneumonia and a behavior problem related to smoking while on oxygen. Interviews and record reviews revealed that the resident was at high risk for falls and elopement, was on multiple medications for various conditions, and was receiving hospice care and oxygen therapy. The resident's MDS assessment indicated moderate cognitive impairment, frequent pain, and incontinence issues. Physician orders and clinical assessments further documented the need for comprehensive care planning in these areas. However, the care plan was not updated to reflect these needs, and essential interventions and goals were omitted. Staff interviews indicated a lack of clarity and follow-through regarding care plan responsibilities. The MDS nurse, DON, ADON, and social worker each described different understandings of who should update the care plan and when, with some staff stating they had never updated a care plan. The facility's policy required a comprehensive, person-centered care plan to be developed and updated as needed, but this was not followed in practice for this resident, resulting in a deficient practice that could impact the delivery of necessary care and services.
Failure to Maintain a Clean and Homelike Environment Due to Persistent Urine Odor
Penalty
Summary
Surveyors observed a strong urine odor throughout the facility, including the front of the building and multiple hallways, during their visit. This odor was consistently noted in several areas, such as the 2200 and 2100 halls, and was present during multiple walkthroughs, including one conducted with the Director of Nursing (DON). The persistent foul smell was also reported by residents and staff, who indicated that the issue had been ongoing and that complaints had been made to facility staff. Three residents were specifically identified as being affected by the unsanitary environment. One resident, with diagnoses including Hepatitis A, bipolar disorder, and depression, reported feeling sick due to the odor and confirmed that the facility had been notified of the issue. Another resident, with a history of cerebral infarction, reduced mobility, and muscle weakness, described the odor as rotten and stated that it was a frequent topic of conversation among residents. A third resident, diagnosed with epilepsy, malnutrition, and polyneuropathy, also confirmed the constant presence of the urine smell and stated that they would seek out staff when the odor was noticeable. Interviews with staff, including two CNAs and the DON, confirmed that they had received complaints from residents about the urine odor and that they themselves had noticed the smell throughout the building. The DON attributed the odor on one hall to residents refusing showers and stated that housekeeping was notified when foul odors were present. Facility infection control policies reviewed by surveyors indicated a requirement to maintain a safe, sanitary, and comfortable environment, which was not met as evidenced by the ongoing odor issue.
Failure to Promote Resident Dignity and Rights During Meal Service
Penalty
Summary
The facility failed to treat several residents with respect and dignity during meal service, as observed and documented in the report. Staff did not complete serving meals to all residents at one table before moving to the next, resulting in some residents waiting while others at their table were served. This practice was inconsistent with the facility's own dining services policy, which requires that meals be served table by table and that all items be set up for the resident before staff move on. Additionally, staff failed to set up meals for some residents, leaving trays in front of them without removing packaging or assisting with setup, as required for residents with functional limitations. Specific residents affected included individuals with significant cognitive and physical impairments, such as dementia, dysphagia, malnutrition, and communication deficits. For example, one resident received her meal tray, but staff did not remove items from the tray or set up the meal, leaving her without the necessary assistance to begin eating. Other residents required extensive or total assistance with eating, but staff either delayed feeding, made only minimal attempts, or stopped feeding after a few bites without offering alternatives or supplements, despite care plans indicating the need for such support. Interviews with staff revealed a lack of understanding regarding the importance of serving all residents at a table before moving on and the need to provide proper meal setup and assistance. The administrator was unsure if the observed serving practice was a dignity issue, and a CNA reported ceasing feeding attempts after a resident refused food, without further efforts or offering alternatives. These actions and inactions directly contributed to the failure to promote and protect resident dignity and rights during meal service.
Failure to Accurately Document and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure that residents' advance directives were accurately documented and consistently reflected across medical records, care plans, and admission face sheets. For one resident, the admission face sheet listed both Full Code and DNR (Do Not Resuscitate) status, while the care plan documented only the DNR, and a completed DNR order was present in the record. Another resident had no documentation of advance directive status in the face sheet, care plan, or electronic records, and the only related form found was incomplete and added after the deficiency was identified. A third resident's admission face sheet lacked any documentation of advance directives, although the care plan indicated Full Code status, but there was no supporting documentation in the medical record. For a fourth resident, the face sheet did not indicate any advance directives, but the care plan and order summary report reflected Full Code status and related interventions. These inconsistencies and omissions were identified through record reviews and interviews with facility staff, who confirmed there was no designated person responsible for ensuring advance directive information was accurately entered and maintained in the system. The facility's policy required staff to inquire about advance directives at admission, provide information to residents, and ensure documentation was completed and honored. However, interviews revealed a lack of clear processes and accountability for entering and verifying advance directive information, resulting in incomplete or conflicting records for multiple residents with complex medical histories and cognitive impairments.
Failure to Provide Palatable, Attractive, and Preference-Based Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. During observation of a lunch meal, the test tray for pureed food was found to be unappetizing in appearance, with food items running together and carrot liquid covering the plate. The pureed carrots tasted strongly of tart orange juice rather than carrots, and the pureed dinner roll was described as doughy and undercooked. Additionally, the rolled silverware for the regular texture tray was wet and soggy, and condiments and beverages were missing from both trays. The dessert cake was noted to be very dry and lacking moisture or frosting. These issues were observed during one of five meals reviewed. The facility also failed to obtain and document food preferences for three residents who consumed food orally. Record reviews showed that these residents had various medical conditions, including dementia, dysphagia, bipolar disorder, depression, hypertension, chronic kidney disease, heart failure, cirrhosis, protein calorie malnutrition, and diabetes. Despite their complex medical needs, there was no evidence that their food preferences were obtained or documented on their meal ticket slips. Interviews with the residents revealed dissatisfaction with the food, lack of choice, and that no one from the kitchen staff had discussed meal preferences with them. One resident reported not receiving a proper dinner meal and having to request coffee daily, while another stated that breakfast was always cold and preferences were never solicited. Interviews with the Dietary Manager (DM) and Administrator (ADM) confirmed that it was the DM's responsibility to obtain and document resident meal preferences, but this was not consistently done. The DM was unaware of the issues with the test trays, including the lack of condiments and the wet napkin, and could not explain how these occurred. The facility's dining service standards policy required that residents be provided a positive meal experience, including meal selection based on resident preferences, but this was not followed for the residents reviewed.
Deficient Food Storage, Preparation, and Sanitation Practices in Kitchen
Penalty
Summary
Multiple deficiencies were identified in the facility's kitchen regarding food storage, preparation, and sanitation practices. Observations revealed that hand hygiene was not properly maintained, as evidenced by the lack of paper towels at handwashing sinks and staff failing to perform hand hygiene after handling trash and before returning to food preparation. Staff were also observed wearing jewelry, such as rings, watches, and bracelets, while preparing food and washing dishes, which is not in accordance with professional standards for food safety. Additionally, some staff did not wear required hair restraints or beard guards while in the kitchen, and one staff member with long fake fingernails was assembling meal trays without gloves. Food storage practices were also found to be deficient. Numerous food items in the pantry, walk-in freezer, and refrigerators were observed to be opened, unlabeled, undated, and not properly covered or sealed. Scoops were stored directly in food containers, and some containers had food debris or crumbs. Temperature logs for refrigeration equipment were not maintained for the month reviewed, and cleaning schedules and logs were not being utilized. The ice machine and microwave were found to have visible debris and residue, and the dish room had physical plant issues such as cracked floor tiles, missing tiles, and chipped plates. Interviews with dietary staff and management revealed gaps in training and knowledge regarding proper sanitation, labeling, and infection control practices. The dietary manager acknowledged that cleaning lists were not being used due to staffing shortages and that the responsibility for food labeling, dating, and kitchen sanitation ultimately fell to him. Staff interviews indicated inconsistent understanding of requirements for hand hygiene, jewelry, and use of gloves with artificial nails. Facility policies required labeling and dating of all food items, use of hair restraints, and adherence to infection prevention protocols, but these were not consistently followed.
Failure to Maintain Infection Control Practices During Resident Care and Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to hand hygiene and equipment disinfection protocols. Observations revealed that a CNA did not perform hand hygiene when passing lunch trays between residents, and this lapse was also noted among other staff, including another CNA, an LVN, and the AD during meal tray distribution. These actions were observed during meal service, where staff moved from one resident to another without sanitizing their hands, despite facility policies requiring hand hygiene between resident contacts. Additionally, a medication aide did not sanitize a blood pressure cuff after use on a resident, nor did she change gloves or perform hand hygiene before returning to the medication cart. The aide acknowledged awareness of infection control practices and had recently received training, yet failed to implement these measures in practice. The facility's policies clearly state that reusable medical equipment must be disinfected between uses, and hand hygiene is required when moving between residents or after contact with potentially contaminated surfaces. Record reviews of the involved residents indicated that they had various medical conditions, including cognitive impairments, mobility limitations, and chronic diseases, which could increase their vulnerability to infections. Interviews with facility leadership confirmed that the expectation was for all staff to perform hand hygiene between resident contacts and to disinfect equipment after each use. However, in-service training records showed that some staff had not signed the infection control training attendance sheet, suggesting possible gaps in staff education or compliance monitoring.
Failure to Provide Accessible Call Device for Dependent Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident with severe physical and cognitive impairments, specifically by not ensuring access to a call device that the resident could use. The resident, who had a history of cerebral infarction, quadriplegia, paraplegia, dysphagia, and severe cognitive impairment, was dependent on staff for all activities of daily living. Observations and interviews revealed that the resident was unable to use the standard call light due to his physical limitations and was not consistently provided with an alternative call device that he could operate. On multiple occasions, the resident was observed without water within reach and reported being unable to summon assistance, stating he had to yell for help as he could not use the call light. Staff interviews confirmed that the resident was unable to use available call devices and that alternative solutions, such as a pad call light, were not reliably provided or were sometimes misplaced. The resident's care plan did not include specific interventions regarding the use of a call device, despite his significant functional limitations. Facility policy required staff to provide care and services that maintain residents' abilities in activities of daily living and communication, but this was not followed in the resident's case. The lack of a consistently accessible and usable call device for the resident resulted in unmet needs for assistance and hydration, as documented during the survey period.
Failure to Develop and Implement Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, resulting in a lack of person-centered and effective care instructions. For one resident with severe cognitive impairment, depression, and insomnia, there was no baseline care plan addressing his wandering and agitation, despite documented incidents of aggressive behavior and difficulty adjusting to the facility. Staff interviews revealed that care plans were not consistently reviewed or updated with relevant behavioral information, and there was confusion among staff regarding responsibility for updating care plans. Another resident with dementia, muscle wasting, and a cognitive communication deficit was admitted without a baseline care plan reflecting her individual needs. The only care plan focus was on elopement risk, omitting other aspects such as personal grooming preferences, which resulted in the resident having long, chipped fingernails and toenails protruding through her socks. Staff interviews indicated uncertainty about care plan content and responsibilities, and the facility was unable to provide a care plan policy during the survey.
Failure to Provide Individualized Activities for Bedbound Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the individual needs, interests, and preferences of two residents with significant physical and cognitive impairments. Both residents were dependent on staff for all activities of daily living and required individualized or one-on-one (1:1) activities due to their conditions, which included severe mobility limitations, cognitive deficits, and communication barriers. Despite care plans specifying the need for structured, simple activities and regular 1:1 engagement, there was no documentation or evidence that such activities were consistently provided. For one resident, records indicated a complete lack of documentation for 1:1 activities over multiple months, and observations confirmed that the resident was not participating in any group or individual activities. Interviews with staff revealed that the resident was primarily confined to bed, watched television, and occasionally received music or reading, but these interventions were not documented. Staff were unable to specify what activities, if any, were provided beyond passive television watching, and the Activity Director, who was new, had not implemented consistent activity logs. The second resident, also bedbound and severely cognitively impaired, had a care plan calling for in-room socialization and sensory stimulation at least three times per week. However, activity logs for multiple months were missing or showed no evidence of 1:1 activities. Observations and interviews confirmed that the resident did not participate in activities due to physical limitations, and staff were unclear about what, if any, activities were provided. Facility leadership acknowledged a lack of awareness regarding activity documentation and the provision of 1:1 activities for bedbound residents, despite policy requirements to meet residents' needs and preferences through individualized activity programming.
Failure to Consistently Monitor and Address Resident Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident by not obtaining consistent weights and not ensuring that dietary recommendations were followed. The resident was identified as having weight loss and was supposed to be weighed weekly, as per facility policy and dietitian recommendations. However, the Restorative Aid, who was responsible for weighing residents, did not consistently weigh the resident weekly and was unsure why the weekly weights had stopped. The Assistant Director of Nursing (ADON) was aware of the resident's weight loss and dietary needs, including the need for house shakes and assistance to the dining room, but did not track the resident's meal attendance or ensure that the dietitian's recommendations were implemented. The ADON also did not communicate effectively with the Restorative Aid regarding the need for continued weekly weights. The administrator expected that any resident with weight loss would be weighed weekly and that all staff would follow the dietitian and physician's recommendations, but was unaware of why these procedures were not followed in this case. Facility policy required weekly weights for residents with significant weight changes, and evidence-based guidelines supported this practice. Despite these requirements, the resident was not weighed as needed, and dietary interventions were not consistently provided, as confirmed by staff interviews and record reviews.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring accurate documentation and administration of controlled medications for two residents. For one resident with multiple diagnoses including hemiplegia, diabetes, hypertension, dementia, and mood disorders, the medication administration record showed that Tramadol was given as ordered, but the corresponding narcotic count sheet was not properly completed. The last count on the control drug record was not signed out with the date, time, or number of pills given, and the observed count in the medication cart did not match the documentation. For another resident with complex medical conditions such as Addisonian crisis, cognitive communication deficit, respiratory failure, and psychiatric disorders, Alprazolam was administered as ordered, but again, the narcotic count sheet was incomplete. The last medication count was not properly signed out, and the number of pills remaining in the blister pack did not match the documentation. Both instances were confirmed through observation of the medication cart and interviews with the nurse responsible, who admitted to not completing the required documentation at the time of administration. The facility's policy requires that all controlled substances be documented with specific details including date, time, quantity remaining, and the signature of the person administering the medication. These requirements were not met for the two residents, as evidenced by incomplete narcotic count sheets and discrepancies between the physical count and the documentation. The failures were identified through record reviews, direct observation, and staff interviews.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which led to deficiencies in the care of four residents. These residents were not provided with appropriate personal protective equipment (PPE) during high-contact care activities such as dressing, bathing, and wound care. Observations revealed that staff did not wear gowns when performing wound care on residents with infected wounds, and there was a lack of signage or bins with PPE at the residents' doors to indicate the need for Enhanced Barrier Precautions (EBP). Interviews with staff members, including registered nurses, licensed vocational nurses, and certified nursing assistants, indicated a lack of training and awareness regarding EBP. Some staff members were unaware of what EBP entailed, while others had not been in-serviced on the procedures. The Assistant Director of Nursing (ADON), who was responsible for infection control, admitted to not having implemented EBP and acknowledged that the facility had not prioritized training staff on these precautions. The Director of Nursing (DON) also expressed a lack of awareness about the updated requirements for EBP. The residents involved had various medical conditions that increased their risk of infection, including pressure ulcers, diabetes, and the need for medical devices such as colostomy bags and urostomy bags. Despite these conditions, the facility's care plans and physician orders did not address EBP, leaving residents vulnerable to the spread of infections. The facility's failure to implement EBP and adequately train staff on infection control measures placed residents at risk for infection, hospitalization, or death.
Inadequate Designation of Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program. During interviews, it was revealed that the Assistant Director of Nursing (ADON) was in charge of infection control but lacked the necessary certification. The Administrator and the Director of Nursing (DON) both had the required certification but were not actively involved in infection control activities. The ADON was working towards certification and completed the Nursing Home Infection Preventionist training course only after the State Surveyor's inquiry. The ADON had been in the position since July 2024, but the certification was only completed in January 2025, indicating a gap in compliance with infection control requirements.
Failure to Provide Necessary Grooming and Personal Care
Penalty
Summary
The facility failed to provide necessary grooming and personal care services for a resident who was dependent on assistance with activities of daily living (ADLs). The resident, a female with severe cognitive impairment and a history of myalgia and knee pain, had long and dirty fingernails with a black substance under them. She reported that her fingernails had not been trimmed since her admission to the facility several months prior, and she expressed a desire for staff to clean and trim her nails, which had not been offered. During an interview, the Assistant Director of Nursing (ADON) acknowledged that nail care should be performed during showers and mentioned that the resident enjoyed having her nails painted. The ADON emphasized the importance of maintaining nail hygiene to prevent infections and diseases. The facility's policies outlined the requirement for providing necessary care and services to maintain residents' physical, mental, and psychosocial well-being, but these were not adhered to in this instance, leading to the deficiency.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans for three residents within the required 48-hour timeframe following their admission. Resident #1, a female with multiple complex diagnoses including sepsis, cocaine abuse, and moderate cognitive impairment, had an incomplete and overdue baseline care plan. Resident #2, also with moderate cognitive impairment and conditions such as metabolic encephalopathy and diabetes, had no baseline care plan initiated. Similarly, Resident #3, a male with dementia and moderate cognitive impairment, lacked a baseline care plan, although his comprehensive care plan was initiated but incomplete. Interviews with facility staff revealed a lack of oversight and accountability in the completion of baseline care plans. The ADON acknowledged the expectation for baseline care plans to be completed within a week of admission, but there was no designated individual overseeing the timely completion of these plans. The MDS Coordinator, who assists with MDS assessments, stated he did not oversee baseline care plans and assumed the ADON or DON was responsible. This lack of coordination and oversight contributed to the deficiency, potentially affecting residents' health due to the absence of individualized care instructions.
Failure to Administer and Document Antibiotic Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was prescribed Ertapenem Sodium Injection Solution for the treatment of unspecified sepsis. The resident, a female with moderate cognitive impairment, was admitted with a diagnosis of sepsis and was supposed to receive the antibiotic intravenously once a day. However, there was no documented administration of the medication on a specific date, and no explanatory notes were found in the resident's progress notes for the undocumented administration. Interviews with various staff members, including the Assistant Director of Nursing (ADON), Certified Nursing Assistants (CNAs), and Certified Medication Aides (CMAs), revealed inconsistencies in the documentation and administration of the medication. The ADON stated that the resident was receiving her antibiotic medication daily, but the resident herself reported not receiving the medication for three days. The ADON also mentioned that if medication administrations were not documented, it was assumed that the medication was not given, which could affect the resident's health. The facility's policy on medication administration requires that medications be administered according to the prescriber's written orders and documented immediately after administration. The policy also states that if a medication dose is withheld, refused, or not available, an explanatory note should be entered, and the physician should be notified if three consecutive doses are missed. The lack of documentation for the resident's antibiotic administration on the specified date indicates a failure to adhere to these guidelines, potentially impacting the resident's treatment for sepsis.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for residents, leading to multiple falls and injuries. Two residents, both with moderate cognitive impairments and high fall risks, experienced frequent falls without appropriate interventions being implemented. Resident #1, a female with COPD, morbid obesity, and a traumatic brain injury, had several falls within a short period, including one that resulted in a hematoma. Despite these incidents, her care plan was not updated with new interventions, and necessary assessments, such as skin and fall assessments, were not conducted after each fall. Resident #2, a female with mild intellectual disabilities and unsteadiness on her feet, also experienced multiple falls, one of which resulted in a major injury. Her care plan was not revised to include new interventions after these falls, and a documented intervention of using a helmet was not implemented. The facility's staff failed to conduct and document required neurological checks and fall assessments consistently, as evidenced by missing documentation in the electronic medical records. Interviews with facility staff, including the Director of Nursing (DON) and other nursing staff, revealed a lack of adherence to the facility's fall prevention policy. The DON admitted to not ensuring that neuro checks were documented and completed, and there was a general lack of communication and follow-up on implementing new safety interventions for residents experiencing frequent falls. This oversight led to the identification of an Immediate Jeopardy situation, highlighting the facility's failure to protect residents from accident hazards and provide adequate supervision.
Removal Plan
- DON and ADON in-serviced by CNO on Fall Documentation and interventions, Assessments and interventions, on Fall policy and procedure, and on Abuse and Neglect.
- In-service on Fall policy and procedure implemented to all nursing staff. All Nursing Staff will complete in-service prior to starting their next shift.
- Inservice on Abuse and Neglect implemented to all staff. Staff will complete in-service prior to starting their next shift.
- Inservice on Fall Documentation, Assessments, and fall intervention, has been implemented with all Nurses. Staff will complete in-service prior to starting their next shift.
- Audit all resident with fall risk to ensure interventions are in place and documented.
- ADHOC Qapi meeting conducted by IDT Team on fall events. Attending staff Admin, DON, ADON, SW, DOR, Activities Director will attend.
Failure to Conduct Proper Assessments and Update Care Plans After Falls
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not conduct fall/skin assessments or consistent neurological checks after unwitnessed falls for two residents. This deficiency was identified during a review of five residents for quality of care. Resident #1, a female with a history of COPD, morbid obesity, TBI, and a risk of falling, experienced multiple falls within a short period. Despite being identified as a high risk for falls, her care plan was not updated with additional interventions after falls on three consecutive days. After these falls, neither skin/fall assessments nor consistent neurological checks were conducted, even though she was found with significant injuries, including a hematoma of the scalp. The lack of proper assessments and monitoring potentially contributed to her deteriorating condition, culminating in her being found unresponsive and without a pulse. Resident #2, a female with mild intellectual disabilities and unsteadiness on her feet, also experienced multiple falls resulting in major injuries, including a scalp contusion and fractures. Similar to Resident #1, her care plan was not revised to include new interventions after her falls. The facility failed to conduct necessary skin/fall assessments and consistent neurological checks following her falls. Despite the severity of her injuries, such as a fractured rib and L1 fracture, the facility did not document or implement appropriate interventions, such as the use of a helmet, in her care plan.
Failure to Document Nursing Progress Notes
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident, leading to a deficiency in maintaining proper nursing progress notes. The resident, an elderly female with Alzheimer's disease, hypertension, seizures, and type II diabetes, was admitted to the facility and had a severe cognitive impairment as indicated by a BIMS score of 6. Despite these conditions, there were no documented nursing progress notes in her electronic medical record since her admission, which was identified during a review on September 4, 2024. The Director of Nursing (DON) expressed that it was unacceptable for a resident to have no progress notes for four months, emphasizing the importance of documentation for tracking changes in residents and implementing new interventions. The facility's Nursing Documentation Policy, revised in June 2020, requires that nursing documentation be concise, clear, pertinent, accurate, and evidence-based, with narrative charting completed by the end of each assigned shift. The lack of documentation for this resident could result in errors in care and treatment, as noted in the report.
Failure to Implement PASRR Recommendations for Specialized Services
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR level II determination for a resident who was reviewed for PASRR. The resident, a male with multiple diagnoses including epilepsy, quadriplegia, and cerebral palsy, was admitted to the facility and was identified as PASRR positive for developmental disabilities. The care plan indicated that the resident was to receive specialized services such as physical therapy (PT), occupational therapy (OT), and speech therapy (ST) as recommended. However, the facility did not ensure that the resident was referred for these specialized evaluations and services by the due date. Interviews with staff revealed a lack of awareness and familiarity with the resident's PASRR status and the required services. The CNA mentioned that therapy sessions occurred on weekends but could not specify the services provided. The RN was unfamiliar with the resident's PASRR status and the additional services required. The administrator, who started working at the facility after the PASRR request, stated that referrals were made later, and the resident was receiving services as directed. This oversight in timely referrals could place residents at risk of decline in functional activities of daily living (ADLs).
Failure to Maintain Safe Temperature in Common Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents by not ensuring that the main dining room and the community television area near nurses' station 2 were kept within the appropriate temperature range of 71 to 81 degrees Fahrenheit. Observations revealed that temperatures in these areas were consistently above the acceptable range, reaching as high as 93 degrees Fahrenheit. This issue persisted despite the presence of rented cooling units, and the air conditioning system had a history of malfunctioning, with several breakdowns reported since April 2024. Residents expressed discomfort due to the high temperatures, with one resident reporting feeling tired and exhausted, and another resident needing to leave the dining room because it was too hot to eat there. The Maintenance Manager confirmed the air conditioning issues and noted that a new unit had been purchased but not yet installed. Staff interviews revealed that activities had to be relocated to cooler areas, and the dining room was closed due to the heat, impacting residents' social connections and daily activities.
Improper Labeling and Storage of Insulin Medications
Penalty
Summary
The facility failed to adhere to professional standards for labeling and storing insulin medications, which affected three residents. Insulin pens in one of the medication carts were not labeled with open dates, which is necessary to ensure the medications are used within their effective period. This oversight was observed in the medication cart at nurses' station 2, where multiple insulin pens for three residents were found without open dates, posing a risk of administering expired medications. Resident #1, a male with a history of cerebral infarction and type 2 diabetes, had several insulin pens in the cart, some of which were opened without an open date. Similarly, Resident #2, a female with congestive heart failure and diabetes, had an opened insulin pen without an open date. Resident #3, a male with dementia and diabetes, also had multiple opened insulin pens without open dates. The lack of proper labeling could lead to the administration of expired insulin, which may not effectively manage blood glucose levels. Interviews with the facility's Medical Director and LVN A revealed a lack of awareness and adherence to the facility's medication storage policy. The Medical Director was unaware of the missing open dates, and LVN A had to dispose of the potentially expired insulin pens and order replacements. The facility's policy requires medications to be labeled with open dates and disposed of after 28 days if opened, but this was not followed, leading to the deficiency.
Failure to Implement Comprehensive Fall Prevention Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced multiple falls. The resident, who had a history of traumatic brain injury and recent falls resulting in serious injuries, was admitted to the facility from a local hospital. Despite the resident's history and ongoing falls, the care plan did not address fall prevention or include interventions to mitigate the risk of further falls. The resident's care plan only included goals and interventions for elopement and antidepressant medication, with no mention of fall prevention strategies. Observations and interviews revealed that the resident's room was not set up to prevent falls, with the bed at a normal height and a fall mat folded against the wall. The resident was unaware of the purpose of the call light and denied needing help, despite being at high risk for falls. Interviews with family members and staff indicated a lack of communication and understanding of the resident's needs, with family expressing concerns about the resident's frequent falls and the facility's failure to implement effective fall prevention measures. Staff interviews highlighted a lack of awareness and training regarding fall precautions for the resident. Some staff were unaware of the need for the bed to be in a low position and the use of a fall mat, and there was no system in place for CNAs to access care plan interventions. The facility's Director of Nursing and Administrator acknowledged the deficiencies in the care plan and communication, with the Administrator admitting that the facility's current system for addressing falls was inadequate.
Repeated Falls Due to Inadequate Supervision and Interventions
Penalty
Summary
The facility failed to ensure a safe environment for a resident, who experienced repeated falls without effective interventions to reduce their frequency and severity. The resident, who had a history of traumatic brain injury and moderate cognitive impairment, was admitted with a high fall risk. Despite this, the care plan did not initially address fall prevention, and the same ineffective interventions were used repeatedly after each fall. The resident experienced multiple falls over a short period, with incidents documented on several dates. Observations revealed that fall prevention measures, such as keeping the bed in a low position and using a fall mat, were inconsistently applied. Staff interviews indicated a lack of awareness and communication regarding the resident's fall precautions, with some staff unaware of the necessary interventions or how to access care plan information. The facility's policy required post-fall assessments and investigations to identify contributing factors and implement systemic changes, but these were not effectively carried out. The resident's family expressed concerns about the falls and the lack of a coordinated care plan, noting that the resident might be attempting to use the bathroom independently, leading to falls. The facility's failure to implement and communicate effective fall prevention strategies resulted in an immediate jeopardy situation.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for five residents. This deficiency was identified during interviews and record reviews, which revealed that the care plans for these residents were not updated following their quarterly MDS assessments. The lack of timely review and revision of care plans could potentially place residents at risk of having their current needs unmet. Resident #1, who was admitted with severe cognitive impairment and multiple diagnoses including dementia and depression, had a care plan that was last reviewed several months prior to the quarterly MDS assessment. Similarly, Resident #2, with severe cognitive impairment and a history of traumatic brain injury, had an incomplete care plan that was not updated after the quarterly assessment. Resident #3, who was cognitively intact but had significant health issues such as heart failure and legal blindness, also had an outdated care plan. Residents #4 and #5, both with complex medical histories including dementia and mobility issues, had care plans that were not revised in accordance with their quarterly assessments. Interviews with facility staff, including the Administrator (ADM), Social Worker (SW), Director of Nursing (DON), and MDS Coordinator, revealed a lack of clarity and responsibility regarding the review and revision of care plans. The ADM acknowledged the issue but did not specify the risks involved. The SW, who was tasked with reviewing care plans without formal training, indicated that this was not part of his official duties. The MDS Coordinator, working part-time, focused solely on MDS assessments and did not engage in care plan revisions. This disorganization and lack of oversight contributed to the failure to maintain up-to-date care plans for the residents.
Failure to Implement PASRR Recommendations for Specialized Therapy Services
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR level II determination and evaluation report into the assessment, care planning, and transitions of care for a resident. Specifically, the facility did not ensure that the resident was referred for specialized occupational therapy (OT) and physical therapy (PT) evaluations and services, which were agreed upon during the interdisciplinary team (IDT) meeting. This oversight placed the resident at risk of decline in functional activities of daily living (ADLs). The resident, a male with a history of spina bifida, abnormal posture, lack of coordination, and other conditions, was admitted to the facility and had a BIMS score indicating intact cognition. Despite the IDT's agreement on the need for specialized OT and PT services, the resident did not receive these services until several months later. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process, with the MDS nurse responsible for inputting service requests no longer working at the facility and the current MDS nurse working remotely. The facility administrator acknowledged the absence of a procedure for timely PASRR service requests and the lack of a specific PASRR policy.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that two residents who were unable to conduct activities of daily living independently received the necessary services to maintain good grooming and personal hygiene. Resident #3, a [AGE] year-old female with hemiplegia following a cerebral infarction and epilepsy, was scheduled to receive showers three times a week. However, from her readmission date through 04/05/2024, she only received 8 out of 22 scheduled showers. There was no documentation of shower refusals, and the resident reported that showers were often missed due to a lack of towels, leading her to wash herself with washcloths brought by a family member, which did not make her feel as clean as a shower would. The facility's shower schedule and progress notes corroborated the resident's account of missed showers without documented refusals. Similarly, Resident #4, a [AGE] year-old female with cerebral palsy, epilepsy, unsteadiness on feet, and adult failure to thrive, was also scheduled to receive showers three times a week. From her readmission date through 04/05/2024, she only received 4 out of 30 scheduled showers. There was no documentation of shower refusals, and the resident reported not having had a shower in over two weeks and waiting for staff to ask her about showers. Interviews with staff revealed inconsistencies in documenting shower refusals and a lack of towels as a recurring issue, which was not documented. The facility's policy stated that residents should be offered a shower at a minimum of once weekly and given per resident request. However, the facility's practice did not align with this policy, as evidenced by the missed showers for both residents. The facility administrator confirmed that the shower sheets were the primary method of tracking showers given and acknowledged that the previous documentation system was no longer in use. The failure to provide scheduled showers as per the facility's policy and the lack of proper documentation of refusals or reasons for missed showers led to the identified deficiencies in resident care.
Failure to Provide Correct Diet for Resident
Penalty
Summary
The facility failed to prepare food in a form designed to meet the individual needs of Resident #5, who required a mechanical soft diet with pureed meats. Despite the physician's order and the resident's care plan specifying this dietary requirement, Resident #5 was served chopped meat during lunch and an entire pureed meal for dinner. This discrepancy was observed by surveyors, who noted that the dietary cards were not being used correctly, leading to the resident receiving inappropriate food textures that could contribute to choking and poor food intake. Observations revealed that the facility's dietary system had been disrupted following a change in ownership. The dietary aide and other staff members admitted that they were not using diet cards consistently and were relying on memory and handwritten labels to identify diet types. This led to confusion and errors in meal preparation and delivery. The dietary manager and other staff members were aware of the issue but had not implemented a consistent solution, resulting in Resident #5 receiving incorrect meal textures. Interviews with various staff members, including dietary aides, registered nurses, and the facility administrator, confirmed that the lack of proper diet cards had been an ongoing issue for several months. The staff were aware of the dietary requirements but failed to ensure that the correct meals were provided to the residents. The facility's policy on diet tray cards was not being followed, leading to the observed deficiencies in meal preparation and delivery for Resident #5.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, leading to the elopement of a resident. The resident, who had diagnoses including Parkinsonism, Prostatic Hyperplasia, Hypothyroidism, Hearing Loss, and Abnormal Involuntary Movements, walked out of the facility unattended. The resident was found by the police approximately 1.5 miles away from the facility with injuries including a hairline fracture above the left eye and cheek, lacerations on the left eyelid, left wrist, and lips, and abrasions on the hands. The facility staff was unaware of the resident's absence until the family called to inform them. The resident's elopement risk was not evaluated prior to the incident, and no care plan was in place to address the risk of elopement before the event occurred. The facility's incident report and interviews with staff revealed that the resident had previously attempted to leave the facility and had requested to leave multiple times. Despite these signs, the staff did not take adequate measures to prevent the elopement. The facility's emergency exit door, which the resident likely used to leave, had a security flaw that allowed it to be opened with an alarm that was not audible at the reception area. The staff's failure to monitor the resident and secure the facility's exits contributed to the resident's elopement and subsequent injuries.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents and one hallway. Observations revealed that the bedroom floors of three residents were sticky, and the hallway floor was sticky and had a foul odor. Interviews with residents and their families confirmed that housekeeping did not thoroughly clean the rooms, leading to the sticky floors. One resident even mentioned that she had to clean her own room because housekeeping did not mop it. Housekeeping staff confirmed that they cleaned residents' rooms once daily and did not document the rooms they cleaned. Additionally, there were no housekeepers working from 9:00 p.m. to 6:00 a.m., leaving a gap in cleaning coverage during the night. The Housekeeping Supervisor (HS) and other housekeeping staff revealed that the cleaning schedule was not consistently followed, and there were no logs or documentation to reflect completed duties. The HS, who had been at the facility for four weeks, observed that housekeepers were not mopping residents' rooms and bathrooms twice daily as expected. The HS also mentioned that the former HS allowed housekeepers to slack off, and she was in the process of finalizing new checklists for daily deep cleaning and weekly tasks. Despite spot-checking to ensure cleanliness, the HS acknowledged that the floors were sticky and that there were frequent complaints from residents and families about dirty floors. The facility's staff schedule and housekeeping policy indicated that there were designated shifts for housekeepers, but no coverage during the night. The policy emphasized the importance of maintaining a clean and sanitary environment to promote the health and safety of residents, staff, and visitors. However, the lack of documentation, inconsistent cleaning practices, and absence of night-time housekeeping staff contributed to the failure to provide a clean and homelike environment for the residents.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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