Bastrop Lost Pines Nursing And Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Bastrop, Texas.
- Location
- 430 Old Austin Hwy, Bastrop, Texas 78602
- CMS Provider Number
- 676222
- Inspections on file
- 40
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Bastrop Lost Pines Nursing And Rehabilitation Cent during CMS and state inspections, most recent first.
A resident with moderate intellectual disability, vascular dementia, bipolar disorder, severe cognitive impairment, and documented wheelchair dependence for mobility and transfers was subjected to verbal, mental, and physical abuse by an LVN and CNAs during toileting care. Video showed staff making profane, demeaning comments about the resident’s incontinence, telling the resident to shut up, calling her nasty, stating she needed a psych ward, and removing her wheelchair while she sobbed on the toilet. Despite care‑planned need for wheelchair use and extensive assistance, staff refused to return the wheelchair, stated she did not need it, and directed her to walk from the bathroom to the bed while providing only minimal assist, during which she fell and struck her left knee, later documented as bruised with a contusion. The resident was repeatedly left alone in the bathroom while crying, and her distress and complaints of knee pain were dismissed as fake crying, constituting a failure to protect her from abuse and neglect.
Two residents with complex medical needs were exposed to potential cross-contamination when a medical assistant failed to perform hand hygiene between providing care to each of them. The staff member did not wash hands or use sanitizer after removing a blood pressure cuff from one resident and before entering the next resident's room to provide similar care, despite facility policies requiring hand hygiene between resident contacts.
Surveyors found that several residents with significant physical and cognitive impairments were living in rooms that were not kept clean, with trash, food crumbs, and soiled bathrooms observed. Staff interviews revealed confusion about cleaning responsibilities, especially when housekeeping was unavailable, and residents reported dissatisfaction with room cleanliness. Facility policies required daily cleaning, but these were not consistently followed, leading to unclean and uncomfortable living conditions.
A medication cart containing both prescribed and over-the-counter medications was found unattended and unlocked near the dining room entrance. The medication aide responsible was away from the cart and did not notice the surveyor accessing it. Interviews confirmed that staff were trained on medication storage, but the cart was left unlocked due to distraction, in violation of facility policy requiring medication carts to be locked when not in use.
A medication cart containing prescribed and over-the-counter drugs was found unattended and unlocked near a dining room entrance. The medication aide responsible had left the cart unsecured while away at the nurses' station, despite being trained on proper medication storage. Interviews with the DON and ADM confirmed staff training and policy requirements for medication security, and facility policy review supported the need for carts to be locked and attended at all times.
The facility failed to maintain a safe and homelike environment, with deficiencies including a detached sink basin, scuffed and peeling walls, a bed without a footboard, and improperly closing windows. Residents reported these issues, but delays in maintenance and lack of a formal repair policy contributed to the persistence of these problems.
Two residents who were unable to perform their own ADLs did not receive proper nail care, resulting in long, uneven, and unclean fingernails with a blackish substance present. Despite care plans and facility policy requiring regular nail care, staff did not ensure nails were cleaned and trimmed as needed, and neither resident had refused care. Staff interviews confirmed awareness of responsibilities but revealed the deficiency in providing necessary hygiene services.
A resident with quadriplegia and bilateral hand contractures was not evaluated or treated for therapy services despite physician orders and care plan interventions. The therapy team was unaware of the order due to communication failures, resulting in the resident not receiving necessary therapy or use of splints for over two months. Staff interviews revealed confusion about responsibility for applying hand braces, and the facility lacked a policy for contracture management.
Staff failed to prevent a resident with cognitive impairment from placing her bare hands into an unattended ice chest, resulting in cross-contamination, and did not intervene despite witnessing the event. Additionally, a nurse and CNA did not wear gowns while providing direct wound care to two residents under Enhanced Barrier Precautions, even though signage and PPE were available and care plans required their use.
A resident with significant medical conditions and moderate cognitive impairment had an OOH-DNR form in their record that was missing required signatures, including the physician's. Staff were aware of the incomplete documentation and attempted to obtain the necessary signature but did not follow up adequately. The facility lacked a policy on timely physician signatures for DNR forms, and staff believed a temporary DNR without a physician's signature could be used, resulting in the resident's wishes not being properly documented.
A resident with severe cognitive impairment and a history of UTIs was given daily prophylactic antibiotics without meeting infection criteria or being monitored for side effects. Facility staff did not question the necessity of the order, and the antibiotic stewardship policy requiring monitoring and justification was not followed.
Surveyors found seven expired disposable syringes with needles in a medication cart, with staff interviews revealing inconsistent practices for checking expiration dates and no specific policy for removing expired supplies.
A resident with severe cognitive impairment and multiple medical conditions was prescribed prophylactic Bactrim without a specified duration or monitoring for side effects, despite not meeting infection criteria. Facility staff did not question the appropriateness of the antibiotic order or follow the facility's antibiotic stewardship policy, which requires clear indication, duration, and use of McGeer’s criteria for infection.
A resident with severe cognitive impairment and multiple health conditions was not properly offered or documented for influenza and pneumococcal vaccinations. The medical record and consent forms did not accurately reflect the resident's representative's wishes or vaccination history, and required education was not provided. Staff interviews confirmed that the process for obtaining immunization consent and history was not consistently followed.
A facility did not ensure a resident's right to an advance directive was respected when a DNR order was not followed. Despite clear documentation of the DNR status in multiple records, nursing staff initiated CPR without verifying the resident's code status. The incident involved LVN A, MA L, and CNA J, who did not effectively communicate or confirm the DNR status before starting CPR. This highlights a gap in staff adherence to protocols for verifying code status during emergencies, despite existing training and procedures.
Abuse and Neglect During Toileting and Transfer Resulting in Resident Fall and Knee Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal, mental, and physical abuse and neglect during toileting and transfer care. The resident was a 75‑year‑old female with moderate intellectual disabilities, vascular dementia (moderate, without behavioral disturbance), bipolar disorder, and severe cognitive impairment (MDS score of 7). Her care plan and functional assessments documented that she used a wheelchair for mobility, could not take four steps, and required supervision/touching assistance for sit‑to‑stand and bed‑to‑chair transfers, as well as partial to extensive assistance for toileting and transfers. She also had documented communication problems related to a hearing deficit and unclear speech, and a care plan focus on attention‑seeking behaviors with interventions directing staff to speak calmly, divert attention, and ensure a safe environment. On the evening in question, video footage showed the resident in her bathroom in a wheelchair when an LVN entered, turned the wheelchair toward the grab bar, and instructed the resident to stand, stating she could not lift her. As the resident stood holding the grab bar, the LVN commented that the resident was “doing all that faking” and, when the resident defecated, the LVN reacted by saying “Eww” and “gross,” and later “Jesus Christ” and “oh my God” while leaving the resident standing partially unclothed. The resident then maneuvered herself to sit down hard on the toilet without staff present. Subsequent video segments showed the LVN outside the open bathroom door, within the resident’s hearing, telling a CNA that the resident had “shit everywhere and shit on me” and that the resident thought it was funny. The LVN and CNA discussed the resident’s behaviors, with the CNA stating the resident “knows better” and calling it a behavior problem, and the LVN agreeing and describing the resident as someone who hits and grabs staff. Further video showed the LVN re‑entering the bathroom, removing the resident’s wheelchair, and telling the resident that what had occurred was the “nastiest shit” she had ever seen, that the resident thought it was funny, and that the resident should be ashamed. While the LVN cleaned the floor and the resident’s feet, the resident began sobbing, and the LVN repeatedly told her to stop crying, stating “what are you crying for shitting yourself,” and telling her she needed to be in a psych ward. Another CNA entered and agreed it was a behavior, and both staff continued to speak derogatorily about the resident in her presence. The LVN and CNA B discussed cleaning the soiled wheelchair and stated the resident would not have a wheelchair and “doesn’t need a wheelchair,” with CNA B telling the resident she was “nasty” and to stop touching herself. The resident was left alone on the toilet sobbing at times while staff were outside the bathroom. In later video segments, CNA B and the LVN were in the bathroom with the resident, who was sobbing while standing and holding the grab bar as CNA B applied a brief. The LVN told the resident “cry cry cry, shut up, just seriously shut up,” and stated that if the resident went to the psych ward she would not think it was funny, adding “you should cry, nasty” and “you ain’t getting your chair.” Despite the resident’s documented need for wheelchair use and extensive assistance, CNA B held the resident’s arm and directed her to walk from the bathroom to the bed, telling her “you’re walking, hush come walk” while the resident said “no” and continued sobbing. The resident attempted to take a step, fell, and her left knee hit the floor. Subsequent video showed CNA B telling the resident she was not going to get her chair and that she knew how to walk, lifting her to a standing position and escorting her with minimal assistance to the bed while the resident held the wall and pulled up a loose brief. Both staff continued to accuse her of “fake crying” and dismissed her complaints as she rubbed her left knee. A skin assessment later documented bruising to the front left knee acquired in‑house, and a psychiatric assessment noted a contusion on the knee. The facility’s own records and interviews confirmed that the resident’s care plan and functional status required wheelchair use and assistance for transfers and toileting, and that she was a high fall risk. The ADON and other staff stated they would never ask this resident to walk from the bathroom to the bed and that she had not been known to walk, and that extra wheelchairs were readily available. The administrator and DON, after reviewing the videos, characterized the staff behavior as verbal and physical abuse, including making the resident walk without her wheelchair when she requested it, speaking to her in a demeaning and profane manner, and failing to treat her with dignity and respect. The resident’s responsible party reported receiving multiple distressed calls from the resident stating she was not allowed to have her wheelchair and later observed the wheelchair placed outside the room. A forensic interview video later showed the resident crying when asked if she had been hit, pushed, or left alone in the bathroom. The survey identified this as past noncompliance at the level of Immediate Jeopardy, beginning on the date of the incident and ending several days later.
Failure to Perform Hand Hygiene Between Resident Care Activities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents who required assistance with personal care. Direct observation revealed that a medical assistant (MA) did not perform hand hygiene after providing care to one resident and before providing care to another. Specifically, the MA removed a blood pressure cuff from the first resident, exited the room without washing hands or using hand sanitizer, and then entered the second resident's room and removed a blood pressure cuff from that resident, again without performing hand hygiene before or after contact. Both residents involved had significant medical histories and were at increased risk for infection. One resident had a urinary catheter, surgical incisions, and wounds, with care plans and physician orders indicating the need for enhanced barrier precautions and close monitoring for infection. The other resident had multiple chronic conditions, including diabetes and cognitive impairment, with care plans highlighting the risk for infection and the need for monitoring and reporting signs of infection. The facility's own policies required staff to perform hand hygiene before and after resident contact and when moving between resident rooms, in accordance with accepted standards of practice. Despite these policies, the observed failure to perform hand hygiene between resident care activities constituted a breach of infection control protocols, as confirmed by staff interviews and review of facility policies.
Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to maintain clean and comfortable resident rooms for four out of eleven residents reviewed. Observations revealed that multiple resident rooms contained trash, food crumbs, used paper towels, and dried spilled substances such as coffee on the floors. In one case, a resident's bathroom had a brown substance around the base of the toilet, used paper towels on the floor, and a black ring in the toilet. These conditions were directly observed during the survey and were corroborated by interviews with residents and staff. The residents affected had significant physical and/or cognitive impairments, including conditions such as mononeuropathy, heart disease, chronic kidney disease, muscle wasting, joint replacements, and amputations. Their care plans indicated varying levels of assistance required for mobility and activities of daily living, with some residents being dependent on staff for picking up objects or cleaning. Interviews with residents revealed dissatisfaction with the cleanliness of their rooms, with some stating they had to wait for housekeeping to return or had to request cleaning from staff. One resident reported not seeing anyone clean her room during her stay, and another stated that the room felt unclean and not homelike when not properly maintained. Staff interviews indicated a lack of clarity and consistency regarding responsibility for cleaning resident rooms, especially outside of housekeeping hours. Housekeeping staff reported that rooms were cleaned daily, but acknowledged that rooms were often dirty in the mornings before cleaning began. CNAs and other staff stated that they were responsible for cleaning when housekeeping was unavailable, but there was confusion about monitoring and follow-through. Facility policies reviewed by surveyors required daily and as-needed cleaning of resident rooms, but these policies were not consistently implemented, resulting in the observed deficiencies.
Unattended and Unlocked Medication Cart Found During Survey
Penalty
Summary
A deficiency was identified when a medication cart (MC #1) on the 300-hall was found unattended and unlocked, containing both prescribed and over-the-counter medications. The medication aide (MA A) responsible for the cart was observed at the nurses station, away from the cart, which was positioned by the dining room entrance. The state surveyor was able to open the drawers and take pictures without being noticed by MA A. During interviews, MA A confirmed she had been trained on medication storage and acknowledged the policy required the cart to be locked when not in use, admitting she forgot to lock it due to being distracted. Further interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that while staff had been trained on medication storage, the DON was unfamiliar with the specific policy details, and both the DON and ADM stated that the person using the cart was responsible for ensuring it was locked. The facility's policy, last revised in 2019, specifies that only licensed nurses or certified medical aides may carry keys and that the cart must be locked at all times when not in use. The failure to secure the medication cart was attributed to staff distraction and lack of adherence to established procedures.
Unattended and Unlocked Medication Cart Found in Resident Care Area
Penalty
Summary
A deficiency was identified when a medication cart (MC #1) on the 300-hall was found unattended and unlocked, containing both prescribed and over-the-counter medications. The medication aide (MA A) responsible for the cart was observed away from the cart, engaged in conversation at the nurses' station, with her back turned and the cart positioned near the dining room entrance. The state surveyor was able to open the drawers and take pictures without being noticed by MA A. During interviews, MA A acknowledged she had been trained on medication storage and was aware of the policy requiring the cart to be locked when not in use, but stated she forgot to lock it due to being distracted. Further interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that staff had been trained on medication storage policies, which require medication carts to be locked at all times when not in use and only accessible to authorized personnel. The DON, new to the facility, was not familiar with the specific policy details but expected staff to follow them, while the ADM described monitoring practices for ensuring compliance. Review of the facility's policy confirmed that only licensed nurses or certified medical aides may carry keys and that carts must not be left unlocked or unattended in resident care areas.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In one instance, a bathroom sink basin in a resident's room was detached from the wall, creating a significant safety hazard. Despite the resident's repeated requests for repair, the issue persisted for months. The Maintenance Director, who was new to the position, was unaware of the problem until it was brought to his attention by the administration. The lack of a timely response to maintenance requests and the absence of a formal policy on maintenance repairs contributed to the delay in addressing this critical safety concern. Another deficiency involved the condition of the walls in a resident's room, which had black scuff marks and large patches of peeling paint. The Maintenance Director was not aware of this issue, and no work order had been created to address it. The resident's family member had noticed the damage but had not reported it to the staff. The facility's failure to maintain the room in a homelike condition was evident, and the Maintenance Director acknowledged that the environment was not suitable for residents. Additionally, the facility failed to ensure that a resident's bed had a footboard, resulting in the mattress sliding off the bed. The resident had reported the issue to the administration and staff, but it took weeks for the facility to respond. The Maintenance Director was aware of concerns regarding beds on the hall but was delayed in addressing them due to being recently hired and catching up on repairs. Furthermore, windows in two rooms did not close properly, creating a potential security risk and affecting room temperature. The Maintenance Director was unaware of these issues, and no work orders were found for the repairs. The facility's lack of a systematic approach to prioritize and address maintenance concerns contributed to these deficiencies.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically nail care, for two residents who were unable to perform these tasks independently. One resident, a male with moderately impaired cognition, dementia, diabetes, and adult failure to thrive, was observed with long, uneven fingernails and a blackish/brownish substance under his nails. He reported having requested nail care from staff within the past three days but had not received it. His care plan required staff to check and trim his nails on bath days and as needed, with nurses responsible for nail care due to his diabetes diagnosis. A second resident, a female with severely impaired cognition, dementia, and generalized muscle weakness, was also observed with rough, unclean fingernails and a similar blackish/brownish substance under her nails. She was dependent on staff for all ADLs, including personal hygiene and nail care. Her care plan also required staff to check, trim, and clean her nails on bath days and as needed. Staff interviews confirmed that neither resident had refused nail care, and that both CNAs and nurses were aware of their responsibilities regarding nail care, especially for residents with diabetes. Staff interviews further revealed that nail care was expected to be performed during showers and as needed, with CNAs responsible for most residents and nurses for those with diabetes. Staff acknowledged the presence of the blackish substance and rough nails, and recognized the potential for health issues if not addressed. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain good grooming and personal hygiene, which was not followed in these cases.
Failure to Provide Timely Therapy Evaluation and Interventions for Resident with Contractures
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, bilateral hand contractures, and a history of traumatic brain injury was not evaluated or treated for therapy services despite having physician orders for PT and OT evaluation and treatment. The resident was assessed as having functional limitations in range of motion for both upper extremities and was dependent on staff for most activities of daily living. Observations revealed the resident had contractures in both hands, with no splints or palm guards in use, and the resident communicated a desire for therapy services. Despite care plan interventions and physician orders for therapy evaluation and treatment, the therapy team was not made aware of the order, and the evaluation was not completed for over two months. Interviews with staff confirmed that the therapy department was unaware of the order due to a breakdown in communication, and the resident had not received therapy services or appropriate interventions such as splints or palm guards during this period. Staff interviews also indicated a lack of awareness regarding therapy orders and responsibility for applying hand braces, with some staff stating they had never seen the resident wear braces and others believing therapy staff were responsible for this task. The facility did not have a policy for contracture management or range of motion, and the delay in therapy evaluation and lack of interventions could have contributed to worsening contractures and pain for the resident. The deficiency was attributed to missed communication of therapy orders, lack of follow-through on care plan interventions, and absence of a formal policy guiding contracture management.
Failure to Maintain Infection Control Protocols for Ice Chest and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses involving both staff and residents. One incident involved a resident with severe cognitive impairment who was observed placing her bare hands into an unattended ice chest located in a hallway. The resident had visible dried residue on her hand and was able to access the ice without staff intervention, despite the presence of the Infection Control Preventionist, who acknowledged witnessing the event but did not redirect the resident or remove the ice chest. Interviews with staff confirmed that the ice chest was not to be left unattended in hallways and that residents touching the ice constituted cross-contamination, yet the protocol was not followed in this instance. Additional deficiencies were observed during wound care for two residents with significant medical needs, including chronic wounds and pressure ulcers. Both the Wound Care Nurse and a CNA failed to don gowns while providing direct care to these residents, despite clear signage indicating Enhanced Barrier Precautions (EBP) and the availability of personal protective equipment outside the rooms. The residents in question had physician orders and care plans specifying the use of gowns and gloves for high-contact care activities due to their risk factors, such as open wounds and medical devices. Staff interviews confirmed knowledge of the EBP requirements, but the protocol was not followed during the observed care. Facility policies reviewed indicated that the Infection Preventionist is responsible for developing and implementing an ongoing infection prevention and control program, including ensuring staff compliance with national standards and guidelines. Despite these policies and prior in-service training on EBP, staff failed to adhere to established infection control procedures during the observed incidents, resulting in potential cross-contamination and failure to prevent the transmission of communicable diseases.
Failure to Ensure Valid DNR Documentation Due to Missing Physician Signature
Penalty
Summary
The facility failed to ensure that a resident's Out of Hospital Do-Not-Resuscitate (OOH-DNR) form was properly completed with all required signatures, including that of the physician. Upon review, it was found that the resident, who had diagnoses of severe chronic kidney disease and a displaced fracture of the femur, had selected a DNR code status and this was reflected in the care plan and physician orders. However, the OOH-DNR forms in the resident's clinical record were missing critical signatures from the resident, witnesses/notary, and the physician, rendering them invalid. Interviews with facility staff revealed that the social worker was aware that the DNR forms were not valid due to missing signatures and had attempted to obtain the physician's signature by emailing the doctor multiple times, but did not follow up further. The social worker also placed a temporary DNR in the file while waiting for the physician's signature, under the belief that it could be used in the interim. The administrator and DON both stated that they would honor a DNR without a physician's signature, and there was no facility policy specifying a timeframe for obtaining the physician's signature on the DNR form. The resident in question was noted to have moderate cognitive impairment and was unable to understand questions regarding her advance directives or DNR during the interview. The facility's policy required that advance directives be reviewed and discussed within 14 days of admission and annually, and state law required that the OOH-DNR form include all necessary signatures. Despite these requirements, the facility did not ensure that the DNR form was properly completed, which could result in the resident's wishes not being honored.
Failure to Monitor and Justify Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the use of prophylactic antibiotics. A female resident with severe cognitive impairment and a history of encephalopathy, urinary tract infection, and dysphagia was admitted with an order for daily Bactrim as prophylaxis, despite not meeting McGeer's criteria for infection at the time. The care plan only included monitoring for UTI symptoms, with no interventions or monitoring related to antibiotic use. The antibiotic clinical review form indicated that the resident did not meet the criteria for infection, yet the antibiotic was still prescribed and administered. Interviews with facility staff revealed that antibiotics were started or continued based on practitioner orders without questioning their necessity, even when used prophylactically. The ADON responsible for infection control acknowledged not being aware of CDC guidelines against prophylactic antibiotic use and admitted to following orders without further review. The DON confirmed awareness of the prophylactic antibiotic order and stated that nurses were expected to question such orders, but this did not occur. The facility's antibiotic stewardship policy required monitoring and justification for antibiotic use, which was not followed in this case.
Expired Syringes Found on Medication Cart Due to Inconsistent Expiration Checks
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles, as evidenced by the presence of seven expired disposable syringes with needles in the top drawer of the 100 hall Nurses' Medication Cart. During observation, these expired supplies were found, and interviews with staff revealed inconsistent practices regarding the frequency of checking for expired items. The LVN stated that floor nurses were responsible for checking expiration dates as they go, while the DON indicated that staff should check carts daily, and the ADM expected checks at least weekly. There was no specific policy in place for the removal of expired supplies.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including encephalopathy, urinary tract infection, and dysphagia, was admitted with an order for prophylactic Bactrim without a specified duration or monitoring for side effects. The resident's care plan addressed bladder incontinence and monitoring for UTI symptoms, but did not include interventions related to antibiotic use. The antibiotic clinical review for the resident did not document any symptoms meeting McGeer Criteria for infection, and it was noted that the resident did not meet the criteria for infection at the time the antibiotic was prescribed. Interviews with facility staff revealed that antibiotics were started or continued based on practitioner orders without questioning the appropriateness, even when used prophylactically, contrary to CDC guidelines and facility policy. The ADON responsible for infection control acknowledged not questioning the order and not being aware that prophylactic antibiotic use was not recommended. The DON confirmed awareness of the prophylactic antibiotic order and stated that there was no approved indication for such use, and that staff were expected to question such orders and complete the required antibiotic clinical review. The facility's policy required all antibiotic prescriptions to specify dose, duration, and indication, and to use McGeer’s criteria to define infections, which was not followed in this case.
Failure to Accurately Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure that each resident was properly offered influenza and pneumococcal immunizations, as required. Specifically, one resident with severe cognitive impairment, hemiplegia, and gastrostomy status was not accurately assessed or documented for her immunization status. The resident's medical record did not reflect her vaccination history for influenza and pneumonia, and the consent form for these vaccinations did not accurately represent her representative's wishes. The form indicated a refusal for the influenza vaccine without a documented reason or history of previous vaccinations, and acceptance of the pneumonia vaccine without any documentation of prior vaccination history or education provided. Interviews with facility staff revealed that the process for obtaining immunization consent and history was not consistently followed. The resident's responsible party stated she wanted the resident to receive all recommended immunizations, contradicting the documentation in the medical record. The ADON acknowledged that the resident had not received the pneumonia vaccination since admission and that her wishes were not accurately reflected in the record. The facility's infection prevention and control policy required offering and documenting immunizations and education, but these steps were not completed for this resident.
Failure to Honor Resident's DNR Status During Emergency Response
Penalty
Summary
The facility failed to ensure the resident's right to formulate an advance directive for Resident #3, who had a DNR in place, resulting in a violation of the resident's right to experience the dying process as predetermined. Despite clear documentation of Resident #3's DNR status in various records, including the face sheet, care plan, physician orders, and Out-of-Hospital Do-Not-Resuscitate Order, nursing staff failed to follow emergency protocol. When Resident #3 became unresponsive, LVN A initiated CPR without verifying the resident's code status, leading to a situation where CPR was administered against the resident's wishes. This failure to honor the advance directive could have significant emotional and physical implications for the resident, as evidenced by the distress expressed by the family members. During interviews with staff members involved in the incident, it was revealed that there was a lack of clarity and adherence to protocols regarding verifying a resident's code status before initiating CPR. LVN A, MA L, and CNA J were present during the incident but did not effectively communicate or confirm Resident #3's DNR status before CPR was initiated. Despite in-services and training provided to staff on how to access a resident's code status in the electronic health record system, there was a breakdown in following these procedures in a timely manner during the emergency situation. The failure to prioritize and verify the resident's advance directive before providing life-saving measures highlights a critical gap in staff knowledge and adherence to facility policies.
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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