Baybrooke Village Care And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mckinney, Texas.
- Location
- 8300 Eldorado Parkway West, Mckinney, Texas 75070
- CMS Provider Number
- 676096
- Inspections on file
- 41
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Baybrooke Village Care And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that two residents requiring oxygen therapy did not receive respiratory care consistent with physician orders and facility policy. One resident with severe cognitive impairment and shortness of breath had an active order and care plan for continuous O2 at 2 LPM via NC, but was observed in bed without the cannula in place, with the tubing buried under bed linens while the concentrator ran. The CNA in the room acknowledged knowing the resident was supposed to be on continuous O2 and that he often removed his cannula but had not informed the nurse, and the assigned RN stated she had not checked on him for hours despite knowing of the continuous O2 order. Another resident with COPD and acute respiratory failure with hypoxia had a care plan directing O2 administration but no active O2 order in the chart, yet was observed on 2 LPM O2; the RN confirmed there was no order and stated O2 should not be given without one. The Regional Nurse Coordinator and facility policies confirmed that O2 use requires a physician order, review of the care plan, and documentation in the eMAR/eTAR.
A resident with severe cognitive impairment and diabetes had a Stage 4 sacral pressure ulcer with orders and a care plan requiring cleansing, application of Santyl and calcium alginate, and coverage with a dry dressing on a scheduled and PRN basis. A CNA removed the sacral dressing after it became soiled with feces, despite knowing she was not permitted to remove dressings and was required to notify nursing staff. During incontinence care, surveyors observed the sacral wound open, uncovered, and draining onto the brief, with the CNA completing care and applying a clean brief without ensuring the wound was redressed. The RN and wound care nurse reported they were not informed the dressing had come off, despite expectations that CNAs report soiled or dislodged dressings so nurses could follow PRN wound orders, and there was no documentation in the record noting the missing dressing.
A resident with a history of hypertension and hypotension experienced multiple episodes of low blood pressure over several days, leading staff to withhold prescribed medication. Despite these significant changes, staff did not notify the physician or responsible party as required by policy. The deficiency was confirmed through interviews and record review, revealing a lack of timely communication regarding the resident's condition.
A resident with epilepsy and severe cognitive impairment did not receive approximately 10 scheduled doses of prescribed Lamotrigine due to medication unavailability, which was caused by an outstanding pharmacy balance. Medication aides reported the issue to charge nurses, but the nurses did not escalate the problem or notify the physician as required by facility policy, resulting in a significant medication error.
A resident with epilepsy missed approximately 10 scheduled doses of Lamotrigine due to medication unavailability, and staff failed to notify the physician as required. Medication aides reported the issue to charge nurses, but the nurses did not escalate the concern or inform the provider, contrary to facility policy and expectations. The physician was only made aware of the missed doses after the issue was resolved.
A resident with severe cognitive impairment and mobility needs eloped from the facility undetected during the night, despite being assessed as low risk for wandering. The resident was found at a nearby hospital and returned without injury. The incident revealed a lapse in supervision and monitoring, as the resident was able to leave the premises without staff awareness until discovered missing during routine rounding.
A resident who required nebulizer treatments did not have her breathing mask properly stored after use, as it was left on her bedside table instead of being placed in a plastic bag according to facility policy. Staff interviews confirmed the mask should have been bagged to prevent infection, and the responsible LVN acknowledged forgetting to do so after the previous treatment.
A CNA failed to change gloves and perform hand hygiene at appropriate times while providing incontinent care to a resident with a UTI, including after contact with soiled items and before handling clean supplies, contrary to facility infection control policy.
The facility failed to provide meals that matched the preferences and dietary needs of three residents. A resident with specific dietary orders often received incorrect meals, leading to reliance on outside food. Two other residents also experienced discrepancies between their meal selections and what was served, with staff interviews revealing systemic issues in meal ticket accuracy and communication. The facility's policy on selective menus was not effectively implemented.
The facility's kitchen was found to have multiple deficiencies in food storage and labeling, including unlabeled, undated, and expired items in the dry storage, refrigerator, and freezer areas. Staff interviews revealed a lack of awareness and adherence to established food safety procedures, despite having received training. These practices pose a risk of cross-contamination and airborne illnesses to residents.
A LTC facility failed to maintain an effective infection prevention and control program, as staff did not adhere to proper hand hygiene and enhanced barrier precautions. An ADON did not change gloves between wound care for two residents, while CNAs failed to don gowns during care for two other residents on enhanced barrier precautions. These lapses increased the risk of infection spread, despite regular staff training on infection control protocols.
A resident with severe cognitive impairment and limited mobility was transferred from a wheelchair to a bed without the use of a gait belt or Hoyer lift, as required by their care plan. LVN and CNA involved in the transfer acknowledged the oversight, which was against facility policy and placed the resident at risk for falls and injuries.
A facility failed to ensure proper enteral feeding protocols were followed for a resident with a feeding tube. The LVN did not check the tube's placement or residual before starting the feeding and used a plunger to flush the tube instead of allowing water to flow by gravity, contrary to facility policy. These actions could lead to resident discomfort and complications.
A facility experienced a 15% medication error rate due to RN G's failure to administer medications as scheduled for three residents. Errors included administering Acetaminophen at the wrong time, omitting Olmesartan, and delaying other medications. The residents had various medical conditions requiring precise medication management. RN G cited workload as a reason for the errors, and the DON confirmed the importance of adhering to medication schedules.
The facility failed to maintain an effective Infection Prevention and Control Program, with staff neglecting proper hand hygiene and equipment sanitation. An RN did not sanitize hands between glove changes during wound care for two residents, and an MA did not clean the blood pressure cuff between uses for three residents. Additionally, a CNA did not change gloves or perform hand hygiene during incontinent care for a resident, potentially leading to cross-contamination.
A facility failed to securely store medications, as a bottle of Nystatin topical powder was found in a resident's room. The resident, who was cognitively intact, stated the medication was discontinued and was unsure how it ended up on his table. Staff interviews confirmed that medications should be stored in medication carts and administered by nurses or medication aides, as per facility policy.
A resident with anxiety and chronic pain did not receive proper respiratory care, as their nasal cannula was improperly stored and the humidifier lacked water. Staff interviews revealed a lack of awareness and adherence to procedures, with the CNA and LVN failing to follow facility policies on oxygen therapy. The ADON and DON confirmed the importance of these practices to prevent respiratory infections and irritation.
A resident with severe cognitive impairment was sexually abused by a CNA, as captured on camera footage. The incident was reported by the family member of the resident's roommate, leading to a police investigation and the CNA's termination. The resident was assessed and sent for a SANE exam, which revealed an abrasion. The facility confirmed the abuse and had previously in-serviced staff on abuse prevention.
Failure to Follow Oxygen Therapy Orders and Obtain Physician Orders for Respiratory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with physician orders and professional standards for two residents requiring oxygen therapy. For the first resident, an older male with severe cognitive impairment (BIMS score of 4), shortness of breath, and an order for continuous oxygen at 2 LPM via nasal cannula, surveyors observed him lying in bed without oxygen in place. The oxygen concentrator was running at 2 LPM, but the tubing was covered by bed sheets and not connected to the resident. His care plan included a problem of respiratory diagnosis with an intervention to administer oxygen as ordered, and active physician orders specified oxygen at 2 LPM every shift for shortness of breath. During observation and interview in the room, the CNA providing incontinent care stated she had not noticed that the resident was not on oxygen. She reported that the resident was known for removing his cannula but acknowledged she had not reported this behavior to the nurse, despite knowing he was supposed to be on continuous oxygen at 2 liters. The RN assigned to the resident stated she was aware of the continuous oxygen order but was not aware the resident was not receiving oxygen and reported she had not been to his room for hours. She stated that nurses were responsible for checking residents on oxygen to ensure they were receiving it and identified difficulty breathing as a possible negative outcome of not receiving oxygen. For the second resident, an older female with moderately impaired cognition (BIMS score of 10), COPD, and acute respiratory failure with hypoxia, the care plan documented a respiratory diagnosis with an intervention to administer oxygen as ordered. However, review of her physician order summary did not show an active order for oxygen. Surveyors observed her in the dining room with a portable oxygen tank set at zero LPM and tubing not connected, and she stated she was on oxygen and received it when provided by nurses, while her family member could not recall her being on oxygen. Later, the resident was observed on oxygen at 2 LPM. The RN caring for her confirmed the resident was on 2 LPM oxygen but could not find an order in the chart and stated there should be an order and that residents should not receive oxygen without one. The Regional Nurse Coordinator stated that residents receiving oxygen should have physician orders, that the charge nurse or person applying oxygen was responsible for obtaining orders, and that nurses were responsible for monitoring and evaluating residents on oxygen. Facility policies on oxygen administration and oxygen therapy via concentrator required verification and review of physician orders and documentation of ordered oxygen therapy in the eMAR/eTAR.
Uncovered Stage 4 Sacral Pressure Ulcer Not Reported or Redressed
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a Stage 4 sacral pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident was an elderly male with severe cognitive impairment, a BIMS score of 4, and diagnoses including diabetes mellitus. His entry MDS documented a Stage 4 pressure ulcer on the sacrum present on admission, and his care plan identified this ulcer with goals for healing and being free from infection, with interventions including treatment as ordered and monitoring. Physician orders directed staff to cleanse the sacrum and bilateral buttocks Stage 4 wounds with wound cleanser, pat dry, apply Santyl and calcium alginate, and cover with a dry dressing daily, with additional PRN orders if the dressing became soiled or dislodged. On the day of the surveyor’s observation, the treatment administration record showed the last wound treatment had been administered two days earlier, before the order was changed to three times weekly. During incontinence care, a CNA was observed cleansing the resident and turning him using a draw sheet. The resident’s sacral wound was observed to be open, uncovered, and draining onto the brief, and the CNA completed care by applying a clean brief and leaving the resident in bed without a dressing over the wound. There was no documentation in the resident’s March progress notes indicating that the wound dressing had been missing earlier that day. In interviews, the CNA stated she had removed the resident’s dressing that morning because it was peeling off and had fecal matter on it, acknowledged she was aware she was not allowed to remove dressings, and admitted she failed to notify the nurse or treatment nurse to replace it, despite prior training to do so. The charge RN and the wound care nurse both reported they had not been informed that the dressing had come off and stated their expectation that CNAs notify nursing staff so the dressing could be replaced per scheduled and PRN orders. The wound care nurse confirmed she had applied a dressing at the last treatment and expected nurses to monitor the dressing each shift and follow PRN orders if it became soiled or dislodged. The facility’s wound dressing change policy stated that dressings should be changed if feces seep beneath the dressing, but no training records were provided to support staff education on these procedures.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Facility staff failed to promptly notify a resident's physician and responsible party of significant changes in the resident's condition, specifically regarding multiple episodes of low blood pressure. The resident, an older male with a history of hypertension, hypotension, heart failure, and other complex medical conditions, experienced several consecutive low blood pressure readings over multiple days. Despite these abnormal vital signs and the withholding of prescribed blood pressure medication due to the low readings, staff did not inform the physician or nurse practitioner as required by facility policy. Documentation showed that the resident's blood pressure was repeatedly below normal, with readings such as 85/59, 70/53, 73/55, and as low as 62/50 over a span of days. These findings were recorded by medication aides and nurses, who also withheld the resident's blood pressure medication in response to the low readings. However, there was no evidence that the physician or nurse practitioner was notified of these changes until the resident was being evaluated for an unrelated hospital transfer. Interviews with the physician and nurse practitioner confirmed that they were not made aware of the resident's ongoing low blood pressure, and both stated that notification should have occurred, especially given the need to withhold medication and the potential for underlying causes. The DON acknowledged that staff did not notify the physician, attributing the oversight to the resident's history of low blood pressure, but facility policy required notification for acute changes in condition. The deficiency was identified through interviews, record reviews, and policy examination.
Failure to Ensure Resident Received Prescribed Seizure Medication
Penalty
Summary
A deficiency occurred when a male resident with diagnoses of encephalopathy and epilepsy, who was severely cognitively impaired and dependent on staff for care, did not receive his prescribed Lamotrigine 250 mg twice daily for epilepsy management. Over a specified period, approximately 10 scheduled doses were missed, as documented in the Medication Administration Record (MAR) and confirmed by multiple medication aides. The medication was not available during this time, and the aides reported the issue to the charge nurses on duty. Despite being informed by the medication aides, the charge nurses did not escalate the issue to the Director of Nursing (DON) or notify the resident's physician about the missed doses. The physician was only informed after the issue was resolved, and she stated that consistent administration of the medication was critical for the resident's health and quality of life. The DON also confirmed that she was not notified of the medication issue until after several doses had been missed and that the nurses failed to follow the facility's policy regarding notification and escalation of medication availability issues. The underlying cause of the medication unavailability was an outstanding balance with the pharmacy, which resulted in the pharmacy withholding the medication until payment was received. The facility's policy required staff to notify the charge nurse, attempt to obtain the medication from an emergency kit, contact the pharmacy for a STAT delivery if needed, and inform the physician of any missed doses due to medication availability. These steps were not followed, leading to the resident missing multiple doses of a critical medication.
Failure to Notify Physician of Missed Epilepsy Medication Doses
Penalty
Summary
Facility staff failed to ensure timely physician notification when there was a significant change in a resident's physical status, specifically regarding missed doses of a prescribed epilepsy medication. The resident, an older adult with diagnoses including encephalopathy and epilepsy, was re-admitted to the facility and required supervision for care. Physician orders indicated the resident was to receive Lamotrigine 250 mg twice daily for epilepsy management, but approximately 10 scheduled doses were missed over a documented period. Medication aides reported that the medication was not available in the cart and stated they informed the charge nurses (LVNs) on duty about the issue. However, the charge nurses did not escalate the matter or notify the resident's physician about the missed doses. The physician later confirmed she was not informed of the medication disruption until after the issue was resolved, despite her expectation to be notified of any missed medications for prompt intervention and resident safety. The Director of Nursing (DON) and the facility administrator both stated that their expectations for staff conduct were not met, as the nurses failed to notify the provider of the missed medication doses. The issue with medication availability was related to an outstanding pharmacy balance, which delayed access to the medication. The facility's policy required notification of the physician when medications were unavailable and missed doses occurred, but this protocol was not followed in this instance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent an elopement for one resident. The resident, an elderly male with diagnoses including encephalopathy and epilepsy, had severely impaired cognition as indicated by a BIMS score of 05. He required supervision and/or set-up assistance for care and used a walker and wheelchair for ambulation. Despite being assessed as low risk for wandering or elopement, the resident was able to leave the facility undetected between 11:30 PM and 12:00 AM. The resident was discovered missing during routine rounding at midnight by a CNA, who then alerted the nurse and initiated the facility's elopement protocol. The resident was found approximately 0.1 miles away at a nearby hospital and was returned to the facility by an LVN around 12:30 AM. Upon return, the resident was assessed and reported no pain or injuries. There was no documentation of previous wandering behaviors or prior elopement attempts for this resident. Interviews with facility leadership confirmed that all residents were expected to remain in the building for safety reasons, but it was unclear how the resident was able to elope. The facility's records indicated that doorways were checked and that the resident was subsequently placed on 1:1 monitoring. The incident was discussed among the physician, administrator, and DON, and the facility's policies on elopement management and abuse prevention were reviewed.
Improper Storage of Respiratory Equipment
Penalty
Summary
A deficiency occurred when a resident who required respiratory care, including nebulizer treatments, did not have her breathing mask properly stored according to professional standards and facility policy. The resident, who was cognitively intact and had a diagnosis of cough and anemia, was observed with her breathing mask left on top of her bedside table after use, rather than being placed in a plastic bag as required. The resident reported that she had not yet received her morning breathing treatment and was unsure where the nurse placed the mask after previous treatments. Later, the mask was observed inside a plastic bag, but it was not clear when this occurred. Interviews with staff confirmed that the expectation was for the breathing mask to be bagged when not in use to prevent cross-contamination and infection. The nurse responsible for the resident's care acknowledged that she had likely forgotten to bag the mask after the previous treatment and confirmed that the mask should be placed in a bag when not in use. Facility policy also required that respiratory equipment be bagged and labeled if it was to be used again. This lapse in following proper storage procedures for respiratory equipment constituted a failure to provide safe and appropriate respiratory care consistent with professional standards and the resident's care plan.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a male resident diagnosed with a urinary tract infection. The resident was cognitively intact and dependent on staff for toilet hygiene. During the observed care, the CNA washed her hands and donned gloves and a gown before beginning care. However, she did not change her gloves or perform hand hygiene after touching the trash can, after cleaning the resident's perineal area, or after cleaning the resident's bottom, and before handling a new brief. The CNA continued to use the same gloves throughout the care process, including after contact with soiled items and before touching clean supplies. The facility's policy required hand hygiene after contact with soiled or contaminated articles and after removal of gloves. The CNA acknowledged during an interview that she should have changed gloves and performed hand hygiene at several points during the care. The Assistant Director of Nursing (ADON) and the Administrator both confirmed that the expectation was for staff to change gloves and perform hand hygiene as outlined in the facility's infection control policy.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that residents received meals that accommodated their preferences and dietary needs, as evidenced by the experiences of three residents. Resident #40, who was cognitively intact and had specific dietary orders for large portions of protein, frequently received meals that did not match his selections. Despite circling his choices on the menu, he often received incorrect items, such as a hamburger instead of a pork chop, and was missing items like potato salad and extra protein portions. This led him to rely on food brought by his family and to stop complaining about the discrepancies. Confidential Resident #1 also experienced issues with meal preferences not being honored. Despite selecting specific items and indicating dislikes, such as pasta and salad, the resident received meals that included these disliked items and were missing selected items like potato salad. The resident expressed dissatisfaction with the meals and felt that complaints were not understood by the staff, leading to a cessation of complaints. Confidential Resident #2 reported similar issues, noting that while breakfast was correct, other meals often did not match their selections. Staff interviews revealed that there were systemic issues with meal ticket accuracy and communication between kitchen and nursing staff. The kitchen staff sometimes substituted items without informing residents, and there were reports of rudeness towards nursing staff when corrections were requested. The facility's policy on selective menus was not effectively implemented, leading to residents not receiving meals according to their preferences and dietary needs.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed multiple instances of improper food storage, including unlabeled and undated food items in the dry storage, refrigerator, and freezer areas. Additionally, there were several open and unsealed food packages, which were not stored in airtight containers as required. Expired food items were also found in various storage areas, indicating a lack of proper inventory management and rotation. During interviews, staff members, including the Regional Dietary Manager and other kitchen staff, acknowledged the presence of expired and unsealed items. They confirmed that all staff were responsible for ensuring proper storage and labeling of food items, as well as checking expiration dates. Despite having received in-service training on these procedures, staff were unaware of the existing deficiencies, suggesting a gap in the implementation of training and oversight. The facility's policy on food storage, dated 2018, outlines specific procedures for maintaining food safety, including the use of airtight containers, proper labeling, and the First In, First Out method for stock rotation. However, the observed practices in the kitchen did not align with these guidelines, posing a risk of cross-contamination and airborne illnesses to residents consuming meals from the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and failure to implement enhanced barrier precautions. Specifically, ADON A did not perform hand hygiene between cleaning Resident #39's wounds and applying clean dressings, and similarly failed to change gloves and sanitize hands between wound sites during care for Resident #40. These actions were acknowledged by ADON A, who admitted to not following proper infection control protocols, thereby increasing the risk of infection spread. Additionally, CNA B did not don a gown while providing incontinent care to Resident #34, who was on enhanced barrier precautions due to a urinary tract infection and other conditions. Despite being aware of the need for enhanced barrier precautions, CNA B prioritized quick care over proper PPE use, which she later recognized as a mistake. This oversight was compounded by the fact that Resident #34 was on contact precautions, further emphasizing the need for strict adherence to infection control measures. Similarly, CNAs C and D failed to wear gowns while transferring and providing care to Resident #52, who was also on enhanced barrier precautions due to her medical condition. Both CNAs acknowledged their lapse in judgment, attributing it to a momentary oversight. The facility's infection preventionist, ADON E, confirmed that staff were regularly trained on infection control protocols, including hand hygiene and enhanced barrier precautions, yet these lapses occurred, highlighting a significant deficiency in the facility's infection control practices.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure that Resident #38 received adequate supervision and assistance devices during a transfer from a wheelchair to a bed. On the specified date, LVN F and CNA J did not use a gait belt or a Hoyer lift, as required by the resident's care plan, when transferring the resident. Resident #38, a severely cognitively impaired male with limited range of motion and a history of falls, required total assistance for transfers and was at high risk for falls. The care plan specifically indicated the use of a gait belt during transfers to prevent falls and injuries. During the incident, LVN F and CNA J transferred the resident without the necessary equipment, despite the availability of gait belts in storage. LVN F acknowledged that the transfer was inappropriate and that the absence of a gait belt placed the resident at risk for falls and injuries. CNA J also admitted to not using the gait belt, which was against the facility's policy and the resident's care plan. The Director of Nursing confirmed that the staff was expected to use a gait belt for transfers due to the resident's condition, and failure to do so could result in falls or dislocation.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. Specifically, the Licensed Vocational Nurse (LVN) did not follow proper procedures for checking the placement and residual of the feeding tube before starting the feeding. During an observation, the LVN connected the feeding tube and started the feeding without verifying the tube's placement or checking for residual, which is necessary to ensure the feeding tube is correctly positioned and that the resident is not retaining too much in the stomach. Additionally, the LVN did not adhere to the correct method of flushing the feeding tube. Instead of allowing water to flow by gravity, the LVN used a plunger to push water through the tube, which is against the facility's policy and can cause discomfort to the resident. The Director of Nursing (DON) confirmed that the staff is expected to follow physician orders and facility policies, which include checking tube placement and residual and allowing water to flow by gravity to prevent discomfort and potential complications.
Medication Administration Errors Result in 15% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 15% error rate during the survey. This was observed in the administration of medications to three residents. RN G administered Acetaminophen 500 mg to a resident at 09:30 AM, although it was scheduled for 12 PM. Additionally, RN G did not administer Olmesartan to another resident during the scheduled 8 AM medication round. Furthermore, medications scheduled for 8 AM were administered at 11:15 AM to a third resident. The residents involved had various medical conditions requiring precise medication management. One resident had a history of femur fracture, chronic obstructive pulmonary disease, and acute respiratory failure, among other conditions. Another resident had a fracture of the left lower leg, hypothyroidism, and depression. The third resident had a history of gait abnormalities, hyperlipidemia, and Type 2 diabetes mellitus. These conditions necessitated strict adherence to medication schedules to ensure therapeutic effectiveness and prevent adverse reactions. Interviews with RN G and the Director of Nursing (DON) revealed that RN G was aware of the medication administration guidelines, which require medications to be given within one hour before or after the scheduled time. However, RN G cited a high workload as a reason for the delays and omissions. The DON confirmed that medications should be administered within the specified time frame and that any unavailability should be reported to the primary care provider. The facility's policy mandates that medications be administered as prescribed, within 60 minutes of the scheduled time, unless otherwise specified by the prescriber.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of improper hand hygiene and equipment sanitation. RN B did not perform hand hygiene between glove changes during wound care for two residents, despite removing soiled dressings and applying new ones. This oversight occurred during the treatment of wounds on the coccyx and back, where RN B failed to sanitize her hands before donning new gloves, potentially leading to cross-contamination. Additionally, MA E did not sanitize the blood pressure cuff between uses for three residents, despite having disinfectant wipes readily available on the medication cart. After taking blood pressure readings, the cuff was placed back on the cart without being cleaned, which could facilitate the spread of germs between residents. MA E acknowledged the importance of hand hygiene and equipment sanitation but did not adhere to these practices during the observed medication administration process. CNA F also neglected proper infection control procedures while providing incontinent care to a resident. After cleaning the resident, CNA F did not change gloves or perform hand hygiene before handling a new brief, which could lead to contamination of clean items. The facility's Director of Nursing and Assistant Director of Nursing both emphasized the importance of hand hygiene and glove changes in preventing cross-contamination, yet these practices were not consistently followed by the staff.
Medication Storage Lapse in Resident's Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by a bottle of Nystatin topical powder being left inside a resident's room. The resident, a cognitively intact male with a history of gastro-esophageal reflux disease, was observed with the medication on his overbed table. The resident stated that the medication was for a rash on his groin but had been discontinued, and he was unaware of how it ended up on his table. This oversight was confirmed by LVN C, who acknowledged that medications should not be left in residents' rooms and should be returned to the medication cart after administration. Further interviews with facility staff, including LVN D, the DON, and ADON A, revealed that the medication was indeed discontinued and should not have been in the resident's room. The staff emphasized that all medications, regardless of their form, should be stored in the medication carts and administered by nurses or medication aides. The facility's policy on medication storage, revised in 2016, supports this practice to ensure safe and effective drug administration. Despite the in-service training conducted by the DON to address this issue, the incident highlighted a lapse in adherence to the facility's medication storage protocols.
Deficiency in Respiratory Care Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, leading to deficiencies in the management of oxygen therapy. The resident, an elderly female with anxiety and chronic pain, was observed using a nasal cannula connected to a humidifier that lacked water, which is essential to prevent nasal and throat irritation. Additionally, the nasal cannula used with the resident's portable oxygen tank was improperly stored, hanging on the backrest of the wheelchair without being bagged, posing a risk of contamination and potential respiratory infection. Interviews with staff revealed a lack of awareness and adherence to proper procedures for handling respiratory equipment. A CNA assigned to the resident admitted to not knowing the correct storage method for the nasal cannula and typically hung it on the wheelchair. The LVN responsible for transferring the resident acknowledged overlooking the need to bag the nasal cannula and failing to check the humidifier's water level. The ADON and DON confirmed the importance of these practices to prevent respiratory infections and irritation, emphasizing the staff's responsibility in maintaining these standards. The facility's policies on oxygen therapy, which require nasal cannulas to be bagged when not in use and humidifiers to be filled with water, were not followed. This oversight in adhering to established procedures resulted in the resident's respiratory care needs not being met according to professional standards and the comprehensive care plan, potentially compromising the resident's health.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse. Resident #1, who had severe cognitive impairment and was unable to consent, was sexually abused by CNA A. The incident was captured on camera footage, showing CNA A engaging in inappropriate, sexually oriented activity with Resident #1. The resident's medical history included unspecified dementia, severe cognitive impairment, and total dependence on staff for personal care and hygiene. The abuse was reported by the family member of Resident #1's roommate, who observed the incident on camera footage and reported it to the local police department. The police initiated an investigation, and the facility suspended CNA A. Resident #1 was assessed by the Director of Nursing (DON) and sent to the hospital for a Sexual Assault Nurse Examiner (SANE) exam, which revealed an abrasion of the labia. The resident returned to the facility with no new orders. The facility's investigation confirmed the abuse, and CNA A was terminated. Interviews with staff and review of CNA A's personal file showed no prior complaints or barriers to employment. The facility had in-serviced staff on abuse and neglect reporting and prevention before the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, and it was found that the facility had failed to protect Resident #1 from sexual abuse. The Immediate Jeopardy (IJ) situation was determined to have existed from the date of the incident until the facility implemented corrective actions. The police investigation concluded with the arrest of CNA A, who admitted to the attempted sexual assault. The facility's failure to protect Resident #1 placed residents at risk for serious injuries, abuse, and serious psychosocial harm.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
