Beacon Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Denison, Texas.
- Location
- 3515 S Park Ave, Denison, Texas 75020
- CMS Provider Number
- 675503
- Inspections on file
- 31
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Beacon Hill during CMS and state inspections, most recent first.
The facility failed to post the most recent survey results in an area readily accessible to residents, families, and legal representatives and did not inform residents of their right to review these results. In a group interview, several residents reported they were unaware of this right and did not know where survey results were kept. The Activity Director, responsible for reviewing resident rights in resident council, acknowledged she had not informed residents about this right and did not know the survey results’ location. The Administrator stated the results were in the front lobby, but they were found stored in a closed cabinet with no notice explaining how to access them, and the facility did not provide the resident rights policy before survey exit.
Surveyors found that residents were not informed about how to file grievances and were unaware of the facility’s grievance policy. In a group interview, multiple residents reported they did not know who to approach with concerns and wanted the ability to write and submit their own grievances, but no forms were available. A binder labeled for grievances in the activity room contained only blank coloring pages and no grievance information. The DON and Administrator stated that residents could report grievances verbally to staff, who would enter them into a computerized system, but confirmed there was no resident-accessible grievance form. The Activity Director, who attended resident council meetings, had not discussed grievances or the grievance policy with residents and was unfamiliar with the specific policy, despite the facility’s written policy requiring that information on how to file a grievance or complaint be made available.
Surveyors found an open vial of Tuberculin PPD in a medication room refrigerator that had been dated more than 30 days earlier but was still in use for resident TB skin testing. The infection prevention LVN, who performed all TB tests, acknowledged she opened, dated, and then failed to discard the vial after 30 days as required, and continued using it on multiple residents. The DON confirmed facility practice and policy require multi-dose vials to be dated when opened, discarded after 30 days unless otherwise directed by the manufacturer, and prohibit use of outdated drugs, with nursing staff responsible for monitoring medication storage.
A resident with severe cognitive impairment and multiple diagnoses was discharged to a memory care facility without receiving the required written 30-day discharge notice, explanation of appeal rights, or notification in a language and manner understood by the resident and responsible party. The facility also failed to notify the Ombudsman of the discharge, and staff interviews revealed confusion about notification responsibilities.
A resident with severe cognitive impairment and multiple medical conditions, who was totally dependent on staff for personal hygiene, was observed with a brown substance under all fingernails on one hand while the other hand’s nails were clean. The care plan and facility policy required staff to provide daily nail cleaning and regular trimming, and to check nails on bath days and as needed. A CNA and an LVN stated that CNAs and nurses were responsible for daily nail checks and nail care, and the DON confirmed expectations that nail care be done on shower days or as needed. Staff had not noticed or addressed the dirty fingernails, resulting in a failure to provide necessary ADL services to maintain grooming and personal hygiene.
Surveyors found that staff failed to label multi-use eye drop bottles with open dates and follow manufacturer discard instructions on two medication carts. A CMA administered TheraTears eye drops from an undated bottle to a resident with dry eye syndrome, while the resident’s active orders listed a different ophthalmic gel. On one cart, open, undated bottles of Latanoprost for a resident with ocular hypertension and Pataday for a resident with dry eye syndrome were observed; on another cart, an open, undated Latanoprost bottle for a resident with glaucoma was found. A CMA, an LVN, and the DON all acknowledged that multi-use eye drops must be dated when opened and discarded within 30 days or per manufacturer directions, and the facility’s medication storage policy prohibits use of outdated or deteriorated drugs and assigns nursing staff responsibility for medication storage.
A resident with Alzheimer’s disease, CVA, anxiety disorder, and moderate cognitive impairment who was frequently incontinent of bladder received urinary incontinence care during which a CNA failed to change gloves and perform hand hygiene between cleaning the front pubic area, removing a soiled brief, cleaning the buttocks, and applying a clean brief. Although the CNA initially washed hands and donned gloves, she continued the entire sequence of care with the same gloves and only performed hand hygiene after removing them at the end, contrary to facility policy and acknowledged expectations for hand hygiene and glove changes when moving from contaminated to clean body sites.
A resident with severe cognitive impairment, dementia, hypertension, and anxiety, care planned as a fall risk with an intervention to keep the call light within reach, was observed in bed with the call light button on the floor and not accessible. A CNA found the call light on the floor and acknowledged the resident would not be able to call for help in that position. The DON and Administrator both stated that staff are responsible for ensuring call lights are always within residents’ reach, consistent with facility policy requiring a system that allows residents to call staff directly from their bed and toileting/bathing areas.
The facility failed to provide necessary nail care for several residents, resulting in long and dirty fingernails. Despite being dependent on staff for personal hygiene, residents did not receive adequate assistance, leading to potential infection risks. Staff interviews revealed a lack of awareness and documentation regarding residents' care needs.
The facility failed to maintain food safety and sanitation standards, with issues including unsealed food storage, improper hand hygiene, and failure to check food temperatures. Dietary staff did not change gloves or wash hands after contamination, and gravy was not temped before serving, risking food-borne illness.
The facility failed to maintain an effective infection prevention and control program, with lapses in hand hygiene and equipment sanitization by staff. An LVN did not sanitize glucose test strips or perform hand hygiene during a blood sugar test and insulin administration for a diabetic resident. A CNA failed to change gloves or perform hand hygiene during incontinence care for another resident. The DON confirmed these actions increased infection risk, contrary to the facility's hand hygiene policy.
A resident's right to self-determination was not respected when the facility rescheduled his medical appointment without his consent and insisted on having a staff member attend his appointments, despite his objections. The resident, who was independent in mobility, expressed his desire to manage his own appointments, but the facility's outdated policies and lack of clear communication led to a deficiency in respecting his rights.
A facility failed to develop a comprehensive care plan for a resident, neglecting her preferences for bed baths and staying in bed. Despite being severely cognitively impaired and dependent on assistance for ADLs, her care plan did not reflect these preferences. Interviews with staff revealed a lack of awareness and documentation, highlighting a breakdown in communication and adherence to the facility's care planning policy.
A resident with severe cognitive impairment and multiple health conditions did not receive adequate foot care, resulting in dry, flaky skin and long, thick toenails. Despite being dependent on staff for personal hygiene, there was no referral to a podiatrist or documentation of wound care treatment. Staff were aware of the issue but failed to ensure proper care, leading to a deficiency in maintaining the resident's foot health.
A resident with an indwelling catheter did not receive appropriate care during a mechanical lift transfer, as the catheter drainage bag was placed above the bladder, risking urine backflow. Staff involved were unaware of the correct procedure, highlighting a training gap. The DON confirmed the importance of keeping the bag below the bladder to prevent UTIs.
The facility failed to label and store medications properly, as observed in a medication room where an open vial of Tuberculin PPD and four syringes with an unknown liquid were found without proper labeling or dating. The infection prevention nurse admitted to overdrawing and not discarding the syringes, while the DON confirmed the requirement to date multi-use vials and discard unused pre-drawn medications.
A facility failed to ensure proper medication administration for a resident with a feeding tube. The resident, who was severely cognitively impaired and dependent on tube feeding, did not receive medications correctly as LVN C did not clamp the tube between administrations, allowing air to enter the stomach. This was against the facility's policy and standard practices, as confirmed by the DON.
Failure to Provide Accessible Survey Results and Inform Residents of Review Rights
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives, and failed to ensure residents were informed of their right to review these survey results. During a confidential group interview with six residents, all residents reported they were not aware they had the right to review recent survey results, that this right had not been discussed with them, and that they did not know where the survey results were located. They stated they would like to know where the results were kept so they could access and review them. In an interview, the Activity Director, who was designated to review resident rights at resident council meetings, stated she had not informed residents about their right to review recent survey results and was unsure where the survey results were located in the facility. The Administrator stated that survey results were accessible in the front lobby and that residents should be aware they can review them without having to ask. However, observation with the Administrator showed that she had to search for the most recent state survey result binder, which was found in a closed cabinet in the front lobby, and there was no notice posted to inform residents or others how to access the survey results. Additionally, the facility failed to provide the resident rights policy prior to exit of the survey.
Failure to Inform Residents of Grievance Process and Provide Accessible Grievance Forms
Penalty
Summary
The facility failed to ensure residents were informed on how to file a grievance or complaint and were not made aware of the facility’s grievance policy, as required by its own policy and resident rights regulations. In a confidential group interview with six residents, all residents reported they did not know how to file a grievance and were unaware of who to approach with individual grievances. All six residents stated they wanted the ability to write down their grievances themselves and submit them to the facility, but reported the facility had not informed them of its grievance policy. Three of the six residents reported there was a binder labeled “grievance” in the resident activity room, but that it did not contain grievance forms. Observation of the grievance binder in the resident activity room showed it contained only blank coloring pages and no grievance forms or information on grievances. The DON stated residents could report grievances to any staff member, who would then enter the grievance into a computerized system, and confirmed there was no specific grievance form available for residents to complete on their own. The Activity Director, who attended resident council meetings, stated she had not discussed grievances or the grievance policy with residents, was unaware of the specific grievance policy, and identified the Administrator as responsible for grievances. The Administrator confirmed she was responsible for overseeing grievances and the grievance policy, stated residents could report grievances orally to staff who would write them down, and acknowledged there was no form available for residents to independently submit written grievances, despite the facility’s policy stating information on how to file a grievance or complaint must be made available to the patient.
Failure to Discard Expired Multi-Dose PPD Vial Used for TB Testing
Penalty
Summary
The deficiency involves the facility’s failure to follow pharmaceutical procedures for multi-dose medications, specifically a vial of Tuberculin Purified Protein Derivative (PPD) stored in the medication room refrigerator for Halls 600-700-800. During an observation with an LVN, surveyors found an open vial of PPD that had been dated more than 30 days earlier, indicating it had not been discarded within the required timeframe. Review of six residents’ immunization records showed that all six had received TB skin tests using PPD from the same lot number as the expired vial on various dates after the 30-day period had passed. In interviews, the LVN responsible for infection prevention stated she performed all TB skin tests, had opened and dated the PPD vial, and acknowledged that facility practice required dating the vial upon opening and discarding it 30 days later. She admitted she forgot to discard the vial and continued to use it beyond 30 days. The DON confirmed that all multi-use vials must be dated when opened and discarded after 30 days unless manufacturer instructions differ, and that all medications must be labeled and checked by nurses for expiration and proper storage. Review of the facility’s “Storage of Medications” policy showed it prohibited the use of discontinued, outdated, or deteriorated drugs or biologicals and assigned nursing staff responsibility for maintaining medication storage, which was not followed in this instance.
Failure to Provide Required Written Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide required written notification of discharge, including the reasons for the move and the right to appeal, to a resident and her responsible party. The notification was not given in writing, in a language and manner they could understand, nor was it provided at least 30 days prior to the discharge as required. Additionally, the facility did not send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman. Interviews revealed that the social worker verbally informed the family member about the need for alternate placement and recommended memory care, but did not initiate a formal 30-day notice. The finance manager and DON were unaware of who was responsible for notifying the Ombudsman, and the family member confirmed that no written notice was received. The Ombudsman also stated she did not receive notification of the discharge. The resident involved was an elderly female with severe cognitive impairment, dementia, Alzheimer's disease, depression, hyperlipidemia, and vitamin deficiency. Her care plan did not include discharge goals or plans, and she was ultimately discharged to a memory care facility. Facility staff cited the lack of a physical address for the responsible party as a reason for not providing the written notice, and there was confusion among staff regarding the process for notifying the Ombudsman. The facility's policy on transfer or discharge was requested but not provided prior to the survey exit.
Failure to Maintain Resident Nail Hygiene and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services to maintain grooming and personal hygiene for a resident who was dependent on staff for care. The resident was an elderly male with a history of cerebrovascular accident, type 2 diabetes, and PTSD, and his MDS assessment documented severe cognitive impairment with no BIMS score recorded. He required extensive assistance of two staff for personal hygiene and was care planned as totally dependent on staff for personal hygiene and oral care, with specific interventions directing staff to check nail length and trim and clean nails on bath day and as necessary. The facility’s written policy on fingernail/toenail care required daily cleaning and regular trimming to keep nails clean and prevent infection. During an observation, the resident was seen lying in bed with a brown substance under all fingernails on his left hand, while the fingernails on his right hand were clean. A CNA, upon viewing the nails, acknowledged they needed to be cleaned and admitted she had not noticed this previously, despite stating that CNAs and nurses were responsible for checking residents’ fingernails daily and providing nail care on shower days or as needed. An LVN confirmed that CNAs were responsible for nail care for non-diabetic residents and nurses for diabetic residents, and that staff were supposed to do daily rounds to check nails for cleanliness and appropriate length. The DON stated her expectation that nail care be provided on shower days or as needed, and that she or her designee conducted routine monitoring rounds, and acknowledged that long and dirty fingernails could be an infection control issue. These observations and interviews showed that staff did not carry out the planned and policy-required nail care for this resident, resulting in unclean fingernails on his left hand.
Failure to Label and Date Multi-Use Ophthalmic Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and labeling of multi-use ophthalmic medications on two medication carts. On one occasion, a CMA administered TheraTears eye drops to a resident with dry eye syndrome; the bottle showed a manufacturer expiration date of 01-2027 but was not labeled with an open date, despite manufacturer instructions to discard 45 days after opening. The resident’s active physician orders instead listed Refresh Liquigel Ophthalmic Gel 1% for dry eye syndrome of bilateral lacrimal glands. During inspection of the Hall 600 medication cart with the same CMA, surveyors observed open, undated bottles of Latanoprost 0.005% eye drops for a resident with ocular hypertension and Pataday allergy eye drops for a resident with dry eye syndrome whose active orders also specified Refresh Liquigel Ophthalmic Gel 1%. The CMA stated that all eye drop solutions should be labeled with the open date and discarded 30 days after opening or per manufacturer instructions, and acknowledged that giving expired medication may not be effective and could be a source of infection. On the Hall 100 medication cart, surveyors observed an open, undated bottle of Latanoprost 0.005% eye drops for a resident with glaucoma, during an observation with an LVN. The LVN reported that the eye drops were administered by evening shift nurses and that she was not the one who opened the bottle, but confirmed that eye drops should be labeled with the open date and discarded 30 days after opening or according to manufacturer labeling, and that failure to do so could result in ineffective medication or infection. In an interview, the DON stated that once a multi-use vial or bottle is opened, staff are required to date it and discard it 30 days after opening unless otherwise directed by the manufacturer, and that all medications must be labeled. The DON further stated that opened TB PPD vials must be dated and discarded after 30 days to prevent use of expired medication, and that use of medication solutions beyond their post-opening expiration could be a source of infection. The facility’s “Storage of Medications” policy stated that discontinued, outdated, or deteriorated drugs or biologicals shall not be used and must be returned to the pharmacy or destroyed, and that nursing staff are responsible for maintaining medication storage.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during urinary incontinence care for one resident. The resident was an older female with Alzheimer’s disease, cerebrovascular accident, anxiety disorder, moderate cognitive impairment (BIMS score of 12), and a need for assistance with personal care. She was frequently incontinent of bladder. During an observed episode of urinary incontinence care, CNA A entered the resident’s room, performed hand hygiene, and donned gloves. CNA A then unfastened the resident’s brief and cleaned the front pubic area using several peri wipes. After cleaning the front pubic area, CNA A did not change gloves or perform hand hygiene before proceeding with the rest of the care. She assisted the resident onto her side, removed and discarded the soiled urine-saturated brief, and cleaned the resident’s buttocks with peri wipes, still without changing gloves or performing hand hygiene. CNA A then placed a clean brief under the resident, repositioned and covered her, and lowered the bed, continuing to use the same gloves. She gathered dirty clothes and trash, then removed her gloves and washed her hands only at the end of care. In interviews, CNA A and the DON both acknowledged that facility policy and expected practice required hand hygiene and glove changes when moving from a contaminated to a clean body site and between dirty and clean tasks, consistent with the facility’s Handwashing/Hand Hygiene policy dated August 2019.
Call Light Not Kept Within Reach of Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system was readily accessible to a resident at the bedside, as required by facility policy and the resident’s care plan. Record review showed the resident was an elderly female with non-Alzheimer’s dementia, hypertension, and anxiety, with a BIMS score of 3/15 indicating severe cognitive impairment. Her comprehensive care plan identified her as being at risk for falls related to impaired mobility and included an intervention to ensure a safe environment by keeping the call light within reach. During an observation, the resident was found sleeping in bed with the call light button on the floor to the right side of the bed, not within her reach. During an interview and observation, a CNA entered the resident’s room, located the call light cord and button on the floor, and then placed it within the resident’s reach. The CNA stated that with the call light on the floor, the resident would not be able to call for help, including if she was incontinent or having an emergency. The DON stated that the expectation was that residents should always have the call light within reach and placed on the resident’s dominant side, and that it was the responsibility of all staff members to ensure this. The Administrator similarly stated that the call light button should always be within residents’ reach, clipped to their clothes or linen where they could reach it. Review of the facility’s “Resident Call light System” policy confirmed that each resident must be provided with a means to call staff directly for assistance from the bed and toileting/bathing facilities, which was not met in this instance.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in four residents who were dependent on staff for assistance with activities of daily living. The residents had long and dirty fingernails, which were not trimmed or cleaned as required. The facility's policy required daily cleaning and regular trimming of nails to prevent infections, but this was not adhered to. Resident #16, a moderately cognitively impaired male, had not received personal hygiene care for the month of September, as evidenced by his long and dirty fingernails. Despite being scheduled for showers and nail care, the staff failed to notice or address his nail condition. Interviews with CNAs and LVNs revealed a lack of awareness and documentation regarding the resident's care needs, leading to the neglect of his personal hygiene. Similarly, Resident #93, who was severely cognitively impaired, had discolored and chipped nails with residue underneath. The staff did not notice the need for nail care until it was pointed out during the survey. Resident #94, who had diabetes, also had long and dirty nails, and the nurse responsible for diabetic residents admitted to not offering nail care recently. Resident #57, who was severely cognitively impaired, had long and thick nails with a brown substance underneath, and despite expressing a desire for nail care, the staff failed to provide it. The facility's failure to adhere to its own policies and procedures for nail care resulted in these deficiencies.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, affecting three of four dietary staff members reviewed for kitchen sanitation. Observations revealed that graham cracker crumbs were not sealed in dry storage, and sugar and flour container lids were sticky with white particles, indicating a lack of proper sanitation. Interviews with the Dietary Manager confirmed that these items should have been sealed and cleaned to prevent contamination. During lunch meal service, dietary staff failed to perform proper hand hygiene. Dietary staff members were observed touching various surfaces with gloved hands and not changing gloves or washing hands afterward. One staff member touched the stove knob and continued to serve food without changing gloves, while another handled meal trays without washing hands. Additionally, a staff member had a torn glove and continued to serve food without changing it. These actions were confirmed through interviews with the staff, who acknowledged the lapses in hand hygiene and glove use. The facility also failed to ensure that food was served at the correct temperature. Specifically, gravy was not checked for temperature before being served, which could lead to food-borne illness. The Dietary Manager acknowledged that the gravy should have been temped to ensure it was hot enough for serving. The facility's policies on food storage, hand washing, and food temperatures were reviewed, highlighting the discrepancies between the policies and the observed practices.
Infection Control Lapses in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene and equipment sanitization by staff members. Specifically, an LVN did not sanitize a bottle of glucose test strips after taking it into a resident's room and failed to perform hand hygiene after removing gloves during a fingerstick blood sugar test and insulin administration for a resident with diabetes. The LVN admitted to forgetting to perform hand hygiene and acknowledged that taking the entire bottle of test strips into the room was a mistake, as it could lead to cross-contamination. Additionally, a CNA did not change gloves or perform hand hygiene while providing incontinence care to another resident. The CNA cleaned the resident's pubic area and buttocks without changing gloves, then proceeded to handle clean items and reposition the resident. The CNA admitted to being nervous and acknowledged the importance of changing gloves and performing hand hygiene to prevent infection spread. Interviews with the Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene after glove changes, after cleaning equipment, and when transitioning between procedures. The DON emphasized that failing to adhere to these protocols posed a risk of cross-contamination and increased infection risk. The facility's hand hygiene policy outlined the necessity of handwashing in various situations, including after glove removal and contact with medical equipment.
Resident's Right to Self-Determination Not Respected
Penalty
Summary
The facility failed to uphold a resident's right to self-determination by not allowing him to schedule his own medical appointments and by involving him inadequately in the rescheduling process. The resident, who had moderately impaired cognition but was independent in mobility, expressed his desire to manage his own appointments, a preference that was not respected by the facility staff. This led to a situation where his appointment with a liver specialist was rescheduled without his consent, causing him distress and a sense of loss of control over his personal affairs. The resident had informed the facility staff about his appointment with a hepatologist and had arranged for a friend to transport him. However, due to a scheduling conflict, the facility's driver rescheduled the appointment without consulting the resident, which upset him. The resident was also informed that the driver would need to attend his appointments, a requirement he disagreed with, as he valued his privacy during medical consultations. Despite his objections, the facility staff did not accommodate his preferences, leading to further frustration. Interviews with facility staff revealed a lack of clear communication and understanding of the resident's rights. The driver and nursing staff were responsible for scheduling and attending appointments, but there was no specific protocol for informing residents about changes or involving them in the decision-making process. The facility's transportation policy was outdated and did not adequately address the resident's rights to self-determination, contributing to the deficiency identified in the report.
Failure to Implement Comprehensive Care Plan for Resident Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #57, which included measurable objectives and timeframes to meet her medical, nursing, and psychosocial needs. Resident #57, a severely cognitively impaired female with multiple diagnoses including acute kidney failure, dementia, and anxiety disorder, was admitted to the facility with a preference for bed baths and staying in bed. However, her care plan did not reflect these preferences, which were identified during observations and interviews. Interviews with various staff members, including CNAs, an LVN, and the DON, revealed a lack of awareness and documentation regarding Resident #57's preferences for bed baths and staying in bed. The facility's policy requires that care plans be reviewed and updated quarterly or upon any change in condition, but this was not adhered to in Resident #57's case. The Patient Care Coordinator was only made aware of these preferences after being informed by the DON, indicating a breakdown in communication and documentation within the care planning process.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, leading to a deficiency in maintaining good foot health. The resident, an elderly female with severe cognitive impairment and multiple health conditions, was admitted to the facility with a need for assistance in activities of daily living, including personal hygiene. Despite these needs, the resident did not receive adequate foot care, as evidenced by her dry, flaky skin and long, thick toenails, which had not been trimmed since her admission. The resident's care plan included interventions for personal hygiene, but there was no documentation of a referral to a podiatrist or any wound care treatment orders. Interviews with staff revealed that the resident's dry and flaky skin had been an ongoing issue since admission, and although lotion was applied, it did not alleviate the condition. The staff, including CNAs and LVNs, were aware of the resident's foot condition but failed to ensure she was seen by a podiatrist or received appropriate nail care. The Director of Nursing (DON) acknowledged the deficiency, noting that CNAs should report skin issues to the charge nurse, who should then assess and contact a physician. The facility's policy on nail care emphasized the importance of regular cleaning and trimming to prevent infections, but this was not adhered to in the resident's case. The lack of proper foot care placed the resident at risk for potential skin and infection control issues.
Improper Catheter Care During Transfer
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, specifically in maintaining the foley catheter drainage bag below the bladder during a mechanical lift transfer. This deficiency was observed during a transfer of a female resident who was moderately cognitively impaired, dependent on two-person assistance for transfers, and had an indwelling catheter. During the transfer, the catheter drainage bag was placed on the arm of the mechanical lift, above the resident's bladder, causing urine to flow back toward the bladder. Interviews with the staff involved revealed a lack of knowledge and training on the proper handling of the catheter drainage bag during transfers. The Unit Manager and CNA involved admitted to not knowing the correct procedure for keeping the bag below the bladder during a mechanical lift transfer. The Director of Nursing confirmed that the catheter drainage bag should always be maintained below the bladder to prevent urinary tract infections, and acknowledged that the facility conducts skills checks annually and as needed when training issues are identified.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with accepted professional principles, specifically in one of the medication rooms. During an observation, an open vial of Tuberculin Purified Protein Derivative (PPD) and four syringes filled with an unknown liquid were found in the medication room refrigerator without proper labeling or dating. LVN B, who was present during the observation, indicated that the infection prevention nurse, Unit Manager D, was responsible for TB skin tests and did not know what was in the syringes. Unit Manager D admitted to drawing up the syringes of Tuberculin PPD and acknowledged that she should have discarded them after overdrawing the previous day. She also admitted to failing to date the vial upon opening it. The Director of Nursing (DON) confirmed that staff were required to date multi-use vials once opened and that pre-drawn medications should be used immediately or discarded. The DON emphasized that unlabeled syringes posed a risk as their contents and the duration since they were drawn were unknown, potentially leading to the use of expired medication.
Failure in Medication Administration via G-tube
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident who required medication administration through an enteral feeding tube. The resident, a severely cognitively impaired female, was dependent on all activities of daily living and received more than half of her total calories through a feeding tube. The resident's care plan and physician's orders specified that medications should be crushed and administered via the G-tube with appropriate flushing before and after each medication. However, during an observation, LVN C did not clamp the tubing between each medication administration, allowing the tube to empty completely, which could introduce air into the stomach. LVN C was observed preparing and administering multiple medications to the resident without clamping the tube between administrations, contrary to the facility's policy and standard nursing practices. The Director of Nursing confirmed that the proper procedure was to clamp the tube to prevent air from entering the stomach, which could cause reflux and discomfort. Despite having been deemed competent in the procedure, LVN C was unaware of the need to clamp the tube, leading to a deficiency in the facility's pharmaceutical services.
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.
