Brentwood Place Four
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 3505 S Buckner Blvd Bldg 5, Dallas, Texas 75227
- CMS Provider Number
- 676270
- Inspections on file
- 42
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brentwood Place Four during CMS and state inspections, most recent first.
Four residents with significant cognitive and physical impairments did not receive necessary assistance with nail care, resulting in long, dirty, and untrimmed fingernails. Staff interviews and observations confirmed that nail care was not consistently provided as required by care plans and facility policy, despite residents' dependence on staff for personal hygiene.
LVNs assigned to a medication cart did not consistently sign the narcotic count sheets at shift changes, despite performing the counts, due to interruptions and workload. This resulted in missing documentation for several shifts, with the DON confirming that signatures are required to verify counts were completed.
Surveyors observed improper food storage, including unlabeled and undated items in the refrigerator and a scoop left in a bulk oatmeal bin, as well as inadequate hand hygiene by a staff member during meal preparation. Staff handled food and kitchen equipment without washing hands between tasks and used a dirty cloth to clean surfaces, contrary to facility policy and professional standards.
A resident who was totally dependent for eating and cognitively intact was assisted with her meal by a CNA who stood while feeding her, contrary to facility policy and training that require staff to be seated to maintain resident dignity. The DON confirmed that all staff are responsible for ensuring dignity during care, and the CNA acknowledged she should have been seated.
A discharge MDS assessment for a resident was not completed or transmitted to CMS within the required 14-day timeframe after discharge. The MDS Nurse, responsible for these assessments, acknowledged the delay, and both the DON and Administrator confirmed the expectation for timely completion and transmission. The facility lacked a specific policy on MDS assessments, relying instead on the CMS RAI manual.
A resident with right-sided hemiplegia and hand contractures did not receive daily application of a prescribed resting hand splint as outlined in their care plan. Multiple observations showed the splint was not in use, and there was no documentation of refusal. Staff interviews revealed confusion about responsibility for the intervention, and the care plan was not updated to reflect the resident's current needs, contrary to facility policy.
Two residents did not receive proper incontinence and catheter care: one resident's Foley catheter was not secured during transfer, resulting in pain, and another resident did not receive appropriate perineal cleaning after a bowel movement, as the CNA failed to separate the labia and used the brief instead of wipes. These lapses were observed by surveyors and confirmed by staff interviews and record review.
A resident with a tracheostomy and respiratory failure did not receive sterile tracheostomy care as required. An LVN failed to maintain sterile technique, did not perform hand hygiene at key steps, and did not change gloves between dirty and clean tasks during the procedure, contrary to professional standards and facility policy. Both the LVN and DON confirmed that the correct sterile procedures were not followed.
A medication aide failed to administer a chewable aspirin and a sublingual buprenorphine as ordered to a resident with multiple chronic conditions and moderate cognitive impairment, resulting in a medication error rate of 8%, which exceeds the acceptable threshold. The aide acknowledged misreading the administration instructions, and the DON confirmed expectations for following medication administration protocols.
Surveyors found that a nurse failed to properly check and label medications on a medication cart, including leaving a controlled medication in a broken blister pack and using an insulin pen for a resident without documenting the open date. The DON confirmed that staff are required to check for broken seals and date insulin pens, but these steps were not followed, in violation of facility policy.
A resident with mild cognitive impairment but intact cognition reported a missing debit card after using it at the front desk. The card was later used for unauthorized purchases by a CNA, as confirmed by surveillance footage and the facility administrator. The incident was reported to the administrator and police, but the facility did not meet required reporting timelines. Staff interviews confirmed awareness of misappropriation policies and recent training.
A resident with mild cognitive impairment reported a missing debit card, which was later found to have been used by a facility employee for unauthorized purchases. Although staff recognized the need to report misappropriation, the administrator did not notify the state agency within the required 24-hour period or submit the investigation report within five days, violating facility policy.
A resident with mild cognitive impairment reported a missing debit card, which was later found to have been used by a facility employee for unauthorized purchases. The facility did not complete and submit the investigation results to the state within the required 5-day period, and the administrator delayed reporting the incident as misappropriation, resulting in noncompliance with facility policy and regulatory requirements.
The facility failed to notify the physician and responsible party of significant weight loss for two residents. One resident's weight dropped from 226.9 lbs to 178 lbs, and another's from 204 lbs to 164.4 lbs, without timely notification. This failure to follow policy could delay treatment and diagnosis.
The facility failed to provide timely incontinence care and personal hygiene for three residents. One resident did not receive incontinence care for over eight hours, another had not had her hair washed in over a month, and a third had long, dirty fingernails. These deficiencies were due to communication lapses and staffing issues.
The facility failed to address significant weight loss in two residents, leading to a lack of timely notification to the physician and Dietitian, and inadequate monitoring of enteral feeding. This resulted in substantial weight loss for both residents, with one losing 44.8 pounds (20%) in less than a month and the other losing 34.1 pounds (17%) in a month.
The facility failed to follow enteral feeding physician orders for two residents, leading to significant nutritional deficits. Both residents experienced substantial weight loss, and the facility did not notify the Consultant Dietitian. The enteral feeding pumps were not reprogrammed every 24 hours, resulting in residents not receiving the prescribed nutrition.
The facility failed to provide proper respiratory care for two residents, as the RT and an LVN did not maintain sterile technique or perform hand hygiene during tracheostomy care, potentially risking respiratory infections.
The facility failed to ensure that a dietary aide wore effective hair restraints while cleaning dishes and using the dish machine. Additionally, one of the facility's freezers had an ice accumulation issue due to a slipped hose, which was not addressed promptly due to the lack of a specific freezer maintenance policy.
The facility failed to maintain an Infection Prevention and Control Program, leading to multiple instances of improper hand hygiene and cross-contamination during incontinence care for three residents. CNAs did not perform hand hygiene after changing gloves and placed contaminated items on beds, risking cross-contamination and infection.
The facility failed to maintain a safe and sanitary environment in the laundry room, with significant lint accumulation in dryers and inadequate handwashing facilities. Observations revealed non-compliance with cleaning protocols and improper soap dispensers, posing sanitary and fire hazards.
The facility failed to ensure a resident's call light was within reach, despite the resident's risk of falls and care plan instructions. The resident and their family member, who only spoke Spanish, confirmed the call light was always on the floor, requiring the family member to pick it up. Staff interviews and observations revealed that the call light was not consistently placed within reach, violating facility policies and endangering the resident's safety.
The facility failed to ensure that a resident with a traumatic brain injury wore a helmet as ordered by the physician to prevent possible injury when ambulating. The resident was observed multiple times without the helmet, and staff interviews revealed a lack of awareness and enforcement of the helmet requirement. The resident's call light was also found out of reach, further compromising safety.
A facility failed to provide proper catheter and perineal care for a severely cognitively impaired male resident with multiple medical conditions. The CNA did not follow proper hand hygiene or cleaning procedures, increasing the risk of infection and skin breakdown.
Failure to Provide Adequate Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for four residents who were dependent on staff for these tasks. Observations and interviews revealed that these residents had long, dirty, and untrimmed fingernails, with some nails being thickened, jagged, or discolored. In several cases, residents expressed a desire to have their nails trimmed and cleaned, and staff acknowledged that nail care had not been performed as needed. Resident records indicated that all four residents had significant cognitive and/or physical impairments, such as hemiplegia, contractures, diabetes, and severe cognitive deficits, requiring substantial or total assistance with personal hygiene. Care plans for these residents specified the need for staff assistance with nail care, yet observations showed that this care was not consistently provided. Staff interviews confirmed that nail care was a shared responsibility between CNAs and nurses, with some staff noting that nail care should be offered during routine hygiene or as needed, and that certain residents had a history of refusals, though this was not always documented or addressed. The facility's own policy required regular cleaning and trimming of fingernails, but this was not followed for the residents in question. Staff interviews further revealed a lack of consistent monitoring and follow-through, with some CNAs stating they had not noticed the condition of the residents' nails during their rounds. The DON and ADON acknowledged that nail care should be performed regularly and that lapses could pose infection control issues, but the deficiency persisted as observed during the survey.
Failure to Document Narcotic Counts at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one of three nurse medication carts reviewed. Specifically, LVNs responsible for the 100/200 hall nurse cart did not consistently count and sign for controlled drugs at every shift change, as required. Record review and observation revealed missing signatures for both off-duty and on-duty nurses on the narcotic count sheet for three consecutive shifts. Interviews with the involved LVNs confirmed that although they performed the narcotic counts, they did not sign the count sheets immediately after, citing interruptions and being busy with resident care or new admissions. The DON confirmed that the expectation is for nurses to sign the narcotic count sheet at the beginning and end of each shift after completing the count with the incoming and outgoing nurse. The DON also stated that without these signatures, there is no proof that the counts were performed. Review of the facility's policy on receiving controlled substances did not address the specific concerns identified in this incident.
Deficient Food Storage and Hand Hygiene Practices in Kitchen
Penalty
Summary
Surveyors identified deficiencies in the facility's food storage, preparation, and hand hygiene practices during observations and interviews. On one occasion, a scoop was found stored inside a bulk oatmeal bin in the dry storage area, and a zip top bag containing cut strawberries, a lemon, and grapes was found in the refrigerator without a date or label. These practices were not in accordance with the facility's policy, which requires all food items to be labeled, dated, and stored properly to prevent contamination. During meal preparation, a staff member was observed making pureed food without wearing gloves, handling a cell phone near the prep area, and moving between the prep and dishwashing areas without performing hand hygiene. The staff member also used a dirty dish cloth to wipe the counter and donned gloves without washing hands beforehand. After removing the gloves, the staff member did not wash hands before handling clean and sanitized plate covers. These actions were inconsistent with the facility's hand hygiene policy, which mandates handwashing with soap and water before and after food preparation and when moving between kitchen tasks. Interviews with dietary staff and the regional dietitian confirmed that all kitchen staff are responsible for proper food storage and hand hygiene. Staff acknowledged awareness of the policies and the importance of these practices, but admitted to lapses during the observed incidents. The facility's policies and the FDA Food Code were reviewed, both of which emphasize the necessity of proper labeling, dating, storage, and hand hygiene to prevent food contamination and ensure food safety.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to assist a resident with eating in a dignified manner. The resident, a cognitively intact female with a history of acute and chronic respiratory failure, artificial larynx, and hypertension, was assessed as being totally dependent on staff for eating. During an observation, the CNA was seen standing while feeding the resident, rather than sitting beside her as required by facility policy and the resident's care plan. The CNA acknowledged during an interview that she should have been seated while assisting the resident, as standing could make the resident uncomfortable. The facility's policy on resident rights, as well as statements from the Director of Nursing (DON), confirmed that all staff are responsible for maintaining resident dignity and are trained to do so. The DON specifically stated that staff should be seated when assisting residents with meals to prevent discomfort. The failure to follow these protocols resulted in the resident not being assisted with eating in a manner that promoted her dignity and quality of life.
Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS system within 14 days after completion for one resident who was reviewed for discharge assessments. Specifically, a female resident who was admitted in September 2024 and discharged in January 2025 did not have a discharge MDS assessment completed or transmitted as required. Review of the resident's MDS assessments revealed that the discharge MDS was more than 120 days overdue at the time of the survey. Interviews with the MDS Nurse, DON, and Administrator confirmed that the MDS Nurse was responsible for completing and transmitting all MDS assessments, including discharge assessments, within the required timeframe. The MDS Nurse acknowledged starting but not completing or transmitting the assessment, and both the DON and Administrator stated their expectation that all MDS assessments be completed and transmitted on time. The facility did not have a specific policy on MDS assessments and referred to the CMS RAI manual for guidance.
Failure to Implement and Update Comprehensive Care Plan for Resident with Contractures
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan with measurable objectives and timeframes for a resident with hemiplegia affecting the right dominant side and right hand contractures. The resident's care plan included an intervention to assist with applying a right resting hand splint daily to prevent complications such as contracture formation, embolism, and immobility. However, observations on multiple occasions revealed that the resident was not wearing the splint, and there was no documentation of the resident refusing the application of the splint. Interviews with staff indicated confusion regarding responsibility for the application of the splint, with the CNA stating that therapy staff were responsible, and the Physical Therapy Manager referencing restorative care and resident refusal, though no such refusal was documented in the care plan. The MDS Coordinator and DON acknowledged that care plan updates were necessary to ensure residents received appropriate care and that failure to update or implement the care plan could negatively impact the resident's condition. The facility's policy required care plans to include measurable objectives, timeframes, and ongoing updates, which was not followed in this case.
Deficient Incontinence and Catheter Care Practices
Penalty
Summary
Two residents were found to have not received appropriate care related to incontinence and catheter management. One male resident with severe cognitive impairment, neuromuscular dysfunction, and an indwelling Foley catheter was observed sitting on the toilet without his catheter tubing secured to his leg. During the process of cleaning and transferring the resident from the toilet to his wheelchair and then to his bed, the catheter remained unsecured. The resident complained of pain in the penile area during this process. Staff interviews confirmed that the catheter should have been secured to prevent pulling and potential injury, and that this step was missed during the observed care. Another female resident with moderate cognitive impairment, a history of septicemia, and requiring substantial assistance for toileting was observed receiving incontinence care. During the cleaning process, the CNA failed to separate the resident's labia and did not clean the area using wipes as required, instead using the brief to wipe. The resident had a bowel movement that had spread between her legs, but the cleaning did not include proper perineal care to ensure all feces was removed from the vaginal area. The CNA acknowledged the correct procedure was not followed and recognized the risk of infection if feces remained. Facility policy required that catheters be anchored with a leg strap to prevent tension and possible injury, and that proper perineal care be performed to reduce infection risk. Both deficiencies were observed directly by surveyors and confirmed through staff interviews and record review.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to provide sterile tracheostomy care to a resident requiring respiratory support. During an observed tracheostomy care procedure, the LVN did not maintain sterile technique, did not perform hand hygiene at appropriate steps, and failed to change gloves between dirty and clean tasks. Specifically, after removing gloves and opening a sterile glove package, the LVN did not sanitize her hands before donning new sterile gloves, handled supplies with sterile gloves, and did not change gloves or perform hand hygiene after removing the old dressing and before applying a clean one. These actions were inconsistent with both professional standards of practice and the facility's own tracheostomy care policy, which requires hand hygiene and the use of clean supplies at each step. The resident involved was a cognitively intact female with acute and chronic respiratory failure, an artificial larynx, and a care plan requiring tracheostomy care and oxygen therapy. The resident's physician orders and care plan specified regular tracheostomy care, including changing and dating trach ties and dressings. The LVN and the Director of Nursing both acknowledged during interviews that the procedure should have been performed using sterile technique to reduce infection risk, and that the correct steps were not followed during the observed care.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% based on 2 errors out of 25 opportunities. During a medication pass observation, a medication aide (MA) administered medications to a female resident with chronic embolism, chronic kidney disease, and muscle weakness, who had moderately impaired cognition. The MA did not instruct the resident to chew the prescribed chewable aspirin and failed to ensure the buprenorphine was administered sublingually as ordered. These actions were confirmed through observation, interview, and record review. The MA acknowledged misreading the administration instructions for both the chewable aspirin and the sublingual buprenorphine, stating that medications must be given as ordered by the physician. The Director of Nursing (DON) confirmed that staff are expected to follow the five rights of medication administration and consult with nursing leadership or the physician if there are any questions about medication orders. Facility policy also requires staff to perform three checks comparing the physician's order, pharmacy label, and medication administration record.
Improper Medication Labeling and Storage on Medication Cart
Penalty
Summary
Surveyors observed that drugs and biologicals on one of the medication carts were not labeled and stored according to professional standards. Specifically, a blister pack containing tramadol for a resident had a broken seal with the pill still inside, and an insulin pen for another resident was in use without an open date indicated. The nurse responsible for the cart did not check blister packs during the narcotic count at shift change and was unaware of when or how the blister pack seal was broken. The nurse also administered insulin without verifying or documenting the open date on the pen, which is necessary to ensure the medication's effectiveness within its shelf life. Interviews with the nurse and the DON confirmed that staff are expected to check for broken seals and to date insulin pens when opened, but these procedures were not followed. The facility's policy requires immediate removal and disposal of medications in compromised containers and mandates dating of certain medications upon opening. The DON acknowledged that keeping a pill in a broken blister pack is not acceptable and that insulin pens must be dated to track expiration. The pharmacy consultant and ADONs are supposed to perform regular checks, but these lapses were still found during the survey.
Unauthorized Use of Resident's Debit Card by Staff Member
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) used a resident's debit card for unauthorized transactions. The resident, who had mild cognitive impairment but was assessed as having intact cognition, reported his debit card missing after last using it at the facility front desk. The resident and his family searched for the card but could not locate it. Subsequent review of the resident's bank transactions revealed several unauthorized purchases, including a bus ticket and department store items. Surveillance footage from a local store showed a facility employee making purchases with the card, and the administrator identified the employee as CNA A. The incident was reported to the facility administrator, who confirmed that the resident's debit card had been used without authorization by CNA A. The administrator attempted to contact CNA A, but the CNA did not respond or return to the facility. The administrator also visited the locations where the card was used, but was unable to obtain video evidence without police involvement. The police were notified, and the incident was reported to the state. The administrator acknowledged that the facility's policy required reporting such incidents within 24 hours and submitting an investigation report within 5 days, but these timelines were not met. Interviews with other staff members indicated that they were aware of the facility's policies regarding misappropriation and had received recent in-service training on the topic. Staff consistently stated that they would not accept cash or bank cards from residents and would direct any such requests to the appropriate department. The resident involved confirmed that he had reported the missing card to staff and the police, and that unauthorized transactions had occurred while he was at the facility.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the timely reporting of an allegation of misappropriation of property for one resident. The resident, a male with mild cognitive impairment, hypertension, and glaucoma, reported his debit card missing after last using it at the facility front desk. The resident and his family searched for the card but could not locate it. Subsequent investigation revealed that the card had been used for unauthorized purchases, and surveillance footage identified a facility employee making these transactions. The police were notified, and the employee was terminated. Despite the facility's policy requiring that suspicions of misappropriation be reported to the state agency within 24 hours, the incident was not reported within this timeframe. The administrator initially learned of the missing card but delayed reporting to the state, waiting to see if the card would be found. The administrator later acknowledged that the misappropriation should have been reported within 24 hours of the initial suspicion, as per facility policy. Additionally, the required investigation report was not submitted to the state within the mandated five-day period. Interviews with staff confirmed their understanding of misappropriation and the expectation to report such incidents immediately to the administrator. However, the administrator and corporate administrator both confirmed that the reporting timelines outlined in facility policy were not followed in this case. The failure to report the incident promptly and submit the investigation report within the required timeframe constituted a breach of the facility's abuse prevention and reporting policies.
Failure to Timely Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that all alleged violations of misappropriation of property were thoroughly investigated and that the results were reported to the administrator and state officials within the required timeframe. Specifically, after a resident reported his debit card missing, the facility did not complete and submit the results of their investigation within 5 days as required by their policy. The initial report of the missing debit card was made to the RN supervisor, who then notified the administrator. The administrator became aware of the missing card and subsequent unauthorized transactions, including purchases and a bus ticket, but did not report the incident to the state within 24 hours or submit the investigation report within 5 days. The resident involved was a male with mild cognitive impairment, primary open angle glaucoma, and hypertension, who required extensive assistance with activities of daily living but had intact cognition according to his BIMS score. The resident reported the missing debit card after last using it at the facility front desk. Unauthorized transactions were discovered, and surveillance footage identified a facility employee making purchases with the card. The police were notified, and the resident's family, physician, and ombudsman were also informed. However, the timeline of reporting and investigation submission did not comply with facility policy or regulatory requirements. Interviews with facility staff, including the administrator, confirmed that the administrator did not consider the incident as misappropriation until after the family had searched for the card, resulting in a delay in reporting. The administrator acknowledged the failure to report the incident to the state within 24 hours and to submit the investigation report within 5 days. The corporate administrator and other staff also confirmed that the required timelines were not met, and the facility's policy on abuse prevention and reporting was not followed in this case.
Failure to Notify Physician and Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to immediately consult with the residents' physicians when there was a significant change in their physical status, specifically significant weight loss, for two residents. Resident #17 experienced a significant weight loss from 226.9 lbs in March to 178 lbs in early May, but the physician was not informed until May 6, and the responsible party was not notified until May 7. The responsible party expressed concern about the lack of detailed information and interventions regarding the weight loss. Similarly, Resident #55 experienced a significant weight loss from 204 lbs in December to 164.4 lbs in early May. The physician and responsible party were not notified of this change. Interviews with the ADON and the Regional Nurse Consultant revealed that the ADON was responsible for notifying the physician and responsible party but failed to do so. The facility's policies on weight management and change of condition notification were not followed, as they require timely notification of significant weight changes to the physician and responsible party. The failure to notify could place residents at risk for delayed treatment and diagnosis of new symptoms, potentially leading to serious health consequences.
Failure to Provide Timely Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for three residents who were unable to carry out activities of daily living. Resident #536, who required extensive assistance, did not receive timely incontinence care from 6:00 a.m. to 2:20 p.m. on 05/07/24. Despite requesting to be changed at 1:15 p.m., no staff attended to him until 2:20 p.m., leading to concerns about his catheter and a bowel movement that had not been addressed. The delay was attributed to a lack of communication among staff members, as the CNA assigned to him was not informed of his needs until much later in the shift. Resident #4, who also required extensive assistance, did not receive timely incontinence care from 6:00 a.m. to 2:50 p.m. on 05/07/24. Additionally, her hair had not been washed in over a month, which she expressed a desire to have done. The CNA assigned to her confirmed that the resident's hair had not been washed due to the shower bed being too short and the resident's preference for bed baths. The CNA also mentioned being behind schedule due to working the hall alone and dealing with residents with behaviors, which contributed to the delay in providing care. Resident #32, who required maximal assistance with personal hygiene, was observed with long, discolored fingernails that had dark brown residue underneath. The CNA responsible for his care admitted not noticing the condition of his nails that morning and stated she would address it immediately. The ADON confirmed that nail care should be completed as needed and observed daily, emphasizing that long and dirty nails could pose an infection control issue. The facility's policy mandates that residents receive necessary care and services to maintain their highest practicable physical, mental, and social well-being, which was not adhered to in these cases.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, leading to significant weight loss for two residents. Resident #17 experienced a weight loss of 44.8 pounds (20%) from 04/05/24 to 04/28/24, and 46 pounds (21%) from 04/05/24 to 05/03/24. The facility did not notify the physician until 05/06/24 and failed to follow the physician's guidance to notify the Dietitian. The Dietitian was only notified after surveyor intervention on 05/07/24. Additionally, the Dietitian did not observe Resident #17 or follow up to ensure the resident was receiving enteral feeding as ordered by the physician. The facility also failed to monitor Resident #17 after a feeding change, resulting in further weight loss. The facility also failed to notify the physician, Dietitian, and responsible party regarding Resident #55's significant weight loss of 34.1 pounds (17%) from 04/05/24 to 05/04/24. Resident #55 was not weighed weekly as per policy for residents dependent on enteral feeding. The facility did not document any nutrition assessment or progress notes for Resident #55 from 04/01/24 to 05/07/24, nor did they notify the physician or responsible party about the significant weight loss. Interviews with staff revealed a lack of awareness and communication regarding the significant weight loss of both residents. The Restorative Aide, who was responsible for weighing residents, was not aware of the weight loss and did not have access to input weights into the electronic record. The ADON, who took over weight management responsibilities, did not notify the Dietitian or physician about the significant weight loss in a timely manner. The newly hired Consultant Dietitian was not informed about the significant weight loss until surveyor intervention and did not observe the residents or verify their enteral feeding. The facility's policy on weight management was not followed, leading to a failure in addressing the residents' nutritional needs.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure enteral feeding physician orders were followed for two residents, leading to significant deficiencies in their nutritional care. For Resident #17, the facility did not verify that adequate nutrition was provided via enteral tube feeding. The resident's enteral feeding pump history revealed a deficit of 600 ml of formula over a 71-hour period, resulting in a significant shortfall in calories and protein. Additionally, the facility did not notify the Consultant Dietitian of Resident #17's significant weight loss, which was observed to be 49.4 lbs over a short period. The charge nurse was unaware of the need to reprogram the tube feeding pump every 24 hours, contributing to the resident not receiving the prescribed nutrition. For Resident #55, the facility also failed to administer enteral feedings as ordered by the physician. The enteral feeding pump history showed a deficit of 570 ml of formula over a 72-hour period, leading to a shortfall in calories and protein. Similar to Resident #17, the facility did not notify the Consultant Dietitian of Resident #55's significant weight loss. The charge nurse acknowledged the importance of clearing the pump every 24 hours but did not ensure this was done, resulting in the resident not receiving the prescribed nutrition. Interviews with staff, including the Consultant Dietitian and Regional Nurse Consultant, revealed a lack of adherence to protocols for monitoring and administering enteral feedings. The facility's policy on tube feeding was not followed, leading to residents not receiving the necessary nutrition as per physician orders. This failure placed residents at risk for nutritional deficits, weight loss, and overall decline in quality of care.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care consistent with professional standards of practice. For Resident #20, the Respiratory Therapist (RT) did not perform hand hygiene during tracheostomy care and failed to maintain sterile technique during the suctioning process. The RT repeatedly changed gloves without performing hand hygiene and used non-sterile techniques, which could introduce infection into the resident's lungs. The RT acknowledged the mistakes and attributed them to nervousness and a misunderstanding of the tracheal suctioning kit contents. For Resident #76, the Licensed Vocational Nurse (LVN) also failed to perform hand hygiene during tracheostomy care and did not change gloves before handling a clean trach drainage sponge. The LVN admitted that trach care was supposed to be a sterile procedure to reduce the risk of infection and pneumonia but did not follow the proper protocol due to nervousness. Both the RT and LVN had been previously validated as competent in tracheostomy care but did not adhere to the facility's policy and procedures during the observed care. The facility's policy on tracheostomy care and the competency validation checklist clearly outlined the steps for maintaining sterility and performing hand hygiene between glove changes. However, these protocols were not followed during the care of Residents #20 and #76, leading to potential risks for respiratory infections. The Regional Director of Respiratory Therapy confirmed the importance of sterile procedures and hand hygiene to prevent lung infections and stated that retraining would be conducted immediately.
Failure to Adhere to Hair Restraint Policy and Freezer Maintenance
Penalty
Summary
The facility failed to ensure that Dietary Aide ZB wore effective hair restraints while cleaning dishes and using the dish machine. Observations revealed that ZB did not cover the back of his hair and facial hair adequately. Despite being aware of the requirement, ZB did not comply with the hair restraint policy. The facility's dietary staff in-service records indicated that ZB had been previously trained on the importance of wearing hair nets and beard guards, but this training was not adhered to during the observed incident. Additionally, the facility failed to maintain one of its three freezers, which had an ice accumulation of about one inch at the bottom. The Dietary Supervisor acknowledged the issue and explained that a hose had slipped off, causing water to drip and freeze at the bottom of the freezer. The Maintenance Supervisor confirmed that ice accumulation had occurred before and required periodic cleaning. The facility did not have a specific policy regarding freezer maintenance, which contributed to the oversight.
Infection Control Failures During Incontinence Care
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program, leading to multiple instances of improper hand hygiene and cross-contamination during incontinence care for three residents. For Resident #536, CNAs K and G did not perform hand hygiene after changing gloves and placed a contaminated catheter bag on the bed, risking cross-contamination. The resident had a history of drainage from his catheter and a wound on his bottom, which was not properly addressed during care. Additionally, the resident reported not being changed for an extended period, further increasing the risk of infection. For Resident #38, CNA H did not perform hand hygiene after removing gloves and before re-gloving, and failed to provide proper catheter care during incontinence care. The resident, who was severely cognitively impaired and had multiple medical conditions including a stage 4 pressure ulcer and a foley catheter, was at increased risk of infection due to the improper care. CNA H acknowledged the failure to perform necessary hygiene steps and catheter care, which could lead to urinary tract infections and further skin breakdown. For Resident #32, CNA U did not change gloves or perform hand hygiene between cleaning soiled areas and handling clean items during incontinence care. The resident, who was severely cognitively impaired and always incontinent of bowel and bladder, was exposed to potential infections due to the improper care. Both CNAs involved in the care of Resident #32 failed to follow proper hand hygiene protocols, increasing the risk of cross-contamination and infection for the resident.
Deficiencies in Laundry Room Maintenance and Sanitation
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in the laundry room. Observations revealed significant lint accumulation in the lint traps and collection areas of the dryers, with layers of lint up to 2 inches thick and clumps on the floor. The Housekeeping Supervisor admitted to not knowing if there was a lint trap cleaning log and acknowledged that the lint traps should be cleaned after each use and at the beginning or end of every shift. Despite posted instructions for cleaning lint traps every 2 hours, the buildup indicated that this was not being followed. The Laundry Supervisor confirmed the unacceptable amount of lint buildup and recognized the sanitary and fire hazards posed by this negligence. An in-service had been started with all laundry staff to address the issue. Additionally, the facility failed to maintain a sanitary handwashing area in the laundry room and the laundry employee restroom. The handwashing sink in the laundry room had a bag of handwashing soap placed next to the faucet handle, which was not compatible with the soap dispenser. The restroom for laundry employees had no soap in the dispenser, which was missing its front panel, and an unlabeled bottle with a pink liquid identified as hand sanitizer. The Housekeeping Supervisor and Maintenance Supervisor both acknowledged the issues and stated that staff had not reported the problems. The facility's policies required daily checks of machines and appliances and proper handwashing before and after laundry tasks, which were not being adhered to.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within their reach, which is a violation of resident rights and safety protocols. The resident, who had a history of traumatic brain injury, Methicillin Susceptible Staphylococcus Aureus infection, and anemia, was observed multiple times with the call light coiled on the floor and out of reach. Despite the care plan indicating that the call light should be within reach to prevent falls, staff did not consistently ensure this was the case. The resident and their family member, who only spoke Spanish, confirmed that the call light was always on the floor, and the family member had to pick it up to use it. The resident stated that he would have to bend over or walk to get a nurse, which was risky given his unsteady condition. Staff interviews revealed that the call light should always be within reach, especially for residents at risk of falls. However, observations showed that this protocol was not followed. The facility's policies on call light placement and fall prevention were reviewed, and both emphasized the importance of keeping the call light within reach to prevent falls and ensure resident safety. Despite these policies, the call light was repeatedly found out of reach, posing a risk to the resident's safety and well-being.
Failure to Ensure Resident Wore Helmet as Ordered
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that a resident with a traumatic brain injury wore a helmet as ordered by the physician to prevent possible injury when ambulating. The resident was observed multiple times without the helmet, despite having a care plan and physician orders indicating the necessity of wearing the helmet at all times when out of bed. Interviews with staff revealed a lack of awareness and enforcement of the helmet requirement, with some staff members never having seen the resident wear the helmet and others relying on verbal communication rather than checking the resident's care plan or Kardex for updated information. The resident, who had a history of traumatic brain injury and a craniotomy, was observed walking around the facility without the helmet on several occasions. The resident and a family member, who only spoke Spanish, indicated that the resident did not wear the helmet often and experienced headaches when wearing it for extended periods. Despite the resident's high risk of falls and potential for serious injury, the staff did not consistently ensure the resident wore the helmet as required. The resident's call light was also found coiled on the floor, out of reach, further compromising the resident's safety. Interviews with various staff members, including a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), an Occupational Therapist, and the Assistant Director of Nursing (ADON), highlighted a lack of consistent communication and adherence to the resident's care plan. The facility's policies on resident rights and fall prevention were not adequately followed, leading to the deficiency. The Regional Nurse Consultant confirmed that the resident's care plan and physician orders required the helmet to be worn when out of bed, and the failure to comply with these orders could result in serious injury due to the resident's condition.
Failure to Provide Proper Catheter and Perineal Care
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a CNA did not provide proper catheter and perineal care for a severely cognitively impaired male resident with multiple medical conditions, including a stage 4 pressure ulcer, a foley catheter, and a colostomy. The resident's care plan required foley catheter care every shift and as needed, but this was not adhered to during an observed care session on 05/08/24. During the observation, the CNA did not perform hand hygiene before or after providing care, and failed to clean the resident's penis, scrotum, and buttocks properly. The CNA used the same wipe for different areas and did not follow the correct procedure for catheter care. Additionally, the CNA did not change gloves or perform hand hygiene after handling soiled materials, which could lead to contamination and increased risk of infection. Interviews with the CNA and the Regional Nurse Consultant confirmed that the proper procedures for catheter and perineal care were not followed. The facility's policies on catheter care and perineal care, which include specific steps for cleaning and hand hygiene, were not adhered to. This failure in care could place residents at risk for urinary tract infections, skin breakdown, and overall poor hygiene.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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