Brentwood Place Three
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 3505 S Buckner Blvd Bldg 4, Dallas, Texas 75227
- CMS Provider Number
- 675352
- Inspections on file
- 51
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Brentwood Place Three during CMS and state inspections, most recent first.
A resident with a history of stroke, psychiatric illness, dementia, and documented exit‑seeking behavior repeatedly attempted and actually left the facility without proper authorization, including one episode where he climbed through a fence, walked several blocks away, called 911, and was transported to a hospital without staff knowing when he had left. Elopement risk assessments were inconsistently and incompletely documented, with earlier assessments identifying moderate risk and later ones marked as no risk despite triggered questions not being completed and clear evidence of wandering and elopement. The care plan did not incorporate multiple prior elopement events, and the dementia diagnosis was discontinued based primarily on a high BIMS score, while the MD was not informed of the resident’s exit‑seeking behaviors or elopements. Staff interviews showed inconsistent awareness and recall of the resident’s elopements and exit‑seeking, and family reported multiple prior episodes of the resident leaving through the fence or gate and contacting them or being found by police or hospitals before the facility, leading surveyors to cite a failure to provide adequate supervision and prevent elopement.
A resident with a history of cerebral infarction, psychiatric illness, cognitive impairment, and documented elopement risk repeatedly attempted to leave the facility, including episodes involving security, police, and transfer to a psychiatric hospital. Care plans and progress notes identified elopement risk, impaired cognition, and use of Donepezil, while family reported a prior dementia diagnosis and described the resident leaving facilities independently and contacting them after leaving. However, elopement risk assessments were inconsistently completed and at times classified the resident as no risk, and documentation characterized him as able to make his own decisions. The RNC removed the dementia diagnosis after noting a high BIMS score and reported that the MD approved discontinuation, but the MD later stated he had not been informed of the resident’s exit-seeking or elopement behaviors and saw no such documentation in his or the NP’s notes. Facility policies required prompt physician notification of changes in condition and elopement events, yet the physician was not notified of these behaviors when the dementia diagnosis was discontinued, resulting in the cited deficiency.
A resident with cerebral infarction, psychiatric diagnoses, and documented cognitive impairment was identified in the care plan and elopement evaluations as at risk for elopement, with multiple documented episodes of exit-seeking and actual elopements that involved police and hospital admissions. Despite progress notes describing two elopements on one date and another incident where the resident independently checked into a local hospital after leaving the facility, these events were not incorporated into the updated care plan, and elopement risk assessments were inconsistently and incompletely documented. Staff interviews confirmed that elopements were considered reportable and that the ADM was responsible for notifying the State, but the ADM disputed that elopements occurred or that the resident was an elopement risk and did not report these incidents within the 24-hour timeframe required by the facility’s abuse/neglect reporting policy and regulatory standards.
A resident with a history of cerebral infarction, psychiatric conditions, and documented dementia was care planned for impaired cognition, dementia medication (Donepezil), and elopement risk, but the facility failed to keep the care plan and elopement risk assessments accurate and up to date after multiple exit-seeking and elopement events. The RNC removed dementia as a primary diagnosis from the record based on a high BIMS score without documenting justification, while the MD, unaware of the resident’s elopement behaviors, approved discontinuation of the diagnosis even though the resident remained on dementia medication. Subsequent care plan revisions emphasized the resident’s autonomy and decision-making ability and described him as a potential safety risk when leaving, but did not incorporate his prior elopement attempts and actual elopements, and elopement risk evaluations were incompletely and inconsistently documented, preventing proper risk classification.
A resident with a history of stroke, psychiatric illness, and documented dementia had conflicting information in the medical record, including a physician‑signed dementia attestation, care plans and MAR entries showing ongoing Donepezil use for dementia, and psychiatric notes describing cognitive impairment, while the RNC later struck out the dementia diagnosis from the diagnoses list based on a high BIMS score without documenting the MD conversation or rationale. At the same time, progress notes and staff interviews described repeated exit‑seeking and elopement episodes requiring 1:1 monitoring and police involvement, but elopement risk evaluations were incompletely filled out and locked as "No Risk," and the care plan revision did not capture multiple elopement events. These inconsistencies violated the facility’s own medical record policy requiring accurate, complete documentation that supports diagnoses, justifies treatment, and reflects assessments and physician notifications.
A resident with a terminal illness was found to have a nasal spray medication unsecured on their bedside table, with no physician order or assessment for self-administration. Facility staff confirmed that medications should not be stored in resident rooms without proper authorization, and the medication was not detected during routine rounds, contrary to facility policy.
A resident who required assistance with personal hygiene was found with long, chipped, discolored fingernails containing residue, despite facility protocols assigning nail care responsibilities to CNAs and nurses. Staff interviews confirmed the need for nail care and the expectation for regular observation and maintenance, but the resident's nails were not properly cleaned or trimmed.
A CNA in an LTC facility failed to perform hand hygiene between serving meals to residents, despite having received training and being provided with hand sanitizer. This oversight involved interactions with multiple residents, some with cognitive impairments and various medical conditions, increasing the risk of cross-contamination and infection. The CNA acknowledged the lapse, citing time constraints as a reason for not following the established hand hygiene protocols.
A resident with a history of mental health issues was verbally abused by a staff member, who called him 'trash' and used profanity. The incident was confirmed by witness statements and the staff member admitted to the behavior, citing provocation. The facility's policy prohibits such mistreatment, but the incident occurred, indicating a failure to adhere to standards for resident treatment.
The facility failed to ensure accurate MDS assessments for two residents, leading to omissions in critical sections such as BIMS, Mood, Behaviors, and Pain. One resident's assessments did not reflect his medical orders for pain management, while another's assessments omitted her medical diagnoses and treatments, including a Central PICC line catheter and oxygen therapy. Interviews with staff revealed a lack of accountability in ensuring assessment accuracy, which could impact resident care.
Failure to Supervise Exit-Seeking Resident Resulting in Unwitnessed Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one resident with known exit‑seeking behavior and prior elopement attempts. The resident was an older male with a history of cerebral infarction, osteoarthritis, schizophrenia, depression, anxiety, and documented dementia/non‑Alzheimer’s dementia in various records. His admission MDS showed a BIMS score of 13 with active diagnoses including non‑Alzheimer’s dementia and stroke, and he had been referred to psychiatry/therapy for depression, confusion, elopement, adjustment disorder, and high‑risk behavior. Progress notes and family interviews documented that he frequently talked about leaving, had a history of leaving prior facilities and psychiatric hospitals independently, and had previously left this facility and checked himself into a local hospital. Elopement risk assessments and care planning for this resident were inconsistent and incomplete despite multiple documented episodes of exit‑seeking and actual elopement. An elopement risk evaluation on 10/13 identified him as a moderate risk, cognitively impaired and ambulatory, but later evaluations on 11/02 and 11/27 were documented as “No Risk” and only the “No Risk” sections were completed, even though the system had triggered questions for moderate or imminent risk that were not answered. There were discrepancies in the assessments regarding his ability to make decisions and ambulate. The care plan initially identified him as at risk for elopement and with impaired cognitive function/dementia, and noted psychotropic medication (Donepezil) for dementia, but the revised care plan dated 11/27 did not incorporate his documented elopement attempt and actual elopements on 10/24, 11/02, and 11/27. Progress notes described episodes where he went to the facility gate wanting to go home, required redirection, had two episodes of elopement with aggression and combativeness, and was sent to a psychiatric hospital with police involvement, as well as an episode where he independently checked himself into a local hospital after leaving the facility. Despite this pattern, the facility’s clinical characterization of the resident’s cognition and risk status was altered without clear supporting documentation of a change in condition, and key information was not consistently communicated to the physician. On 11/27, the resident’s dementia diagnosis was struck out by the RNC after she determined he had a high BIMS score and was not exhibiting signs of dementia based on nursing assessments; she reported that the MD approved discontinuation of the dementia diagnosis based on the BIMS score. The MD later stated he was not aware of the resident’s exit‑seeking behaviors or elopements and that there was no documentation of these behaviors in his or the NP’s notes, although he saw that the resident was on dementia medication and did not know if the resident was safe to leave or ambulate independently. Staff interviews showed inconsistent awareness and recall of the resident’s elopements: some staff remembered retrieving him from the security gate, one nurse reported he was “very tricky” and had been on 1:1 observation and was not safe to be out alone, while others minimized or did not recall elopement events. Family members reported that the resident had dementia, wore a medical bracelet listing dementia and stroke, had left the facility multiple times through the fence or gate, sometimes calling them before the facility did, and that by the third time he left it was “scary.” Ultimately, on the cited elopement date, staff did not know what time he left the building; he climbed through the fence, walked several blocks away, contacted 911 himself, and was transported to a nearby hospital, where he was later located by the social worker calling local hospitals. These actions, inactions, and documentation failures led surveyors to identify a deficiency for failure to ensure adequate supervision and prevention of elopement, with Immediate Jeopardy cited on 02/05/2026.
Failure to Notify Physician of Elopement Behaviors Before Discontinuing Dementia Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a resident’s significant change in condition related to repeated elopement behaviors when requesting discontinuation of the resident’s dementia diagnosis. The resident was an older male with diagnoses including cerebral infarction and osteoarthritis, and had a documented history of psychiatric conditions such as schizophrenia, depression, anxiety, cognitive impairment, and high-risk behaviors including elopement. His care plan, initiated and revised in October and November, identified him as at risk for elopement, having impaired cognitive function/dementia, and requiring Donepezil for dementia. Despite this, on a late November date, the Resident Nurse Coordinator (RNC) struck out dementia as a primary diagnosis, and it no longer appeared on the face sheet. The RNC later stated she removed the dementia diagnosis because of a high BIMS score and nursing assessments, and reported that the MD said it was acceptable to discontinue the diagnosis. The resident’s record showed multiple episodes of exit-seeking and elopement-like behavior. Progress notes documented that on one October date, security called nursing staff because the resident was at the gate wanting to go home; he was ambulatory with a walker and had to be redirected back into the building, after which he was placed on two-hour monitoring. On an early November date, notes described two episodes of elopement from the facility, aggression and combativeness when he was prevented from leaving, statements that he was being held hostage, inability to articulate a destination, involvement of police to control behavior, and transfer to a psychiatric hospital. Family members reported that the resident had a long-standing pattern of leaving facilities and psychiatric hospitals independently, often checking himself out or attempting to leave, and that this behavior had occurred at multiple prior settings. They also stated he had records of a dementia diagnosis, wore a medical bracelet listing dementia and stroke, and that he sometimes contacted them after leaving before the facility did. Elopement risk evaluations and documentation in the record were inconsistent with the resident’s behaviors and abilities. An October elopement risk evaluation identified him as a moderate risk, cognitively impaired, ambulatory, and potentially going outdoors but not leaving the grounds. Subsequent evaluations in November were locked as “No Risk,” with staff only completing the “No Risk” section and not answering triggered questions for moderate or imminent risk, resulting in the system not classifying him as higher risk. These evaluations also contained discrepancies about his decision-making ability and ambulation status. Psychiatry/therapy notes from November indicated he was referred for depression, confusion, elopement, adjustment disorder, and high-risk behavior, described him as an unreliable historian who did not remember attempting to elope, disoriented to situation, endorsing decreased concentration, forgetfulness, and ADL difficulties, and receiving Donepezil for cognitive symptoms. During interview, the MD confirmed he approved discontinuation of the dementia diagnosis based solely on the reported BIMS score, stated he was not aware of the resident’s exit-seeking or elopement behaviors, and noted there was no documentation of such behaviors in his or the NP’s notes. Facility policies required physician notification for changes in condition and for elopement events, but the MD’s lack of awareness of the resident’s elopement behaviors at the time the dementia diagnosis was discontinued demonstrated that the facility failed to ensure the physician was properly informed of these significant changes. Additional documentation and interviews further highlighted the disconnect between the resident’s documented behaviors and the information provided to the physician. A late November progress note described the resident as aware of his needs, able to make decisions regarding his care and safety, and independently checking himself into a local hospital, characterizing this as consistent with his baseline pattern and as evidence of preserved decision-making capacity. This narrative contrasted with psychiatric documentation of cognitive impairment and with family statements that he could not make decisions for himself and had dementia. The Administrator later stated that he did not consider the resident’s departures to be elopements because of the high BIMS score and belief that the resident could make his own decisions, and he did not report the events as elopements. The DON and other staff reported that they had been in-serviced on elopement, exit-seeking behaviors, and the need to notify the physician, and facility policies on wandering and elopement required physician notification when a resident was missing and upon return after leaving without proper procedures. Despite these policies and the documented episodes of exit-seeking and elopement-like behavior, the MD was not informed of these behaviors when the dementia diagnosis was discontinued, resulting in the identified deficiency. The facility’s Medical Record Content policy required accurate, timely documentation and prompt physician notification of changes in condition and unusual occurrences involving the resident, including documentation of attempts to notify the physician. The wandering and elopement policy required assessment of elopement risk upon admission, quarterly, and with changes in condition, and mandated physician notification when a resident could not be located and upon return after leaving without following proper procedures. In this case, the resident’s repeated attempts to leave, documented episodes involving security and police, transfer to a psychiatric hospital, and independent check-in to a local hospital were not fully or consistently reflected in the elopement risk evaluations or in communications to the physician. The MD’s statement that he was unaware of the resident’s exit-seeking and elopement behaviors at the time he agreed to discontinue the dementia diagnosis, combined with the facility’s own policies requiring such notification, formed the basis of the deficiency for failure to ensure the physician was notified of significant changes in the resident’s condition related to elopement behaviors.
Failure to Timely Report Elopement-Related Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report alleged neglect related to elopement to the State Agency within 24 hours, and failure to report subsequent actual elopements. A male resident with diagnoses including cerebral infarction, osteoarthritis, and a documented dementia diagnosis in the care plan was admitted in October 2025 and discharged in December 2025. His care plan, initiated and revised in October and November 2025, identified him as at risk for elopement based on an Elopement Evaluation risk score, with impaired cognitive function/dementia, use of Donepezil for dementia, and psychiatric diagnoses including schizophrenia, depression, and anxiety. The care plan also documented that he was a potential safety risk when leaving the facility, with a history of leaving facilities independently and self-admitting to hospitals. However, the care plan revised on 11/27/2025 did not reflect his elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/26/2025. Elopement risk evaluations showed inconsistencies and incomplete assessments. On 10/13/2025, the resident was assessed as a moderate elopement risk, cognitively impaired, and able to ambulate or propel himself. On 11/02/2025 and 11/27/2025, the evaluations were locked as completed but only the “No Risk” section was filled out, and questions that would have evaluated him as moderate or imminent risk were not completed, despite additional information stating he was at risk for elopement. These later evaluations also contained discrepancies regarding his ability to make decisions and ambulate. Progress notes documented that on 10/24/2025 security called nursing staff because the resident was at the gate wanting to go home; he was redirected back into the building and placed on two-hour monitoring. On 11/02/2025, notes described two episodes of elopement from the facility, aggressive and combative behavior when he insisted on leaving, inability to articulate a destination, involvement of police, and transfer to a psychiatric hospital, with notifications made to the physician, administrator, DON, and family. Further documentation showed that on 11/26/2025 the resident again left the facility and independently checked himself into a local hospital, with no injuries reported. A subsequent progress note characterized this as consistent with his baseline pattern of independently leaving prior facilities and seeking his own care, and stated he was aware of his needs and able to make decisions regarding his care and safety. Psychiatry/therapy notes from November 2025 indicated he was referred for depression, confusion, elopement, adjustment disorder, and high-risk behavior, and described him as an unreliable historian who did not remember attempting to elope, disoriented to situation, and endorsing cognitive impairment symptoms such as decreased concentration and forgetfulness. Interviews with staff and family revealed that the resident had a history of dementia, wore a medical bracelet listing dementia and stroke, had previously left the facility through the gate or fence, and that family sometimes learned of his departures from him or from hospitals or police. The RNC reported striking out the dementia diagnosis on 11/27/2025 after a high BIMS score and discussion with the MD, who confirmed he discontinued the dementia diagnosis based on the BIMS score and was not aware of the resident’s exit-seeking or elopement behaviors. Interviews with nursing staff, the DON, social worker, and the administrator clarified the facility’s internal reporting practices and the failure to report these elopements to the State. RN E stated that elopements were reportable to the State, that nurses did not report directly, and that the administrator was responsible for reporting. The previous social worker recalled the 11/26/2025 elopement, stating that facility staff notified the administrator that the resident was not in the facility, and she then located him at a local hospital and contacted the family. The DON stated that staff reported incidents to her and the administrator, and that the administrator was responsible for deciding if an incident was reportable to the State, emphasizing that reporting was important for regulatory compliance and resident safety. The administrator stated that he was responsible for reporting incidents, that elopements without injury were to be reported within 24 hours, and that staff were to report to him immediately so he could investigate. He also asserted that the 11/02/2025 notes were not accurate, that there were no elopements, and that the resident was not an elopement risk because of a high BIMS score and lack of dementia. The facility’s Abuse Prevention and Prohibition Program policy required reporting allegations of abuse, neglect, exploitation, and other qualifying incidents, including neglect, to the state survey agency and other authorities within 2 hours if involving abuse or serious bodily injury, and within 24 hours if not, and specified that failure to file reports within required time frames could result in disciplinary action. Despite these policies and the documented elopement-related events, the facility did not immediately report the alleged neglect and actual elopements to the State Agency within the required 24-hour timeframe. The facility’s written policy designated the administrator as responsible for coordinating and implementing the abuse prevention program, including investigation and reporting of abuse, neglect, and related incidents. It specified that all mandated reporters must report reasonable suspicion of neglect and that the administrator would submit initial and follow-up written reports of investigations to appropriate agencies. Interviews with staff confirmed that they relied on the administrator to determine reportability and submit reports. However, in this case, the administrator did not report the resident’s elopement attempt and actual elopements as required, and instead disputed that elopements had occurred or that the resident was an elopement risk, despite documentation in progress notes, care plans, and interviews describing exit-seeking behavior, elopement episodes, and involvement of police and hospitals. This failure to follow the facility’s own abuse/neglect reporting policy and federal/state reporting requirements constituted the cited deficiency.
Failure to Maintain Comprehensive Care Plan for Dementia and Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables to address a resident’s medical, nursing, mental, and psychosocial needs, specifically related to dementia and elopement risk. The resident was an older male with diagnoses including cerebral infarction and osteoarthritis, and his admission MDS documented non-Alzheimer’s dementia and a BIMS score indicating intact cognition at that time. Despite this, on a later date the Resident Assessment Coordinator (RNC) struck out dementia as a primary diagnosis from the medical record and it no longer appeared on the face sheet, based on the resident’s high BIMS score and nursing assessments, without documenting the rationale or the conversation with the MD. The MD confirmed he discontinued the dementia diagnosis after being informed of the BIMS score, and he was not aware of the resident’s exit-seeking or elopement behaviors. The resident’s care plan initially included problems for impaired cognitive function/dementia, use of psychotropic medication (Donepezil) for dementia, and risk for elopement related to an elopement evaluation risk score. However, the most recent care plan revision did not include the resident’s elopement attempt and actual elopements that occurred on multiple dates. Instead, the revised care plan described the resident as a potential safety risk when leaving the facility, referenced his history of leaving facilities independently, and emphasized his autonomy and independent decision-making, citing a BIMS score of 13 and his pattern of self-checking into hospitals. The care plan continued to list impaired cognitive function/dementia and dementia medication, even though the dementia diagnosis had been removed from the medical record, and it did not incorporate the documented episodes of exit-seeking, aggression, and involvement of police. Elopement risk evaluations for the resident were inconsistently completed and contained discrepancies. An evaluation on one date identified the resident as a moderate elopement risk, cognitively impaired and able to ambulate or propel himself, while later evaluations marked him as no risk and either unable or able to make decisions and ambulate, with only the “No Risk” section completed. Questions that would have evaluated him as moderate or imminent risk were triggered but left incomplete, preventing the electronic system from classifying him appropriately. Progress notes documented that security called nursing when the resident attempted to leave through the gate, that he had two episodes of elopement with aggressive behavior and statements about wanting to leave, and that he later left the facility and independently checked into a local hospital. Staff interviews confirmed awareness of his unsafe status to be out alone and acknowledged that care plans are the guide for care and must be updated with changes in condition, yet the resident’s care plan was not revised to reflect his dementia diagnosis status, his ongoing dementia medication, or his repeated elopement attempts and actual elopements. Facility policy required the IDT to develop a culturally competent, trauma-informed, comprehensive person-centered care plan with measurable objectives and timetables, to be completed and periodically reviewed and revised with each assessment and with changes in condition, behavior, or care. The policy also specified that the care plan must describe services to meet the resident’s highest practicable well-being and be revised for changes in behavior and care. Interviews with the DON and Administrator confirmed that admitting nurses initiate care plans, the MDS nurse and nursing leadership are responsible for updates, and that failure to keep care plans current poses a risk because staff may miss needed care. Despite these requirements and acknowledgments, the resident’s care plan and elopement risk tools were not accurately or fully updated to reflect his dementia-related diagnosis history, his use of dementia medication, and his documented exit-seeking and elopement events.
Inaccurate Dementia Diagnosis Documentation and Mismanaged Elopement Risk Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, accessible, and systematically organized medical records for a male resident with a history of cerebral infarction, osteoarthritis, schizophrenia, depression, anxiety, and documented dementia. The resident’s admission MDS showed a BIMS score of 13 (cognitively intact) with an active diagnosis of non‑Alzheimer’s dementia and no wandering behaviors. His clinical history and a Mental Illness/Dementia Resident Review signed by the MD indicated a dementia diagnosis, and the MD attested on 11/11/2025 that the resident had a primary or dementia diagnosis. The care plan initiated in October and revised in late November documented impaired cognitive function/dementia, use of Donepezil for dementia, and psychiatric diagnoses, as well as risk for falls and safety concerns related to leaving the facility without notice. Despite these records, on 11/27/2025 the RNC struck out dementia as a primary diagnosis from the resident’s medical diagnoses, and the diagnosis no longer appeared on the face sheet. The RNC reported she discontinued the dementia diagnosis based on the resident’s high BIMS score and nursing assessments, after a verbal conversation with the MD, but she did not document this conversation or any justification for changing the medical record. The MD confirmed he approved discontinuation of the dementia diagnosis after being informed of the BIMS score, but he was not aware of the resident’s exit‑seeking behaviors or elopements, and there was no documentation of those behaviors in his or his NP’s notes. At the same time, the resident continued to be care planned and medicated for dementia, and psychiatric notes documented cognitive impairment symptoms, including decreased concentration, forgetfulness, difficulties with ADLs, disorientation to situation, and unreliable history. The facility also failed to accurately and consistently complete and document the resident’s elopement risk evaluations. Progress notes described multiple episodes of exit‑seeking and elopement, including the resident going to the facility gate wanting to go home, two elopement episodes leading to transfer to a psychiatric hospital with police involvement, and an incident where he independently left and checked himself into a local hospital. Staff interviews (LVN, RN, previous SW) described the resident as an elopement risk, with behaviors such as exit‑seeking, frequent talk of leaving, digging under the fence, and requiring 1:1 monitoring. However, elopement risk evaluations on 11/02/2025 and 11/27/2025 were locked as “No Risk,” and staff only completed the “No Risk” section despite triggers for moderate or imminent risk. These evaluations contained internal discrepancies regarding the resident’s ability to make decisions and ambulate, and the care plan revised on 11/27/2025 did not reflect the documented elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/27/2025. The DON and ADM acknowledged the importance of accurate records and documentation of physician notifications and elopements, but the facility’s records for this resident remained inconsistent with his diagnoses, behaviors, and treatment. The facility’s own Medical Record Content policy required accurate, timely, and complete records that support diagnoses, justify medical necessity, and facilitate continuity of care, including consistent assessments and progress notes aligned with care plans and documented physician notifications and orders. In this case, there was no documentation of the physician order or rationale to discontinue the dementia diagnosis, no integration of the PASRR/MD‑signed dementia attestation into the record review, and incomplete elopement risk assessments that did not match the resident’s documented behaviors and staff observations. These inconsistencies resulted in a medical record that did not accurately reflect the resident’s active diagnoses, dementia treatment, or elopement risk status as required by facility policy and accepted professional standards. The DON stated that residents with high BIMS scores or who could make decisions were not considered elopement risks, and that if a resident had dementia but could make decisions, they were not an elopement risk. This view contrasted with other staff who identified the resident as an elopement risk regardless of his BIMS score. The administrator also stated that the resident was not an elopement risk because of his high BIMS score and lack of dementia, and he asserted that certain nursing notes about elopement were not accurate. These differing interpretations and the lack of consistent documentation contributed to the inaccurate and incomplete medical record for the resident, including the discrepancy between the discontinued dementia diagnosis and ongoing dementia‑related care and medications, as well as the under‑documented and misclassified elopement risk.
Unsecured Medication Found in Resident Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and accessible only to authorized personnel, as required by state and federal regulations. During an observation, a nasal spray was found on top of a resident's side table in plain view. The resident, who was cognitively intact and had a terminal prognosis related to hepatic malignancy, reported that the nasal spray was obtained during a prior hospital admission and had remained on his side table. Record review confirmed there was no physician order for the nasal spray, no assessment for self-administration, and no documentation indicating the resident was permitted to self-administer medications. Interviews with nursing staff and facility leadership confirmed that medications should not be kept in residents' rooms unless there is a documented assessment and order for self-administration. Staff acknowledged that the presence of the nasal spray in the resident's room was not noticed during routine rounds, and there was no indication that the medication had been brought in by family or authorized for use. The facility's policy requires that medications be stored securely and only accessible to licensed nursing or authorized personnel, which was not followed in this instance.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required partial to moderate assistance with personal hygiene was observed to have fingernails that were approximately 0.5 cm in length, chipped, discolored, and with dark brown residue underneath. The resident expressed a desire to have his fingernails trimmed and cleaned. Record review indicated the resident had a history of lack of coordination, unsteadiness, muscle weakness, and moderately impaired cognition. The care plan specified that the resident needed extensive assistance with personal hygiene, including nail care. Interviews with staff revealed that both CNAs and nurses were responsible for ensuring residents' fingernails were cleaned and trimmed, with CNAs permitted to trim nails for non-diabetic residents. Staff acknowledged that the resident's nails needed attention and confirmed that nail care should be performed as needed and observed daily. Facility policy also required nail care to maintain cleanliness and proper trimming. Despite these protocols, the resident's fingernails were not maintained, resulting in a failure to provide necessary services for activities of daily living.
Inadequate Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A, who did not perform hand hygiene after direct contact with residents while serving meals. This deficiency was observed during a survey where CNA A interacted with eight residents, including those with various medical conditions such as schizoaffective disorder, hypertension, Parkinson's disease, and diabetes. Despite having been provided with hand sanitizer and having received training on hand hygiene, CNA A neglected to sanitize her hands between serving meal trays to different residents. During the observations, CNA A was seen entering multiple residents' rooms, setting up breakfast trays, and making physical contact with residents without washing her hands or using hand sanitizer. This occurred repeatedly as she moved from one resident to another, increasing the risk of cross-contamination and infection among the residents. The residents involved had varying levels of cognitive impairment and required assistance with activities of daily living, making them particularly vulnerable to infections. Interviews with CNA A and the Director of Nursing (DON) revealed that CNA A was aware of the hand hygiene protocols but failed to adhere to them due to time constraints and the desire to serve meals promptly. The DON confirmed that staff were trained to use hand sanitizer between each tray service and acknowledged the potential for germ spread if proper hygiene practices were not followed. Despite previous in-service training sessions on hand hygiene, the facility's policy was not effectively implemented by CNA A during the meal service.
Verbal Abuse Incident Involving Resident and Staff Member
Penalty
Summary
The facility failed to ensure the right to be free from abuse for a resident, identified as Resident #36, who was subjected to verbal abuse by a staff member. On March 7, 2024, Hospitality Aide B called Resident #36 'trash' and used profanity during an interaction. This incident was reported by Resident #36, who has a history of anxiety, depression, and schizophrenia, but was assessed with no cognitive impairment as per his BIMS score of 15. The resident expressed that the incident made him mad but did not cause him harm. Hospitality Aide B admitted to calling the resident 'trash' after an altercation where she felt provoked by the resident's comments. Witness statements from two other residents confirmed the aide's use of derogatory language. The aide justified her actions by claiming that the resident was verbally abusive towards her, but acknowledged that her response could be considered abuse. The facility's policy on abuse prevention clearly states that residents have the right to be free from mistreatment, including verbal abuse. Despite this policy, the incident occurred, highlighting a lapse in adherence to the facility's standards for resident treatment. The Director of Nursing (DON) and Administrator (ADM) were involved in addressing the situation, with the DON noting that the aide's actions were dismissed as insignificant due to the resident's cognitive status, which was a misjudgment of the potential impact of verbal abuse.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the residents' status for two residents. Resident #1's discharge and quarterly MDS assessments did not address critical sections such as BIMS, Mood, Behaviors, and Pain, which were necessary to reflect his current medical orders for pain management. Additionally, Resident #1 had a history of schizophrenia and substance abuse, which were not adequately addressed in the assessments. The MDS assessments were completed by the MDSC and approved by the DON, but they failed to capture the resident's cognitive and behavioral status accurately. Resident #3's admission and discharge MDS assessments also contained significant omissions. The assessments did not address her medical diagnoses of anxiety and depression, nor did they reflect her use of a Central PICC line catheter and other treatments such as oxygen therapy and IV medications. Despite having a BIMS score indicating cognitive intactness, the assessments failed to document her active diagnoses and special treatments, which were crucial for her care. The MDS assessments were completed by LVN R, but they did not accurately capture the resident's medical and treatment needs. Interviews with facility staff, including the MDSC, ADON, SW, and DON, revealed a lack of accountability and responsibility in ensuring the accuracy of the MDS assessments. The staff acknowledged that inaccurate assessments could lead to a decline in resident care. The facility's policy on the RAI process emphasized the need for accurate assessments, but the deficiencies in the MDS assessments for Residents #1 and #3 highlighted a failure to adhere to these guidelines.
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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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