Briarcliff Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcallen, Texas.
- Location
- 3201 N Ware Rd, Mcallen, Texas 78501
- CMS Provider Number
- 675162
- Inspections on file
- 32
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Briarcliff Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, diabetes, prior stroke, heart disease, and a documented DNR status in the care plan and physician orders had an OOH-DNR form that was not fully executed because the attending physician had not signed the required sections. The social worker obtained the family’s signature and forwarded the form per facility practice, and another staff member reported emailing the physician for signature, but the physician’s signature was delayed and remained missing at the time of review. This was inconsistent with the facility’s policy and the OOH-DNR instructions, which require the attending physician to sign and document the order in the medical record.
Surveyors found that two residents with dementia-related diagnoses were routinely given antipsychotic medications (including Lurasidone, Haldol Decanoate, and Seroquel) based on orders citing unspecified psychosis, without adequate indication documented in the clinical record. Care plans and MARs showed ongoing use of these psychotropics with black box warnings, while the facility’s own policy required that such drugs be used only for clearly diagnosed and documented conditions and not as chemical restraints. In interviews, a MHNP defended broad antipsychotic use in dementia, an LVN acknowledged limited understanding of appropriate indications and reliance on provider orders and consents, and the DON confirmed that psychosis is not an appropriate indication for antipsychotics in residents with Alzheimer’s or dementia but stated staff still administered medications even when indications were inappropriate.
Multiple residents with severe cognitive and behavioral impairments engaged in physical altercations, resulting in injuries such as lacerations and abrasions. Despite known risks and care plans addressing wandering and aggression, staff did not consistently prevent residents from entering others' rooms or intervening before altercations occurred. There was also inconsistency in recognizing and reporting these incidents as abuse.
The facility did not report a resident-to-resident altercation resulting in minor injuries to local law enforcement and failed to report an allegation of staff-to-resident verbal abuse within the required two-hour timeframe. In both cases, staff either did not recognize the incidents as reportable or assumed others would report them, leading to delays in notifying authorities as required by facility policy and regulations.
A resident with severe cognitive impairment and urinary issues exhibited behaviors of urinating in inappropriate areas, such as trash cans and the floor, over several months. Despite staff awareness and evidence of the behavior, the care plan did not document these behaviors or interventions until after surveyor inquiry. This omission resulted from a lack of timely updates and communication among the interdisciplinary team, contrary to facility policy and training requirements.
A CNA slapped a resident with severe cognitive impairment and a history of aggression after the resident became agitated and struck the CNA during care. The incident was witnessed by staff, confirmed through investigation, and determined to be abuse, placing the resident in Immediate Jeopardy.
Three residents were found to have bathroom sinks with hot water temperatures exceeding the required range, with readings as high as 124°F, while a shower bed used for bathing was observed to have frayed mesh and visible residue. Staff interviews revealed that water temperature checks were performed randomly and documented weekly, but did not identify the elevated temperatures in these rooms. The shower bed's poor condition had not been reported by staff prior to the surveyor's findings.
Two residents did not have comprehensive, person-centered care plans that addressed their specific needs. One resident with severe cognitive impairment required total assistance with feeding, but this was not reflected in her care plan. Another resident with advanced dementia and PTSD did not have identifiable triggers for PTSD documented in his care plan, nor a statement indicating the absence of such triggers. Staff interviews and record reviews confirmed these omissions, resulting in care plans that were not consistent with the residents' current needs.
A resident with moderate cognitive impairment and a need for assistance with personal care was found to have a disposable razor on his sink and a bag of new razors in his dresser drawer, despite facility policy requiring razors to be kept under lock and key. Staff interviews revealed a lack of awareness and adherence to the protocol regarding sharps, resulting in the resident having unsupervised access to razors.
A resident with severe cognitive impairment and multiple comorbidities was receiving oxygen therapy via nasal cannula, but staff failed to post the required oxygen sign on the door to indicate oxygen was in use. Nursing staff acknowledged responsibility for posting the sign and confirmed it was not done due to oversight, despite facility policy and professional standards requiring such signage for safety.
Staff failed to follow infection prevention protocols during care for two residents, including an LVN who did not sanitize hands after touching potentially contaminated surfaces before administering G-tube medications, and a CNA who did not change gloves or perform hand hygiene between catheter care and cleaning a bowel movement. Both staff acknowledged the lapses, and facility policies required proper hand hygiene and glove use.
A resident with cerebral infarction and aphasia reported being hit by nephews while on a pass, but the CNA failed to report the allegation immediately. The delay in reporting violated the facility's protocols, placing the resident in Immediate Jeopardy. Despite training on abuse reporting, the CNA only informed the facility upon returning to work, leading to a police investigation that found no crime.
A CNA in a long-term care facility verbally abused a resident by using a derogatory term in Spanish during a greeting. The resident, who had a history of dementia and was non-verbal, was unable to express if she was offended. The CNA admitted to using the term in a joking manner, but the facility's policy defines such language as verbal abuse.
The facility failed to accurately document significant health events in the MDS for two residents. One resident's fall was not recorded, and another resident's unstageable pressure ulcer was omitted from the discharge MDS. Staff acknowledged these oversights, noting that the MDS was primarily used for billing, while care plans were updated through other assessments. The discrepancies did not have immediate negative outcomes, but could affect communication if residents were transferred.
The facility failed to adhere to physician's orders for oxygen therapy for two residents, leading to incorrect oxygen settings. One resident with COPD had oxygen set at 3 liters per minute instead of the prescribed 2 liters, while another with hypoxia had it set at 1.5 liters per minute. Staff interviews revealed a lack of adherence to orders and absence of a specific policy on oxygen administration.
A resident on anticoagulant therapy experienced a fall, but the facility failed to accurately document the medication and neurological checks. LVN inaccurately noted the resident was not on an anticoagulant, and inconsistent neurological findings were not reported to the NP. The DON acknowledged the documentation errors and potential negative outcomes.
The facility failed to document the risk of elopement and secure unit placement in the care plans of three residents with severe cognitive impairments. Despite being placed in a secure unit due to their conditions, the care plans did not reflect these risks, potentially leading to inadequate care. Errors in completing a new wandering evaluation form led to the resolution of these care plans, removing critical information about the residents' needs.
The facility's pest control program was ineffective, leading to a roach infestation in resident rooms, hallways, and the dining room. Despite monthly pest control services and staff efforts to document and address sightings, roaches were frequently observed alive. Delays in pest control services and insufficient fumigation contributed to the ongoing issue, with residents and staff expressing concerns about the pest presence.
A resident with severe cognitive impairment and diabetes did not receive necessary podiatry services, resulting in overgrown toenails. Despite having an order for podiatry care, the resident was not added to the podiatrist's list, and staff were unaware of the issue until it was highlighted by an investigator. The facility lacked a specific foot care policy, leading to a deficiency in maintaining the resident's foot health.
Failure to Obtain Physician Signature on OOH-DNR for a Resident with DNR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order was properly completed in accordance with the resident’s advance directive and the facility’s own policy. The resident was an elderly female with dementia, Type 2 diabetes mellitus, orthopedic aftercare following a nondisplaced fracture of the left femur, cerebral infarction affecting the right dominant side, and heart disease. Her Quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment. Her comprehensive care plan documented an advanced directive with a DNR code status, including interventions such as ensuring a signed DNR in the medical record, not calling 911 or initiating CPR in the event of cardiac arrest, keeping the resident comfortable, sending a copy of DNR paperwork upon transfer, and consulting social services if the family wished to change code status. The physician’s orders also reflected a DNR status. Record review of the resident’s OOH-DNR form showed that it had been executed by the resident’s adult child as a qualified relative in Section C, but the attending physician had not signed in Section E (Physician’s Statement) or Section F (acknowledgment that the document was properly completed). The OOH-DNR instructions specified that the attending physician must document the existence of the order in the medical record and sign the appropriate sections of the form, along with the required witnesses. Despite the care plan directive to ensure a signed DNR in the medical record, the physician’s signature was missing from the OOH-DNR form at the time of the survey. Interviews with staff clarified the internal process and where it broke down. The social worker stated she was responsible for reviewing advance directives with the family, obtaining the family’s signature, and then giving the OOH-DNR to another staff member, who was responsible for obtaining the physician’s signature. That staff member reported that the social worker would scan OOH-DNRs to her, and she would email the physician for signature, and that the physician typically signed within a day or two; she stated that in this case the physician’s signature was delayed by the physician’s office. The DON acknowledged that the resident’s DNR had been care planned and ordered, but the OOH-DNR form itself had not been signed by the physician as required, despite the facility’s policy to support and facilitate residents’ rights to formulate and implement advance directives and to place copies of existing directives in the chart and communicate them to staff.
Inadequate Indications for Antipsychotic Use and Chemical Restraint Concerns
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from chemical restraints and unnecessary psychotropic medications, specifically antipsychotics with black box warnings, for two residents reviewed. For one resident with dementia, Alzheimer’s disease, hypertension, and Type 2 diabetes, the facility administered Lurasidone 40 mg daily based on a physician order that cited “unspecified psychosis not due to a substance or known physiological condition (F29)” as the indication. The resident’s care plan documented use of antipsychotic medications for mood disorder and psychosis and included monitoring for adverse reactions and black box warnings, but the record did not show an adequate indication for the use of Lurasidone in the context of dementia-related psychosis. The medication was administered routinely over several days as reflected on the MAR. For another resident with early-onset Alzheimer’s disease, heart disease, Type 2 diabetes, hypertension, bipolar disorder with psychotic features, intermittent explosive disorder, mood disorder due to a known physiological condition, and unspecified intellectual disabilities, the facility administered two antipsychotics—Haldol Decanoate and Seroquel—without an adequate indication documented in relation to dementia. The care plan identified the use of Seroquel and Haldol for psychosis with targeted behaviors of agitation, yelling, and grabbing at others. Physician orders directed monthly intramuscular injections of Haldol Decanoate 50 mg and oral Seroquel 300 mg tablets, initially two tablets at bedtime and later one tablet daily in the morning, all tied to a diagnosis of unspecified psychosis (F29). MARs showed consistent administration of these medications over multiple months. The orders and associated black box warnings noted increased mortality in elderly patients with dementia-related psychosis, yet the indication remained psychosis in residents with dementia diagnoses. Interviews with facility staff and prescribers further illustrated the circumstances leading to the deficiency. A mental health nurse practitioner stated that psychosis was a proper diagnosis for many dementia residents and asserted that more than half of dementia residents in nursing homes are psychotic and need antipsychotics, expressing disagreement with CMS concerns about antipsychotic use and black box warnings. An LVN reported that staff called the provider for behaviors such as crawling on the floor, yelling, aggression, or agitation, and that the provider would order medication; he acknowledged sometimes needing to ask for the indication and stated he did not know that psychosis was not an appropriate indication for an antipsychotic in residents with dementia or Alzheimer’s, adding that nurses followed provider orders as long as consents were signed. The DON confirmed there were numerous active antipsychotic orders, acknowledged that psychosis was not an appropriate indication for antipsychotic use in residents with Alzheimer’s or dementia, and stated that when a doctor or NP wrote an order, staff could not refuse to give the medication even if the indication was inappropriate. The facility’s own psychotropic drug use policy required that psychotropics be used only to treat specific, diagnosed, and documented conditions and not as chemical restraints, underscoring the discrepancy between policy and practice in these cases. The facility’s policy on psychotropic drug use defined chemical restraint as any drug used for discipline or staff convenience and not required to treat medical symptoms, and emphasized that psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and when a practitioner determines the medication is appropriate for a specific, diagnosed, and documented condition. Despite this, the records for the two residents showed routine administration of antipsychotics with black box warnings based on indications of unspecified psychosis in the presence of dementia diagnoses, without adequate documentation that the medications were necessary to treat clearly defined medical symptoms as required by the policy. This mismatch between documented indications, resident diagnoses, and policy requirements formed the basis of the cited deficiency.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injuries
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, resulting in multiple resident-to-resident altercations involving five residents. Several incidents occurred where residents with severe cognitive impairments and behavioral issues engaged in physical altercations, leading to injuries such as facial lacerations, abrasions, and scratches. For example, one resident with Alzheimer's disease and severe cognitive impairment wandered into another resident's room, resulting in a physical confrontation where both parties sustained injuries. Another incident involved two residents in a hallway altercation, where one attempted to grab the other, leading to a physical response that caused further injury. The residents involved had significant medical and behavioral histories, including diagnoses of Alzheimer's disease, dementia, mood disorders, and psychosis. Many required extensive assistance with activities of daily living and exhibited behaviors such as wandering, aggression, and rejection of care. Despite these known risks, the facility did not consistently prevent residents from entering others' rooms or from coming into close contact in common areas, which contributed to the altercations. Staff interviews confirmed that some residents were known to wander and had a history of confusion regarding room locations, yet interventions to prevent these interactions were not always effective or timely. Documentation and interviews revealed that staff were aware of the behavioral risks and had care plans in place, but these interventions did not prevent the incidents from occurring. In some cases, staff were not able to intervene before physical contact was made, and there was inconsistency in reporting incidents to local authorities. The facility's approach to determining whether an incident constituted abuse varied, with some staff not initially recognizing resident-to-resident altercations as abuse. This lack of consistent prevention and recognition of abuse led to multiple residents sustaining injuries as a result of altercations.
Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, or exploitation, as required by regulations. Specifically, the facility did not report a resident-to-resident physical altercation to local law enforcement, nor did it report an allegation of staff-to-resident verbal abuse within the mandated two-hour timeframe. These failures were identified through interviews and record reviews for two residents out of ten reviewed for abuse/neglect reporting. In the first incident, a male resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in a physical altercation with another male resident who had moderate cognitive impairment. The altercation resulted in minor injuries, including discoloration to the hands and an abrasion to the chin. Although the incident was documented and the residents were monitored, the Assistant Director of Nursing (ADON) did not report the event to local authorities, stating she did not consider it abuse due to both residents' mental illnesses and the belief that the act was not willful. There was no evidence or case number to show that the incident had been reported as required. In the second incident, a female resident with intact cognition and hemiplegia was subjected to inappropriate comments by a nursing assistant, including remarks about her weight and sexual orientation. The certified nursing assistant who witnessed the event did not report it immediately, assuming another staff member present would do so. The Director of Nursing and Administrator confirmed that the incident was not reported to the state agency until several days later, after the ombudsman became involved. The facility's policy requires immediate reporting of all alleged violations, but this protocol was not followed in these cases.
Failure to Include Resident Behaviors in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for a resident with severe cognitive impairment and multiple medical diagnoses, including vascular dementia and urinary retention. Specifically, the care plan did not include documentation or interventions related to the resident's behavior of urinating in inappropriate areas, such as trash cans or the floor, despite evidence of this behavior occurring over a period of approximately six months. The omission was identified during a review of the resident's records and interviews with facility staff, who acknowledged awareness of the behavior but had not ensured it was reflected in the care plan. Interviews with the DON, SW, and ADON revealed that although the behavior had been discussed among leadership and was known to staff, it was not documented in the care plan until after the surveyor's inquiry. The DON confirmed that the behavior should have been included to ensure all staff were aware and could implement appropriate interventions, and that the facility's policy required care plans to be updated as needed to reflect changes in resident behavior. The ADON and SW also indicated that the behavior had not been reported or observed directly, but evidence such as urine in trash cans and odor was present, and the issue had been discussed in meetings. The facility's policy and in-service training required comprehensive care plans to describe all services necessary to maintain the resident's highest practicable well-being, including behavioral interventions. However, the failure to update the care plan as required resulted in a lack of communication among staff regarding the resident's behaviors and the necessary interventions, as confirmed by staff interviews and record reviews.
Resident Slapped by CNA Following Agitation and Aggression
Penalty
Summary
A certified nursing assistant (CNA) failed to ensure a resident's right to be free from abuse when she slapped a resident on the face. The incident occurred while two CNAs were attempting to provide care to a resident with severe cognitive impairment, Alzheimer's disease, and a history of physical aggression and agitation. During the care attempt, the resident became agitated and struck the CNA, who then responded by slapping the resident in return. This act was witnessed by another CNA and a registered nurse (RN), who immediately intervened. The resident involved was an elderly female with diagnoses including Alzheimer's disease, cognitive communication deficit, and dementia, requiring moderate assistance with all activities of daily living and exhibiting daily wandering behavior. At the time of the incident, the resident was severely cognitively impaired, as indicated by a BIMS score of 00, and had a documented history of combative behavior toward staff and other residents. The incident was confirmed through interviews, written statements, and review of the facility's incident report, which documented the abuse. The facility's investigation confirmed that the CNA's action constituted abuse. The event was witnessed by staff, and the CNA involved admitted in a written statement to having hit the resident in response to being struck. The incident was reported to the facility administration and was determined to have placed the resident in an Immediate Jeopardy situation.
Removal Plan
- Resident #101 was immediately protected by RN J, who separated Resident #101 and CNA H, instructed CNA H to exit the memory unit and report to the Administrator's office, performed a head-to-toe assessment for any physical injuries, and reported the incident to the Administrator.
- CNA H was immediately removed from the facility, suspended, and terminated.
- A head-to-toe assessment was conducted on Resident #101, revealing no physical harm, pain, or mental anguish.
- The facility's social worker assessed Resident #101 for signs of psychosocial harm and referred Resident #101 for counseling evaluation.
- Staff were in-serviced on the topics of Dealing with challenging residents and Abuse Prohibition Policy.
- All residents in the memory unit were interviewed and observed for abuse with no concerns mentioned.
- Staff in the memory unit were interviewed and all were familiar with the facility's protocol when dealing with residents with cognitive impairment and aggressive behaviors and abuse prohibition policy.
Failure to Maintain Safe Water Temperatures and Shower Bed Condition
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for three residents and one shower bed, as evidenced by observations of excessively high hot water temperatures in resident bathroom sinks and a shower bed in poor condition. During an observation, the hot water temperatures in the bathroom sinks of three occupied rooms were found to be above the facility's required range, with readings of 124, 118, and 116 degrees Fahrenheit. The maintenance director and assistant confirmed that water temperatures are checked daily in one room per hall and documented, but the process did not identify or address the elevated temperatures in these specific rooms. The facility's logs showed that temperatures were generally within range, but the specific rooms in question were not flagged prior to the surveyor's findings. The residents affected included individuals with severe cognitive impairment and limited mobility, as well as a resident with intact cognition but requiring assistance with personal care. Interviews with these residents revealed that they used the sinks regularly but had not sustained burns. Staff interviews indicated that the maintenance team relied on random daily checks and weekly documentation, with alerts set for out-of-range temperatures. However, the system did not prevent the occurrence of excessively hot water in the rooms observed by surveyors. Additionally, the facility failed to ensure that the shower bed in one hall was in good condition. The shower bed was observed to have a white and black film, frayed and worn mesh, and water residue. Staff, including the Central Supply Director and DON, acknowledged the poor condition of the shower bed upon inspection, noting that it needed to be sanitized or replaced. The CNA responsible for using the shower bed stated she had not noticed the need for repair but was trained to report such issues. The facility did not have a policy related to shower beds, and no staff had reported the condition prior to the surveyor's observation.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy. For one resident, an elderly female with diagnoses including vascular dementia and Alzheimer's disease, the care plan did not address her need for assistance with feeding. Despite documentation and staff interviews confirming that she required total assistance with feeding at all meals due to severe cognitive impairment, her care plan was not updated to reflect this need. Staff members, including CNAs and nurses, were aware of her dependency but the MDS nurse and DON were not informed, resulting in the care plan lacking accurate and current interventions for feeding assistance. For another resident, an elderly male with multiple psychiatric and cognitive diagnoses including post-traumatic stress disorder (PTSD), bipolar disorder, and advanced dementia, the care plan did not address identifiable triggers for his PTSD. Although the resident had a history of behavioral issues and a complex psychiatric background, staff interviews and record reviews indicated that no specific triggers had been identified or documented in his care plan. The care plan lacked a statement regarding the absence of identifiable triggers, despite staff monitoring his behaviors and acknowledging his advanced dementia and inability to communicate. Observations and interviews with staff revealed gaps in communication and documentation regarding both residents' needs. The facility's policy required care plans to include measurable objectives and timeframes based on comprehensive assessments, but these requirements were not met for the two residents. The lack of accurate and individualized care planning could result in residents not receiving necessary care or services tailored to their specific needs.
Failure to Secure Disposable Razors in Resident Room
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, epilepsy, and a need for assistance with personal care was found to have a disposable razor in his restroom and a bag of 18 new disposable razors in his dresser drawer. The resident, who required partial or moderate assistance for personal hygiene due to weakness, history of spinal fractures, and poor balance, stated that he sometimes preferred to shave himself and that CNAs would provide him with a new disposable razor from his drawer when he wished to shave. During observation, a disposable razor was found on the resident's sink, and staff interviews revealed uncertainty about who placed it there and a lack of awareness of the facility's protocol regarding sharps. Further interviews with CNAs and nursing staff confirmed that facility policy required razors to be kept under lock and key in the shower room or medication cart, and that residents were not permitted to keep razors in their rooms. Despite this, the resident had access to multiple razors in his room, and staff were unaware of their presence. The DON and RN both acknowledged that the presence of razors in resident rooms was against facility policy and could result in harm if not properly controlled.
Failure to Post Oxygen Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of acute and chronic respiratory failure, congestive heart failure, hypertension, hyperlipidemia, peripheral vascular disease, and type 2 diabetes mellitus was not provided with appropriate respiratory care signage. The resident, who was severely cognitively impaired, had an active order for oxygen therapy via nasal cannula at 2 liters per minute as needed for hypoxia. During observation, the resident was found receiving oxygen therapy, but there was no oxygen sign posted on the outside of the resident's door or doorframe to indicate oxygen was in use in the room. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that it was the responsibility of nursing staff to post the oxygen sign as soon as possible after receiving the oxygen order. The LVN acknowledged forgetting to post the sign due to being busy, and both the ADON and DON emphasized the importance of the sign for alerting staff and for safety reasons. Review of facility policy and professional standards also indicated the need to post no smoking signs when oxygen is in use.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene and glove use by staff during resident care. In one instance, an LVN washed her hands before administering G-tube medications to a female resident with a history of cerebral infarction, dysphagia, and diabetes, but then touched the privacy curtain and bed remote before donning gloves and proceeding with medication administration without sanitizing her hands. The LVN acknowledged the importance of hand hygiene, especially given the resident's G-tube as a potential entry point for infection, but did not follow proper protocol after touching potentially contaminated surfaces. In another case, a CNA provided catheter care to a male resident with chronic kidney disease and an indwelling urinary catheter. After performing initial hand hygiene and donning gloves, the CNA completed catheter care and then, without changing gloves or performing hand hygiene, proceeded to clean a bowel movement and apply a clean brief. The CNA later recognized that gloves should have been changed and hand hygiene performed between these tasks to minimize infection risk, and the DON confirmed that this was the expected standard of care. Record reviews confirmed that the facility's policies required staff to perform hand hygiene in accordance with established procedures and to adhere to standard precautions during resident care. Both staff members involved acknowledged their lapses in following these protocols during interviews, and facility leadership reiterated the importance of proper hand hygiene and glove use as outlined in their infection prevention policies.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, specifically in the case of a resident who was reviewed for abuse. The incident involved a resident who had been admitted with diagnoses including cerebral infarction, aphasia, and mild intellectual disabilities. The resident reported to a CNA that she had been hit by her nephews while out on a pass with her sister. However, the CNA did not report this allegation immediately, as required by the facility's policies. The CNA, who was responsible for the resident's care, did not communicate the resident's allegation of abuse to the appropriate authorities or facility staff in a timely manner. The CNA stated that she was busy and forgot to report the incident, and she was off work following the day of the incident. It was only upon her return to work that she reported the allegation to a nurse, who then informed the facility's Social Services and Administrator. This delay in reporting the allegation of abuse was a significant failure in the facility's duty to protect the resident from potential harm. Interviews with facility staff, including the Social Services, LVN, DON, and Administrator, revealed that the facility had protocols in place for reporting abuse, but the CNA did not follow these procedures. The facility had conducted training on abuse, neglect, and exploitation, emphasizing the importance of immediate reporting. Despite these measures, the CNA's failure to report the allegation promptly placed the resident in an Immediate Jeopardy situation, although no crime was discovered upon investigation by the police.
Verbal Abuse Incident Involving CNA
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who verbally abused a resident. The CNA referred to the resident using a derogatory term in Spanish, which translates to 'my stupid pretty,' during a greeting. This incident was reported anonymously to the facility's compliance line, prompting an investigation. The resident involved in the incident was a female with a history of vascular dementia, Parkinson's disease, major depressive disorder, and schizophrenia. She was non-verbal and rarely understood others, as indicated by her quarterly MDS assessment. During an observation, the resident was seen lying in bed, listening to the radio, and not responding to questions, showing no facial expression. The investigation revealed that the CNA admitted to using the derogatory term in a joking and loving manner, believing it was well-received by the resident. However, the facility's policy defines verbal abuse as the use of disparaging and derogatory terms, regardless of the resident's ability to comprehend. The CNA's behavior was deemed inappropriate, and the facility confirmed the allegations of abuse.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care documentation. Resident #4, a male with a history of intervertebral disc disorders, Alzheimer's disease, muscle wasting, and osteoporosis, experienced a fall on 2/28/24. However, this fall was not recorded in the Minimum Data Set (MDS) assessment, which inaccurately reflected zero falls since admission. The MDS coordinator acknowledged the oversight, stating that the fall should have been documented, although it did not affect the resident's care plan or payment level. The Director of Nursing (DON) noted that the MDS was not the primary driver for care plans, but acknowledged that missing information could impact communication if the resident was transferred to another facility. Resident #6, who was admitted with chronic kidney disease, acute pulmonary edema, and vascular dementia, had an unstageable pressure ulcer on the sacrum that was not documented in the discharge MDS. The MDS/LVN responsible for the assessment admitted to omitting this information, explaining that the MDS was primarily used for billing purposes and that the care plan was updated based on other assessments. The DON confirmed the presence of the pressure ulcer, which was attributed to constant diarrhea and skin excoriation, and noted that the facility did not have a specific policy for MDS documentation. The report highlights the facility's failure to accurately document significant health events in the MDS, which could potentially affect resident care and communication between facilities. The discrepancies in the MDS assessments for both residents were acknowledged by the staff involved, but were not seen as having immediate negative outcomes due to the presence of other care planning processes.
Failure to Adhere to Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during a survey. Resident #2, diagnosed with chronic obstructive pulmonary disease (COPD), was found with her oxygen set at 3 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. Similarly, Resident #3, who has hypoxia, was observed with his oxygen set at 1.5 liters per minute instead of the prescribed 2 liters per minute. These discrepancies were noted during observations and confirmed through interviews with nursing staff, who acknowledged the deviations from the physician's orders. Interviews with the nursing staff, including an RN, LVN, ADON, and DON, revealed a lack of adherence to the physician's orders for oxygen settings. The RN admitted to noticing the incorrect settings since starting at the facility but was told by a training nurse that it was acceptable. The LVN and ADON confirmed that nurses were responsible for checking oxygen settings at the beginning and end of each shift, yet the facility lacked a specific policy on oxygen administration. The DON also confirmed the absence of a policy and emphasized the importance of following physician orders to prevent adverse reactions. The facility's medication reconciliation policy was reviewed, but it did not specifically address oxygen administration.
Inaccurate Documentation of Anticoagulant and Neurological Checks
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of anticoagulant medication and neurological checks following a fall. The resident, an elderly female with vascular dementia, hypertension, muscle wasting, and atrial fibrillation, was on anticoagulant therapy with Xarelto. However, LVN A inaccurately documented that the resident was not on an anticoagulant, which was contrary to the resident's care plan and medication administration records. Following an unwitnessed fall, LVN A documented the resident's neurological checks inaccurately, noting that the resident's pupils were not reactive to light initially, but later documented them as reactive. This inconsistency was not reported to the nurse practitioner, NP C, who stated that had she been informed of the resident being on an anticoagulant, she would have sent the resident to the emergency room for further evaluation. The documentation errors and lack of communication could have led to a failure in providing appropriate care. The Director of Nursing (DON) acknowledged the discrepancies in documentation and the potential negative outcomes due to poor documentation practices. The facility's policy requires accurate and timely documentation, which was not adhered to in this case. The DON admitted to not following up on the documentation regarding abnormal findings, which could have resulted in neurological damage to the resident.
Failure to Document Elopement Risks in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which did not include measurable objectives and timeframes to address their risk of elopement and wandering. These residents, all with severe cognitive impairments and diagnoses such as dementia and Alzheimer's, were placed in a secure unit due to their behaviors and conditions. However, their care plans did not reflect this placement or the associated risks, which could lead to inadequate care and services. Resident #2, a female with severe cognitive impairment and a history of wandering, was placed in a secure unit due to her dementia-related behaviors. Despite meeting the criteria for secure unit placement, her care plan did not document the risk of elopement or her secure unit status. Similarly, Resident #3, also with severe cognitive impairment and a history of wandering, was placed in the secure unit, but her care plan lacked documentation of her elopement risk and secure unit placement. Resident #10, with Alzheimer's and a history of exit-seeking behaviors, was also in the secure unit, but her care plan did not reflect her risk of wandering or her secure unit status. Interviews with facility staff, including CNAs, RNs, and administrative personnel, revealed that the care plans were not updated correctly due to errors in completing a new wandering evaluation form. This form, when filled out incorrectly, resolved the care plans, removing the documentation of the secure unit placement and elopement risks. Staff acknowledged the importance of having these interventions documented in the care plans to ensure that all staff members were aware of the residents' needs and how to care for them appropriately.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in multiple areas, including resident rooms, hallways, and the dining room. Interviews with residents and staff revealed that roaches were seen alive in various locations, and although some staff attempted to address the issue by killing the roaches and documenting sightings, the problem persisted. The pest control company was contracted to service the building monthly, but there were delays in service, and not all areas were fumigated as needed. Residents reported seeing roaches in their rooms and common areas, with some sightings occurring as recently as a week before the survey. Staff interviews indicated that while there was a process for logging pest sightings, there was uncertainty about the frequency of pest control visits and the effectiveness of the measures taken. Housekeeping staff cleaned daily, but the presence of food and crumbs in resident rooms contributed to the pest issue. The pest control program specifications outlined monthly services for interior and exterior areas, with emergency services available. However, the facility's documentation showed numerous pest sightings over several months, indicating that the pest control measures were insufficient to eradicate the problem. The lack of a comprehensive facility policy for pest control and reliance on a contracted company that did not always respond promptly contributed to the ongoing issue.
Failure to Provide Adequate Foot Care for Resident
Penalty
Summary
The facility failed to provide adequate foot care for a resident, leading to a deficiency in maintaining the resident's foot health. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including diabetes, had an order for podiatry services that was not fulfilled. Her toenails were observed to be overgrown, approximately an inch longer than the nailbed, indicating a lack of proper foot care. Despite having an order for podiatry services, there was no record of the resident being added to the podiatrist's visit list or consent being obtained for such services. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for podiatry services. The CNA assisting the resident with bathing and dressing was unaware of the resident's diabetic condition and had not noticed the overgrown toenails. Similarly, the LVN and other nursing staff did not observe the long toenails and were unsure about the podiatrist's schedule or whether the resident had been added to the list for podiatry care. The ADON and DON acknowledged the oversight and confirmed that the resident's toenails were excessively long, but no action had been taken until the issue was brought to their attention by an investigator. The deficiency was further compounded by the absence of a specific policy for foot care, although the facility's ADLs policy included grooming and nail care. The DON admitted that the resident's foot care needs were missed due to a lack of communication and coordination among staff. The resident's toenails were eventually trimmed by an LVN after the issue was identified, but the initial failure to provide timely podiatry services and foot care represents a significant lapse in the facility's duty to maintain the resident's health and well-being.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
