Brookdale Galleria
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 2929 Post Oak Blvd, Houston, Texas 77056
- CMS Provider Number
- 675834
- Inspections on file
- 27
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Brookdale Galleria during CMS and state inspections, most recent first.
A cognitively impaired post-stroke resident with severe deficits in orientation and communication was able to leave the building during the night without staff awareness. Nursing staff last observed the resident in bed late in the evening, but during early-morning rounds the RN found the room empty and initiated a search. A security guard had encountered the resident in the pool area, opened a locked gate for her, assumed she was a homeless person based on her statement about entering through a back door, and escorted her out the front entrance without verifying her identity or notifying nursing. The resident, who had documented cognitive impairment and an ADL self-care deficit, was later found by staff walking along a nearby street and returned to the facility, revealing failures in supervision, resident identification, and security procedures around exit points and outdoor amenities.
A resident with dysphagia, as identified by a speech therapy evaluation, received crushed medications without a current physician order and without this need being reflected in the care plan. Nursing staff administered crushed medications despite lacking proper orders, and the resident's swallowing issues were not documented in the medical record or care plan during the relevant period.
A resident with multiple complex medical conditions did not have a documented diagnosis of dysphagia or related care interventions in the face sheet, MDS, or care plan, despite a speech therapy evaluation indicating swallowing difficulties and the need for a modified diet and crushed medications. Staff interviews confirmed the omission, and the records were not updated until after the deficiency was identified by surveyors.
A resident with multiple complex medical conditions, including Parkinson's disease and a history of stroke, was not provided with a comprehensive care plan addressing their dysphagia and need for crushed medications, despite clear documentation from speech therapy and staff interviews indicating these needs. The care plan, face sheet, and MDS did not reflect the resident's swallowing disorder or required interventions, resulting in a lack of person-centered planning for the resident's medical and functional needs.
A resident with multiple respiratory conditions did not receive proper respiratory care when staff failed to ensure the oxygen concentrator's humidifier contained water as required. Although staff documented weekly tubing and water changes and were expected to monitor oxygen therapy each shift, the water bottle was found empty and outdated while the resident was still receiving oxygen. This lapse occurred despite facility policy and staff expectations for regular monitoring and documentation.
A nurse inaccurately documented the completion of changing a resident's oxygen tubing and humidifier water, despite not performing the task. The resident, who was receiving oxygen therapy for respiratory and cardiac conditions, was found with an empty water bottle on the oxygen concentrator. Staff interviews confirmed that documentation was intended to reflect both tubing and water changes, but this was not done, resulting in incomplete and inaccurate medical records.
The facility did not ensure that daily staffing postings were complete and prominently displayed on both floors, with missing facility names and resident census information, and postings placed in locations not readily accessible to all. The Staffing Coordinator lacked training on CMS requirements, and the postings did not meet the facility's own policy for visibility and content.
A nurse failed to remain in the room to observe a resident taking oral medications, instead allowing a family member to administer the pills and leaving before confirming all medications were taken. Facility policy and leadership interviews confirmed that staff are required to observe residents during medication administration to ensure compliance.
Surveyors found multiple expired food items in the kitchen, including meats and condiments, despite staff training and facility policies requiring regular checks and immediate disposal of expired foods. Staff interviews confirmed awareness of procedures, but expired items remained in storage, indicating a lapse in adherence to food safety standards.
A resident developed a Stage IV pressure ulcer due to the facility's failure to provide necessary treatment and services. Upon admission, the resident had a healed area on the sacrum that was not properly identified or documented, leading to skin breakdown. The resident was not repositioned frequently enough, and initial interventions were ineffective. The facility's lack of consistent documentation and communication contributed to the deficiency.
A facility failed to maintain effective infection control when a nurse did not perform hand hygiene during wound care for a resident with skin integrity issues. Despite recent training, the nurse neglected to wash or sanitize hands after removing soiled dressings, which is crucial for preventing infection. This lapse was confirmed by the Unit Manager and DON, highlighting a deficiency in the facility's infection control practices.
A resident's quarterly MDS assessment was not completed on time, as required. The MDS Nurse admitted to forgetting the assessment, and the DON confirmed she does not audit the MDS Nurse's work. The resident had vascular dementia, Parkinson's disease, and protein calorie malnutrition.
A resident did not receive her prescribed doses of Esomeprazole on three consecutive days due to a failure in reordering the medication in time. The nursing staff and DON confirmed the oversight, and the facility's policy lacked clear guidelines on when to reorder medications.
The facility had a medication error rate of 7%, involving two residents. One LVN failed to administer Esomeprazole due to it being out of stock, and another LVN administered Vitamin B12 with Folate instead of the ordered Vitamin B12 without folate.
A facility failed to notify a physician of a significant change in a resident's condition, leading to a delay in wound care. The resident developed an infected sacral wound that required hospitalization and surgical intervention. Poor communication and responsibility among staff members contributed to the resident's deteriorating condition.
A resident with a sacral wound did not receive timely and appropriate wound care, leading to the wound becoming unstageable and infected. Facility staff failed to perform and document a wound assessment, notify the physician, or obtain wound care orders promptly. Lack of communication and responsibility among staff members contributed to the deterioration of the resident's condition.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Security Screening
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents when a cognitively impaired resident was able to leave the building unnoticed during the night and was later found on a public street. The resident was an older female admitted for rehabilitation after a cerebral infarction (stroke) and had a Brief Interview for Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment. Her care plan identified an ADL self-care performance deficit related to weakness and deconditioning from a recent hospital stay, with interventions focused on encouraging participation in care, use of the call bell, explanation of procedures, and PT/OT evaluation and treatment. The care plan did not identify or address elopement risk or specific supervision needs related to her cognitive status. On the night of the incident, nursing documentation shows that at approximately 11:00 p.m. the resident was observed in bed sleeping and vital signs were taken without changes. Around 1:00–1:15 a.m., the RN making rounds discovered the resident was no longer in her bed, checked her bathroom and adjacent rooms, and did not find her. Security was alerted, and the RN searched the stairwell and pool area without locating the resident, then proceeded to the front of the building. A security guard reported that he had allowed a woman to exit the building around that time, believing she was homeless. Staff then searched outside and found the resident walking on a pedestrian walkway along the road to the right side of the building. She was returned to the facility, assessed with no injuries noted, and one-on-one supervision was initiated. Interviews and record reviews revealed multiple failures in supervision and identification that led to the elopement. The security guard stated he saw the resident in the swimming pool area, opened a locked gate for her when she could not open it, and escorted her out the front door without asking her name or any identifying questions, without checking for identification, and without notifying nursing staff. He reported assuming she was homeless based on her statement that she came through a back door used by homeless individuals and stated he did not see any identifying bracelets or clothing that would make him think she was a resident, although the family member reported the resident was wearing a fall-risk bracelet and a visible heart monitor. The facility had a pool area and dog park accessible from emergency exits and gates, and the resident was able to reach these areas and then the front of the building without being recognized or stopped by staff. The family member and speech therapist both described the resident as having significant cognitive and communication deficits, including difficulty understanding verbal instructions, needing repeated explanations and visual aids, and not consistently being oriented to person, place, or time, yet these deficits were not effectively incorporated into supervision practices that would have prevented her from leaving the facility unnoticed.
Removal Plan
- Instituted immediate monitoring of emergency exit doors leading outside to the pool and common areas by assigning a staff person at each door of egress; implemented a sign-in/sign-out sheet and prohibited resident/visitor/staff exit unless there is an emergency; ensured assigned staff are relieved for breaks/lunches with documentation on an assigned form.
- Implemented staff exterior walking rounds with documentation, including hourly rounds in the dog park and pool areas; verified dog park gate and pool gate are secured with staff initials.
- Implemented walkie-talkie protocol: charge nurses check out walkie talkies at the beginning of each shift and return them at the end to enhance communication with security.
- Re-educated staff on emergency exit and fire door usage: staff must not use these doors unless there is an emergency and must investigate each time an alarm sounds.
- Re-educated staff on elopement/missing resident procedures: alert staff by calling a Code Yellow, complete skills check quiz for each employee, and ensure elopement binders are located on the 1st and 2nd floor nurses' stations and at the front desk.
- Provided in-service on abuse and neglect (definitions, types, reporting) and identified the abuse coordinator.
- Provided instant in-service on unfamiliar person protocol to remind staff of obligations to identify all persons on the property.
- Completed elopement risk assessments on all residents in the facility.
- Conducted impromptu QAPI meetings addressing resident elopement, binder use, behavior monitoring, swimming pool concerns, and staff assignment at fire door/egress monitoring.
- Began facility-wide education on emergency exit usage and alarm investigation for all departments; ensured staff not in-serviced would be in-serviced prior to their next shift with documentation.
- Completed facility-wide education on resident elopement/missing resident search procedure, proper notification, resident assessments, and resident monitoring; ensured staff not reeducated would be reeducated before their next shift; began elopement skills testing with documentation.
- Began facility-wide education on abuse and neglect (definitions, abuse coordinator, types, importance of timely notification); ensured staff not reeducated would be reeducated before their next shift; implemented abuse/neglect skills testing once per shift.
- Re-educated security/concierge staff on initial contact and verification of a wandering resident: ask identifying questions, check for identifying markers, call nurses’ stations to verify, and refer to the elopement binder; required retraining prior to returning to duty with documentation.
- Implemented additional communication protocol between nursing and front desk/security using walkie talkies: devices located/charged at concierge desk; at least one security associate and one direct care associate on each floor carry walkie talkies; one issued per floor with sign-out and return at end of shift; education completed prior to next shift with documentation.
- Educated night shift staff on security protocol, unfamiliar persons protocol, and abuse and neglect.
- Provided immediate re-education to all security and concierge staff on safety monitoring protocols: hourly walking rounds in pool and dog park areas, continuous monitoring of pool area via security cameras with feed visible at all times, prompt reporting of adverse findings to leadership, and accurate/timely documentation; documented on an in-service sheet.
- Re-educated the Healthcare Administrator on the facility abuse policy and elopement policy.
- Regional Director of Clinical Services educated the Executive Director and Healthcare Administrator on missing resident policy and swimming pool/spa policy.
- Provided ongoing oversight by the Executive Director and Healthcare Administrator to ensure adherence to protocols, with prompt corrective action and additional training for deviations.
- Placed a staff member at the emergency exit door between the dog park and pool area to redirect anyone attempting to exit unless there is an active emergency; maintained coverage until the gate could be reassessed and an appropriate locking mechanism installed.
- Scheduled a meeting with an approved technology company with the Administrator, Director of Maintenance, and Executive Director to assess and implement an appropriate locking mechanism for the gate between the dog park and pool area.
- Required security to complete hourly walking rounds of the pool and dog park areas; document and report any adverse findings to the Director of Resident Services, Executive Director, and Healthcare Administrator.
- Reviewed the pool area policy and reaffirmed that access is restricted to Independent Living residents and skilled care residents are not allowed access.
- Conducted monitoring observations and interviews across all shifts to verify in-service training completion and staff competencies/understanding, including reenactment drills and knowledge checks.
Failure to Obtain Orders for Crushed Medications in Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of dysphagia, as identified by a speech therapy evaluation, received appropriate orders for crushed medications. Despite the speech therapy evaluation documenting the need for crushed medications due to swallowing difficulties, there was no corresponding physician order in place from the time of the evaluation until nearly two months later. The resident's care plan did not include interventions for dysphagia or the need for crushed medications, and the medical record lacked a documented diagnosis of dysphagia during this period. Observations and interviews revealed that the resident was receiving crushed medications without a current physician order. Multiple nursing staff members confirmed that medications were being crushed and administered to the resident, but they were unaware of the specific reason or lacked knowledge of the resident's swallowing issues. Staff interviews consistently indicated that an order is required before crushing medications, and the absence of such an order was acknowledged as a deviation from facility policy and professional standards of practice. The speech pathologist confirmed the resident's need for crushed medications and swallowing precautions, stating that these requirements should be reflected in the care plan and supported by physician orders. The administrator and nursing staff acknowledged that the lack of orders for crushed medications could place residents at risk, and that the facility's policy requires medications to be crushed only with appropriate orders and documentation. The deficiency was identified through record review, staff interviews, and direct observation.
Failure to Accurately Document and Assess Dysphagia Diagnosis and Care Needs
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically regarding a diagnosis of dysphagia and the need for a modified diet and crushed medications. The resident, an older adult male with multiple diagnoses including kidney failure, dementia, Parkinson's disease, stroke, and a history of stomach cancer, did not have dysphagia documented on his face sheet, Minimum Data Set (MDS), or care plan, despite evidence from a speech therapy evaluation indicating the presence of dysphagia and the need for swallowing precautions, a modified diet, and crushed medications. Review of the resident's records showed that the care plan and MDS did not include a diagnosis of dysphagia or interventions related to swallowing difficulties or medication administration. The speech therapy evaluation documented specific swallowing impairments and recommended interventions, but these were not reflected in the resident's official diagnoses or care planning documents. Interviews with facility staff, including the speech pathologist and MDS nurse, confirmed that the resident required these interventions and that the diagnosis should have been included in the resident's records and care plan. The MDS nurse acknowledged that the omission of the dysphagia diagnosis and related care plan interventions was an error and that the resident's assessments and care plan were inaccurate at the time of the survey. The facility's policy on certifying the accuracy of resident assessments did not specifically address the accuracy of assessments, and the responsible staff confirmed that the resident's records were not updated to reflect the dysphagia diagnosis and required interventions until after the surveyor identified the discrepancy.
Failure to Develop and Implement Comprehensive Care Plan for Dysphagia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a diagnosis of dysphagia, as identified through a speech therapy evaluation. Despite the resident's medical history, which included kidney failure, difficulty walking, dementia, Parkinson's disease, stroke, and a history of stomach cancer, there was no documented diagnosis of dysphagia on the face sheet or in the Minimum Data Set (MDS). The resident's care plan did not address dysphagia or the need for crushed medications, even though the speech therapy assessment indicated the resident required a modified diet, swallowing precautions, and crushed medications due to difficulty swallowing. Observations and interviews revealed that the resident reported receiving crushed medications for swallowing difficulties but noted inconsistency in this practice. The speech pathologist confirmed the resident was on swallowing precautions and required a soft diet, thin liquids, alternating bites, crushed medications, and upright positioning during meals. The speech pathologist also stated that the resident's dysphagia and need for crushed medications should have been included in the care plan, and that it was nursing's responsibility to ensure this was addressed. The nurse practitioner acknowledged the resident's swallowing difficulties but deferred to speech therapy for medication orders. The MDS nurse, responsible for updating diagnoses and care plans, confirmed that the resident's dysphagia was documented in therapy notes but not reflected in the face sheet, MDS, or care plan at the time of the survey. The nurse stated that this omission could result in the resident not receiving proper care, as the care plan did not accurately reflect the resident's needs for swallowing precautions and medication administration. The facility's policy required comprehensive care plans to include measurable objectives and timeframes based on comprehensive assessments, which was not followed in this case.
Failure to Provide Safe and Appropriate Respiratory Care with Oxygen Humidification
Penalty
Summary
A deficiency occurred when a resident with respiratory failure, hypoxia, pneumonia, COPD, and heart failure did not receive appropriate respiratory care as required by professional standards and the resident's care plan. The resident was ordered to receive oxygen therapy at 2 liters per minute via nasal cannula, with humidification and weekly changes of oxygen tubing and water for infection control. Documentation indicated that staff signed off on changing the tubing and water, but on observation, the water bottle attached to the oxygen concentrator was found empty and dated from ten days prior, while the resident was still receiving oxygen. Interviews with nursing staff revealed that they were expected to monitor oxygen settings, tubing, and water levels each shift, and to document these checks. However, staff did not notice the water bottle was empty or that the date was outdated. Some staff believed that changing the water was part of the tubing change task, and that documentation of tubing change included water change, but there was inconsistency in actual practice and awareness. Staff also reported that the water was supposed to be changed weekly, but if it emptied sooner, it could be changed as needed, which did not occur in this instance. The facility's policy required humidifiers to be checked and changed per manufacturer recommendations, and for nurses to monitor and record the resident's response to oxygen therapy. Despite these policies, the lack of water in the humidifier while the resident was receiving oxygen was not identified or addressed by staff, resulting in a failure to provide safe and appropriate respiratory care as ordered and per professional standards.
Inaccurate Documentation of Oxygen Tubing and Humidifier Change
Penalty
Summary
A deficiency occurred when a nurse inaccurately documented the completion of changing a resident's oxygen tubing and water in the medical record, despite not having performed the task. The resident, an elderly female with diagnoses including respiratory failure, pneumonia, COPD, and heart failure, was receiving oxygen therapy as ordered. Documentation in the Treatment Administration Record (TAR) indicated that the oxygen tubing was changed on a specific date, but an observation revealed that the water bottle attached to the oxygen concentrator was empty and had not been changed since a prior date. Interviews with nursing staff and the interim Director of Nursing confirmed that the nurse's signature on the MAR was intended to indicate both the tubing and water had been changed, which was not the case. Facility policy required that all services provided to residents be documented in the medical record, and that oxygen humidifiers be checked and changed as needed. However, the policy did not specifically address the accuracy of documentation. The failure to accurately document the completion of required care tasks resulted in incomplete and inaccurate medical records for the resident.
Failure to Properly Post and Complete Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the daily staffing postings were complete and readily accessible for review on both the 1st and 2nd floors. Observations revealed that the Daily Associate Postings were hung on clipboards on the corner walls across from the nursing stations, located at the end of a T-shaped hallway, making them not easily visible or accessible to all residents, staff, and visitors. Additionally, the postings did not include the facility name on certain days, and on other days, the resident census was omitted from the postings. Interviews with the Staffing Coordinator indicated a lack of knowledge regarding CMS requirements for the Daily Associate Posting, as well as an absence of training prior to assuming responsibility for creating and posting the schedules. The Staffing Coordinator admitted to using a template without understanding all required elements and acknowledged that the postings' locations were not prominent or visible to everyone entering the facility. The Administrator confirmed that the postings were not in a location visible to all and that the Staffing Coordinator had not received appropriate training. Record reviews showed that the blank Daily Associate Posting forms did not have the facility name, and the postings observed in the open sitting areas before the resident room hallways included the facility name but omitted the resident census. The facility's policy required that the postings include the facility name, current date, resident census, and staffing for each shift, and that they be displayed in a prominent, accessible location. These requirements were not met during the survey period.
Failure to Observe Medication Administration by Licensed Staff
Penalty
Summary
A licensed vocational nurse (LVN) failed to provide pharmaceutical services in accordance with facility policy by not remaining in the room to observe a resident taking prescribed oral medications. The LVN entered the resident's room with a cup containing pills, which was handed to the resident's family member, who then administered the medications to the resident one by one. While the family member was still administering the last two pills, the LVN left the room to return to the medication cart, without confirming that all medications had been taken. The LVN later acknowledged that she should have stayed in the room to ensure all medications were administered and that the metformin pill was still in the cup when she left. Interviews with the unit manager and the director of nursing (DON) confirmed that nurses are required to follow the five rights of medication administration and must observe residents taking their medications to completion. The facility's medication administration policy also specifies that staff must observe the client taking the medication. The resident involved had multiple diagnoses, including spinal stenosis, hypertension, diabetes mellitus, and anxiety disorder. The care plan did not address medication administration, and the resident's BIMS score was not completed at the time of the incident.
Expired Food Items Found in Kitchen Storage
Penalty
Summary
Surveyors identified that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the kitchen, multiple food items were found in the walk-in refrigerator and pantry that were past their use by dates, including bay leaves, pork, beef, beef tips, brisket, and chocolate fudge icing. These items had use by dates ranging from several days to over a month prior to the observation. Staff interviews confirmed that all kitchen personnel, including dietary management and administration, had received training on proper food storage, labeling, and the requirement to discard expired foods. Staff consistently stated that expired foods should be thrown away immediately and acknowledged the potential for illness if expired foods were consumed. A review of the facility's policy on labeling, safety, and sanitization indicated that all food items must be labeled with received dates and that prepared items must be labeled with preparation and discard dates, with specific timeframes for discarding leftovers and hazardous foods. Supervisors are responsible for ensuring that no food items are kept past their expiration or use by dates. Despite these policies and staff training, expired food items were still present in the kitchen, indicating a failure to follow established procedures for food safety.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident, leading to the development of a Stage IV pressure ulcer. Upon admission, the resident had a healed area on the sacrum with a scab and pink skin, which was not properly identified or documented by the nursing staff. This oversight resulted in the area developing into a pressure ulcer within approximately 12 days of admission. The resident, who was non-verbal and required substantial assistance for mobility, was initially placed on a regular mattress and not repositioned frequently enough, contributing to the skin breakdown. The resident's care plan included interventions such as dietary supplementation, a low air loss mattress, and assistance with turning and repositioning. However, these measures were not effectively implemented from the start. The CNA responsible for the resident admitted to not repositioning the resident frequently enough and was unaware of the specific care requirements due to a lack of communication from the nursing staff. The resident's condition was further complicated by issues with hydration, nutrition, and immobility following a fracture, which were not adequately addressed in a timely manner. Interviews with facility staff revealed a lack of consistent documentation and communication regarding the resident's skin condition and care needs. The DON acknowledged that the initial interventions were ineffective and that the air mattress was introduced later as an additional measure. The wound physician noted that the resident had a pre-existing wound, which increased the risk of reopening, and emphasized the importance of frequent repositioning and appropriate mattress use. Despite these insights, the facility's failure to implement timely and effective interventions led to the resident's pressure ulcer worsening to a Stage IV.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN B during wound care for a resident. The resident, an elderly female with a history of a left femur fracture, hypertension, and the presence of a left artificial hip joint, was admitted to the facility with skin integrity issues, including a blister and pressure injury. During an observation, RN B did not perform hand hygiene after removing the resident's soiled dressing and before applying a new dressing, which is a critical step in preventing infection. RN B was observed conducting wound care without washing or sanitizing her hands or changing gloves after handling the resident's soiled dressing. Despite having received recent training in wound care and infection control, RN B neglected to follow the facility's established procedures, which require hand hygiene after removing soiled dressings and before applying new ones. This lapse in protocol was acknowledged by RN B, who admitted the importance of hand hygiene in protecting residents from infection. Interviews with the Unit Manager LVN P and the Director of Nursing (DON) confirmed that RN B should have performed hand hygiene as per the facility's policies. The facility's infection prevention and control program, as well as its hand hygiene and wound care procedures, emphasize the importance of hand hygiene in preventing the spread of infections. Despite these established guidelines, the failure to adhere to them during the observed wound care session represents a deficiency in the facility's infection control practices.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment was updated at least once every three months. Specifically, Resident #4's quarterly MDS assessment, which was due for completion by 4/10/2024, was not completed by the time of the record review on 04/24/2024. This oversight was identified during an interview with the MDS Nurse, who admitted to forgetting to complete the assessment. The resident, a [AGE] year-old female diagnosed with vascular dementia, Parkinson's disease, and protein calorie malnutrition, had her last comprehensive MDS dated 01/09/2024. The MDS Nurse stated that assessments are typically completed within 14 days, with the DON having an additional 7 days to sign off and transmit the MDS to CMS. However, the MDS Nurse was unaware that she had missed the quarterly assessment for Resident #4. The DON confirmed that while she signs off on MDS assessments, she does not audit the MDS Nurse's work. The failure to complete the MDS on time could affect billing and updates in resident care plans, as per the RAI Manual guidelines.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer the medication Esomeprazole to a resident on three consecutive days as ordered by the physician. The resident, who has a history of GERD and other digestive system diseases, did not receive her prescribed doses on 04/21/2024, 04/22/2024, and 04/23/2024. The medication was noted as pending in the nursing progress notes, and the pharmacy was contacted, but the medication was not available in the Omnicell system. The resident reported experiencing indigestion due to the missed doses. Interviews with the nursing staff revealed that the nurses were responsible for reordering medications when only 3-4 doses were left. However, the medication was not reordered in time, leading to the missed doses. The Director of Nursing (DON) confirmed that the medication should have been reordered on 04/19/2024 or 04/20/2024. The DON also stated that the medication could have been picked up at a local pharmacy but required a higher dose, which needed to be ordered. The facility's policy on reordering medications did not specify when to place reorders when medications run low. The policy allowed for reorders to be written, submitted verbally, faxed, or electronically. The failure to administer the medication as ordered and the lack of a clear policy on reordering medications contributed to the deficiency, potentially placing the resident at risk of inadequate therapeutic outcomes and discomfort.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in a medication error rate of 7%. This was based on two errors out of 28 opportunities, involving two residents. One error involved an LVN failing to administer Esomeprazole Magnesium delayed release 40mg to a resident with GERD and a history of digestive system disease because the medication was out of stock. The LVN did not know why the medication was unavailable and had to contact the pharmacy, resulting in the medication being put on hold. The resident's care plan specifically required the administration of medications as ordered, which was not followed in this instance. The second error involved another LVN administering Vitamin B12 with Folate instead of the physician-ordered Vitamin B12 without folate to a resident with cardiovascular issues and a pressure ulcer. The LVN was unaware that the Vitamin B12 contained folate and administered it along with a separate folic acid tablet. The LVN later acknowledged the mistake and indicated that she would check for the correct medication and contact the NP for a possible order change. The facility's policy required verification of the correct medication, dose, and route each time a medication is administered, which was not adhered to in this case.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status. Specifically, the staff identified a sacral wound on a resident but failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until four days later. This delay in care led to the resident's condition worsening, resulting in an infected decubitus ulcer that required hospitalization and surgical intervention. The resident, who was admitted with multiple diagnoses including a fracture, morbid obesity, and type 2 diabetes, was found to have a sacral wound on 2/16/2024. Despite the presence of the wound, nursing notes from 2/16/2024 to 2/19/2024 did not document any new or worsening skin conditions. It was not until 2/20/2024 that the wound was assessed, and appropriate wound care orders were obtained. Interviews with various staff members revealed a lack of communication and responsibility in reporting and managing the wound. The failure to notify the physician and obtain timely wound care orders resulted in the resident being taken to the hospital by a family member due to the severity of the wound. The hospital records indicated that the resident had an infected decubitus ulcer with significant necrotic tissue, requiring incision and drainage. The facility's inaction and poor communication among staff members contributed to the resident's deteriorating condition and subsequent hospitalization.
Failure to Provide Timely and Appropriate Wound Care
Penalty
Summary
The facility failed to ensure that a resident with a sacral wound received necessary treatment and services consistent with professional standards of practice. The resident was identified with a sacral wound on 2/16/2024, but the facility staff did not perform and document a wound assessment, notify the physician, or obtain wound care orders until four days later on 2/20/2024. The wound care physician assessed the resident on 2/22/2024 and diagnosed the resident with an unstageable sacrum full-thickness pressure wound with a surface area of 129.72 cm². During this period, facility staff were performing dressing changes without a physician's order, which contributed to the deterioration of the wound. Interviews with various staff members revealed a lack of communication and responsibility regarding the wound care of the resident. The Assistant Director of Clinical Services acknowledged that there was no notification to the physician and no orders for wound care for two days. LVN A admitted to assuming that the weekend supervisor would manage the wound care, while CNA K reported the wound to LVN B but did not see any immediate action taken. CNA L and CNA M also observed the wound and reported it to different nurses, but no timely intervention was made. The lack of proper documentation and communication among the staff led to the resident's wound worsening and eventually becoming infected. The resident's medical history included morbid obesity, type 2 diabetes, and a urinary tract infection, which made her more susceptible to pressure ulcers. Despite the resident's high risk for pressure injuries, the facility staff failed to reposition her adequately and did not follow the care plan interventions. The resident's condition deteriorated to the point where she was removed from the facility by a family member and taken to the hospital, where she was diagnosed with an infected decubitus ulcer and underwent surgical intervention. The facility's failure to provide timely and appropriate wound care resulted in significant harm to the resident.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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