Brookhaven Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carrollton, Texas.
- Location
- 1855 Cheyenne, Carrollton, Texas 75010
- CMS Provider Number
- 455412
- Inspections on file
- 49
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Brookhaven Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with quadriplegia and mental health diagnoses did not receive recommended occupational therapy services following an IDT meeting, due to lack of care planning, delays in obtaining physician signatures, and failure to follow facility policy for initiating and documenting PASARR services.
A resident with multiple diagnoses was transferred to a hospital without a completed discharge summary or proper clinical documentation, and the required notice to the Long-Term Care Ombudsman was not provided. Staff interviews revealed that the necessary paperwork and notifications were not completed, and responsibilities for these tasks were unclear among staff.
Multiple residents experienced verbal and physical abuse, including threats with a weapon, from another resident with a history of behavioral disturbances. Despite staff awareness and documentation of repeated aggressive incidents, facility leadership did not implement effective interventions to prevent further abuse, resulting in psychosocial harm and ongoing distress among residents.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A facility failed to ensure a Hospitality Aide had the necessary CNA certification while providing care to residents. The aide was counted as a CNA in staffing numbers and performed various care duties without a license. The ADON and DON were aware of the lack of certification but did not prevent the aide from being included in the schedule. The Administrator could not provide a policy for competent nursing staff.
A resident with severe cognitive impairment and a high risk for wandering eloped from the facility through a door with a faulty alarm. The resident was missing for over 15 hours before being found by police. The care plan indicated the resident was an elopement risk, but inadequate supervision and a malfunctioning alarm system contributed to the incident.
Two residents with cognitive and health issues were found smoking without supervision, violating the facility's smoking policy. Despite being assessed as needing supervision, they kept smoking materials in their possession and smoked outside designated times. Staff were aware of the non-compliance but were unable to enforce the policy effectively.
A resident with dementia and mobility issues was not provided with a functional and comfortable wheelchair, affecting her independence and safety. Despite reporting the issue, the wheelchair remained faulty, with a broken arm pad and difficulty in maneuvering. Facility staff, including the Maintenance Assistant, DON, and Social Worker, were unaware of the ongoing issues, and no specific person was responsible for ensuring the functionality of mobility devices.
A resident's grievance regarding a malfunctioning wheelchair was not resolved in a timely manner, despite being reported to the ADON. The resident, with moderately impaired cognition and several medical conditions, continued to face difficulties in mobility and daily activities. Interviews revealed a lack of awareness and communication among staff about the grievance, and the facility's grievance procedures were not effectively followed.
A resident with severe cognitive impairment and a diagnosis of Major Depressive Disorder was not accurately reflected in the MDS assessment at the facility. Despite being treated with Trazodone and referred for psychiatric services, the MDS did not include this diagnosis. Interviews with staff, including LVN, MDS nurses, DON, and the Administrator, revealed a lack of awareness about the resident's current diagnosis, highlighting a failure to ensure MDS accuracy as per facility policy.
A facility failed to update a PASARR Level 1 screening for a resident diagnosed with Major Depressive Disorder after admission. Despite the new diagnosis, the necessary screening was not submitted, potentially affecting the resident's access to needed services. Interviews with staff revealed a lack of awareness about the requirement to update the screening, and the facility did not provide a related policy when requested.
A facility failed to include a resident's Major Depressive Disorder in their comprehensive care plan, despite it being identified in assessments. The resident exhibited symptoms of depression and was on medication, yet staff were unaware of the diagnosis's omission from the care plan. Interviews with staff, including an LVN, MDS nurses, the DON, and the Administrator, revealed a lack of awareness and responsibility for ensuring care plans matched residents' current needs, leading to potential missed care opportunities.
A resident with diabetes did not receive podiatry services since admission, leading to long, curved toenails and self-managed foot care. Facility staff, including the ADON, DON, and Social Worker, were unaware of the resident's need for podiatry services, resulting in a deficiency in maintaining proper foot health.
A resident with a complex medical history did not receive documented doses of Ipratropium-Albuterol and Robitussin as ordered, due to RN and LVN oversight. The facility staff were unaware of the missed doses, and there was no documentation or physician notification, contrary to facility policy.
A resident with severe cognitive impairment and health issues did not receive necessary dental care due to the facility's failure to complete a dental referral. Despite the resident's desire to see a dentist and a family member's request for services, the care plan lacked dental interventions, and staff were unaware of the resident's needs. Observations noted dental issues, and interviews revealed a lack of communication and coordination among staff.
The facility failed to provide proper catheter care for three residents, leading to potential infection risks. A resident's catheter bag was placed above the bladder during a transfer, causing urine backflow. Another resident's catheter bag was improperly positioned during wound care, and a third resident's catheter bag was found touching the floor. Staff acknowledged the risks of infection due to these actions.
The facility failed to ensure proper handling of damaged medications on a medication cart, as observed with tramadol blister packs having broken seals and taped-over pills. An LVN noticed the issue during a shift change but did not report it due to being busy. The DON emphasized the need for immediate disposal of such medications to prevent drug diversion and infection risks, as per facility policy.
The facility's kitchen failed to meet food safety standards, with issues such as improperly covered and labeled food items, and the use of unclean utensils in bulk food containers. Observations revealed beef patties not covered, a box of diced potatoes without a visible use-by date, and a scoop left in a bulk sugar container, posing risks of food-borne illness and contamination.
Three CNAs in an LTC facility failed to follow proper hand hygiene protocols while providing incontinence care to residents with severe cognitive impairments and various health conditions. The CNAs did not perform hand hygiene after removing soiled gloves and before donning clean gloves, increasing the risk of infection and cross-contamination.
The facility failed to maintain proper nail care for two residents who required assistance with activities of daily living. One resident with severe cognitive impairment and another with moderate impairment were found with long, dirty fingernails, despite the facility's policy requiring regular grooming. Staff interviews revealed that CNAs and LVNs were responsible for nail care, but this was not adequately performed.
The facility failed to ensure that call lights were within reach for two residents, both with a history of falls and severely impaired cognition. Observations and interviews revealed that the call lights were inaccessible, posing a risk to the residents' safety and ability to call for assistance. Staff acknowledged the importance of having call lights within reach, as per facility policy, but failed to ensure compliance, leading to the deficiency.
A resident with a history of stroke and contractures did not receive the prescribed splint treatment on two consecutive days, despite staff signing off as if it had been applied. Observations showed the resident without the splint, and interviews revealed confusion among staff about who was responsible for its application. The facility's policy emphasized the importance of such interventions to prevent further reduction in range of motion.
A resident with paraplegia and chronic respiratory failure, requiring a two-person assist for incontinence care, was inadequately supervised by a CNA who provided care alone. Despite the resident's care plan and MDS assessment indicating the need for two-person assistance, the CNA rolled the resident and pulled him up in bed without help. Interviews revealed that the CNA often worked alone and sometimes called for assistance. The facility's policy prioritized resident safety and supervision, yet this incident placed the resident at risk for accidents and injury.
A facility failed to label and date a hydration bag used for a resident's enteral feeding, which could lead to complications such as incorrect hydration or infection. The resident, dependent on tube feeding due to medical conditions, had a hydration bag with no label indicating its contents or the date it was hung. Interviews with staff confirmed that labeling and dating are standard protocols, which were not followed in this instance.
The facility failed to ensure the resident environment was free of accident hazards by not properly managing contaminated sharps disposal bins. Observations revealed that sharps bins on two medication carts were overfilled, preventing the lids from closing properly and posing a risk to residents and staff. Interviews with staff confirmed the bins should not be filled past the full line and that medications should not be disposed of in the sharps bins.
The facility failed to administer medications timely for two residents due to staff shortages, leading to delays in medication administration. One resident with hypertension and other conditions received her medication over two hours late, while another resident with multiple diagnoses received her morning medications nearly three hours late.
The facility failed to store all drugs and biologicals in locked compartments and permitted unauthorized access to medications on one of the six medication carts reviewed. Eight pills were found stuck between the plastic insert of the sharps container and the lid, preventing the lid from closing properly. Staff acknowledged that medications should not be disposed of in the sharps bin and posed a potential hazard to residents.
Failure to Coordinate PASARR Assessments and Initiate Recommended Occupational Therapy
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program as required, resulting in a resident not receiving recommended occupational therapy services. The resident, who was cognitively intact with a history of seizure disorder, quadriplegia, anxiety, and depression, had a PASARR Level 1 Screening indicating mental illness and developmental disability. The interdisciplinary team (IDT) meeting recommended occupational therapy to help the resident regain the ability to feed herself, a goal important to her. However, there was no care plan for PASARR services, and the occupational therapy was not initiated as recommended. Interviews revealed that the MDS Coordinator, who was new to the position, was unaware of the resident's status and did not know why occupational therapy had not started. The Rehabilitation Director stated that an initial request for occupational therapy was denied, and a subsequent request was delayed because the physician was unavailable to sign it. The DON confirmed that the request should have been signed upon the physician's return but was not, and the MDS Coordinator was responsible for sending the request. Facility policy required initiation of specialized services within 20 business days of the IDT meeting and documentation within 3 business days, but these steps were not followed.
Failure to Provide Required Discharge Summary and Notification
Penalty
Summary
The facility failed to complete and provide a discharge summary for a resident who was transferred to a hospital. The discharge summary was required to include a recapitulation of the resident's stay, diagnoses, course of treatment, pertinent laboratory results, a final summary of the resident's status, and a reconciliation of all pre-discharge medications with post-discharge medications. Record review showed that there was no documented discharge summary for the date the resident was sent to the hospital, and staff interviews confirmed that the necessary clinical documents were not prepared or sent to the receiving facility. The resident involved had a history of schizophrenia, anemia, and hypertension, and had exhibited both physical and verbal behavioral symptoms. The transfer to the hospital was ordered for further evaluation and treatment, but the facility did not provide the required clinical discharge summary or documentation to the hospital. Staff interviews revealed confusion about responsibilities, with the nurse on duty stating she did not complete the discharge summary due to a busy day, and the social worker indicating that the former administrator and DON oversaw the transfer. The physician reported giving a verbal report to the hospital but did not prepare a written discharge summary. Additionally, the facility failed to provide the required notice of discharge to the Office of the Long-Term Care Ombudsman. The Ombudsman confirmed that she was contacted for a list of alternative placements but was not provided with the necessary discharge notice or clinical summary. The facility's own policy required notification of the attending physician, the receiving facility, and the resident's representative, as well as preparation of a transfer form and forwarding of the medical record within 24 hours, but these steps were not documented as completed.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from abuse by another resident, resulting in psychosocial harm and threats to safety. One resident, with a history of anxiety, depression, PTSD, and schizophrenia, reported being threatened and verbally abused by another resident who had a diagnosis of non-Alzheimer's dementia and schizophrenia. This resident was observed to have delusions and both physical and verbal behavioral symptoms directed toward others. Multiple incidents occurred, including one where the aggressive resident pushed another resident's wheelchair, leading to a physical altercation, and another where he pulled out a knife and threatened to kill two residents. Staff and other residents reported ongoing verbal abuse, threats, and aggressive behavior from this individual. Despite these repeated incidents, the facility's leadership, including the Administrator and DON, did not take sufficient action to prevent further abuse or to protect the affected residents. Documentation and interviews revealed that staff were aware of the aggressive resident's behaviors, but interventions were limited to redirection and enhanced supervision, which proved inadequate. There was a lack of consistent follow-up with the victims, and some staff and residents expressed that they did not feel safe. The aggressive resident continued to have access to other residents and was able to bring prohibited items, such as a knife and lighter, into common areas. The facility's failure to act promptly and effectively allowed the abusive behavior to continue, resulting in psychosocial harm to at least one resident and ongoing distress among others. Staff interviews indicated that the aggressive resident's behavior was a known issue, and some staff felt that the DON did not adequately address the situation. The Administrator and DON were not fully aware of all incidents, and there was a lack of communication and documentation regarding the threats and abuse. The situation escalated to the point where an Immediate Jeopardy was identified due to the risk of continued abuse and harm.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Facility Fails to Ensure Proper Certification for Hospitality Aide
Penalty
Summary
The facility failed to ensure that Hospitality Aide A had the appropriate nurse aide certification while employed and actively providing care for residents. Hospitality Aide A was listed as a CNA on the facility's schedule and counted as a CNA in the staffing numbers for several shifts, despite not having a CNA license. Interviews revealed that Hospitality Aide A performed duties such as making beds, taking out trash, feeding residents, performing incontinence care, and assisting with two-person transfers, even though she had not completed her CNA test. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were aware that Hospitality Aide A did not have a CNA license and stated that she was not supposed to work independently or be counted in the schedule numbers. However, the ADON included her in the numbers, and the DON, despite reviewing the schedule daily, did not notice this discrepancy. The Administrator was unable to provide a facility policy for competent nursing staff before the exit of the surveyors.
Resident Elopement Due to Faulty Door Alarm
Penalty
Summary
The facility failed to ensure a safe environment for a resident who was at risk of elopement. The resident, who had severe cognitive impairment and was identified as a high risk for wandering, managed to leave the facility through a door that did not sound an alarm. This incident occurred despite the resident having a Wander guard and being known to wander aimlessly. The resident was missing for over 15 hours before being found by the police. The resident's care plan indicated that he was an elopement risk and required interventions such as distraction and redirection from exits. However, on the day of the incident, the resident was not adequately supervised, and the door alarm system failed to alert staff when he exited the building. The resident's absence was noticed when he did not appear for dinner, prompting a search by the staff and the involvement of the police. Interviews with staff revealed that the door was usually alarmed, but the alarm did not function as expected on the day of the incident. The facility's administrator confirmed that the alarm system was checked and found to be working after the incident, but the reason for the failure was not determined. The resident was eventually found attempting to enter a school and was returned to the facility by the police.
Failure to Supervise Smoking Residents
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents who were observed smoking without supervision. Resident #55, a male with severe cognitive impairment and multiple health issues including dementia and hemiplegia, was found to be non-compliant with the facility's smoking policy. Despite being assessed as requiring supervision while smoking, he was observed with cigarettes and lighters in his possession and smoking outside the designated smoking times. His care plan indicated that he should not smoke without supervision, yet he was found with smoking materials in his room and was seen smoking unsupervised in the designated smoking area. Resident #12, who has intact cognition but multiple health diagnoses including hypertension and schizoaffective disorder, was also found to be non-compliant with the smoking policy. Although his smoking assessment indicated he required supervision while smoking, he was observed smoking without supervision and admitted to keeping cigarettes and lighters in his room against facility policy. Both residents were aware of the facility's smoking policy but chose to disregard it, keeping smoking materials on their person and smoking outside the scheduled times. Interviews with the ADON, DON, and Administrator confirmed awareness of the residents' non-compliance with the smoking policy. Staff had observed both residents smoking outside the designated times and with smoking materials in their possession. Despite efforts to educate and enforce the policy, the residents continued to violate the rules, posing a risk of fire and injury. The facility's smoking policy clearly outlined the need for supervision and secure storage of smoking materials, which was not adhered to in these cases.
Failure to Provide Operable and Comfortable Mobility Device
Penalty
Summary
The facility failed to provide a resident with a mobility device that was operable and comfortable, which compromised her independence, safety, and psychosocial needs. The resident, who has unspecified dementia, unsteadiness on feet, muscle wasting and atrophy, and unspecified glaucoma, reported that her wheelchair was not in working condition and uncomfortable. Despite filing a grievance and having the Maintenance Assistant attempt repairs, the wheelchair remained faulty, with a broken left arm pad and a narrowing size that made maneuvering difficult. The resident relied on the wheelchair for daily activities and outings with her family, but the unresolved issues made these tasks harder. Interviews with facility staff, including the Maintenance Assistant, DON, Social Worker, and Administrator, revealed a lack of awareness and responsibility regarding the resident's needs. The Maintenance Assistant was not informed of the ongoing issues after his initial repair attempt. The DON and Social Worker were unaware of the resident's discomfort, and the Administrator stated that the resident had not reported any issues. The facility's policy requires ongoing evaluation of residents' needs and preferences, but there was no specific person or department responsible for ensuring the functionality of mobility devices, leading to the oversight in addressing the resident's needs.
Failure to Resolve Resident Grievance in a Timely Manner
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for a resident who relied on a wheelchair for mobility. The resident, who had a moderately impaired cognition and several medical conditions including unspecified dementia and glaucoma, reported that her wheelchair was not in working condition and uncomfortable. Despite filing a grievance with the Assistant Director of Nursing (ADON) months prior, the issue remained unresolved, affecting her ability to perform daily tasks and participate in activities. Interviews with facility staff revealed a lack of awareness and communication regarding the grievance process. The ADON acknowledged receiving the complaint but did not recognize it as a grievance, instead reporting it to the maintenance department. The Maintenance Assistant confirmed working on the wheelchair but was unaware of any ongoing issues. The Director of Nursing (DON) and the Social Worker, who is the designated grievance official, were also unaware of the unresolved grievance, indicating a breakdown in the grievance reporting and resolution process. The facility's grievance procedures were not effectively followed, as evidenced by the absence of the resident's grievance in the grievance logs and the lack of a timely resolution. The Administrator and other staff members did not identify any risks associated with unresolved grievances, and the facility did not provide a grievance policy when requested. This oversight could potentially impact the resident's ability to voice grievances without fear of reprisal and have them resolved promptly.
Inaccurate MDS Assessment for Major Depressive Disorder
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, specifically regarding the diagnosis of Major Depressive Disorder. The resident, a male with severe cognitive impairment, was admitted with active diagnoses including aphasia and hemiplegia. Despite being referred for psychiatric services and being treated with Trazodone for Major Depressive Disorder, the MDS assessment did not reflect this diagnosis. This oversight was identified during a review of the resident's records, which included a psychiatric assessment confirming the diagnosis and active treatment for depression. Interviews with facility staff, including Licensed Vocational Nurse (LVN) I, MDS Nurse G, and MDS Nurse Q, revealed a lack of awareness regarding the resident's current diagnosis of Major Depressive Disorder. LVN I, who had observed the resident's depressive symptoms, was unaware of the active diagnosis and treatment. Both MDS nurses, responsible for ensuring the accuracy of MDS assessments, admitted to not knowing that the resident's MDS did not reflect the current diagnosis. The Director of Nursing (DON) and the Administrator also confirmed their unawareness of the discrepancy in the MDS assessment. The facility's policy and job description for MDS coordinators emphasize the responsibility for ensuring accurate MDS assessments. However, the failure to update the resident's MDS with the correct diagnosis of Major Depressive Disorder indicates a lapse in following these guidelines. This deficiency could potentially lead to missed care and unmet needs for the resident, as the MDS assessment is crucial for planning and delivering appropriate care services.
Failure to Update PASARR Screening for Resident with New Diagnosis
Penalty
Summary
The facility failed to submit an accurate PASARR Level 1 (PL1) screening for a resident diagnosed with Major Depressive Disorder after admission. This oversight was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted with diagnoses including aphasia and hemiplegia following a cerebral infarction, was later diagnosed with Major Depressive Disorder. Despite this new diagnosis, the facility did not update the PASARR Level 1 screening to reflect the presence of a mental illness, which is necessary to determine if a Level II PASARR evaluation is required for accessing needed services. Interviews with facility staff, including MDS nurses and the Director of Nursing (DON), revealed a lack of awareness regarding the need to submit a new PASARR Level 1 screening following the resident's new diagnosis. The MDS nurses were responsible for ensuring the accuracy of PASARR screenings, but they did not submit an updated screening for the resident. The facility also did not provide a policy related to PASARR services or assessments when requested. This failure could result in missed care opportunities for residents who require additional services due to mental illness, intellectual disability, or developmental disability.
Failure to Include Major Depressive Disorder in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames that addressed the resident's clinical and psychosocial needs. Specifically, the care plan did not include the resident's diagnosis of Major Depressive Disorder, despite it being identified in the comprehensive assessment. This oversight was discovered during a review of the resident's records, which showed active diagnoses of aphasia, hemiplegia following cerebral infarction, and muscle weakness, along with a severe cognitive impairment indicated by a BIMS score of 1. The resident had been referred for psychiatric services due to symptoms of depression, withdrawal, and other related issues, yet these were not reflected in the care plan. Interviews with staff, including an LVN, MDS nurses, the DON, and the Administrator, revealed a lack of awareness regarding the resident's current diagnosis and its absence from the care plan. The LVN was unaware of the resident's treatment for Major Depressive Disorder, despite the resident taking medications for depression. Both MDS nurses acknowledged their responsibility for ensuring care plans were personalized and matched residents' current needs, but they were unaware of the omission. The DON and Administrator also confirmed the oversight and recognized the risk of missed care opportunities due to the lack of a personalized care plan. The facility's policy on comprehensive person-centered care plans, dated December 2016, emphasized the need for care plans to include measurable objectives and timetables to meet residents' needs, which was not adhered to in this case.
Failure to Provide Podiatry Services for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with diabetes, leading to a deficiency in maintaining proper foot health. The resident, a male with a history of diabetes and other health conditions, had not received podiatry services since his admission to the facility. His toenails were observed to be long and curved into his skin, causing him to self-manage a hangnail, which resulted in pain. Despite being assisted with bathing and hygiene, the resident did not receive assistance with toenail clipping, and he did not request help from the staff. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Social Worker, revealed a lack of awareness and communication regarding the resident's need for podiatry services. The ADON and DON acknowledged the importance of regular podiatry visits for residents with diabetes to prevent foot injuries and complications. However, the Social Worker, responsible for making podiatry referrals, was not informed of the resident's condition and had not included him on the referral list for podiatry services. The facility's policies on pharmacy services and activities of daily living (ADLs) emphasize the importance of providing appropriate care and treatment to maintain mobility and foot health. However, the lack of documentation and communication among staff members resulted in the resident not receiving the necessary podiatry care. This oversight could potentially lead to negative outcomes for the resident's foot health, as noted by the staff during interviews.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, resulting in missed medication doses. Specifically, RN B and LVN C did not document the administration of Ipratropium-Albuterol Inhalation Solution and Robitussin Mucus+Chest Congest Oral Liquid as ordered for a resident. This oversight placed the resident at risk of not receiving medications as prescribed by the physician, potentially leading to a worsening of their condition. The resident, a male admitted from an acute care hospital, had a complex medical history including hypertension, pneumonia, septicemia, atrial fibrillation, influenza A, prostate cancer, and muscle weakness. The resident required total assistance with transfers and was on a mechanical soft diet. Despite these needs, the Medication Administration Record (MAR) showed several instances where doses of the prescribed medications were left blank and not signed as administered. Interviews with facility staff, including RN B, LVN E, the ADON, and the DON, revealed a lack of awareness regarding the missed doses. The staff did not document any refusals or reasons for the missed doses in the MAR or progress notes, nor did they notify the physician. The attending physician, upon being informed, stated that the missed doses would not have changed the resident's prognosis or outcome, although the facility's policy required documentation and physician notification for missed doses.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to assist in obtaining routine and emergency dental care for a resident, leading to a deficiency in dental services. The resident, a male with severe cognitive impairment and multiple health issues, expressed a desire to see a dentist but was unaware of whom to contact within the facility. Despite the resident's family member requesting a dental referral, it was not completed, and the resident's care plan did not address his dental needs. Observations revealed the resident had cracked and missing teeth, along with a strong odor from his mouth, indicating potential dental issues. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Social Worker, the Director of Nursing (DON), and the Administrator, revealed a lack of awareness regarding the resident's dental pain and the request for dental services. The Social Worker, responsible for coordinating ancillary services, was not informed of the resident's needs, and the facility's policy on dental services was not followed. The deficiency highlights a breakdown in communication and coordination among staff, resulting in the resident not receiving necessary dental care.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for three residents, leading to potential risks of urinary tract infections. Resident #52, a cognitively intact male with obstructive and reflux uropathy, diabetes, and obesity, was observed during a mechanical lift transfer with his catheter drainage bag placed on his abdomen, above the bladder level. This improper positioning allowed urine to flow back toward the bladder, increasing the risk of infection. Both CNAs involved acknowledged their mistake and the potential for cross-contamination. Resident #70, a cognitively intact female with morbid obesity, chronic heart failure, and a stage 4 pressure ulcer, experienced a similar issue during wound care. RN P placed the catheter bag on the bed, above the bladder level, causing urine to flow back toward the bladder. The RN admitted to knowing the correct procedure and recognized the risk of infection due to the improper placement of the catheter bag. Resident #85, a male with moderate cognitive impairment and a history of hypertension, anxiety, and depression, was found with his catheter bag in contact with the floor while in his wheelchair. Both the CNA and RN responsible for his care acknowledged the increased risk of infection from the catheter bag touching the floor. The resident himself noted that the bag often touched the floor, and he had experienced several urinary infections in the past. The facility's policy clearly stated the importance of keeping the catheter bag below the bladder and off the floor to prevent infections.
Failure to Properly Handle Damaged Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper handling and disposition of damaged medications on one of the medication carts, specifically Nurses Cart Hall 300. During an observation and record review, it was found that the blister packs for tramadol 50 mg tablets, a controlled medication used for pain, for three residents had broken seals with the pills still inside and taped over. This issue was identified during a change of shift count by an LVN, who acknowledged seeing the broken blisters but failed to report it to the Director of Nursing (DON) due to being busy. The DON stated that any medication with a broken seal should be discarded immediately to prevent potential drug diversion and infection control issues. The facility's policy requires discontinued, outdated, or deteriorated drugs to be returned to the pharmacy or destroyed. The responsibility for checking medication blister packs for broken seals during shift changes lies with the nurses and medication aides, and the DON and ADON are expected to check the carts weekly. However, this protocol was not followed, leading to the deficiency.
Deficiencies in Food Storage and Utensil Use in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the refrigerator and freezer were not properly covered or labeled with visible use-by dates. For instance, beef patties in the walk-in freezer were not covered appropriately, and a box of diced potatoes in the refrigerator lacked a visible use-by date. Additionally, a bunch of cilantro was found to be rotten. These lapses in food storage and labeling could potentially lead to food-borne illnesses among residents. Furthermore, the facility did not ensure that staff used clean utensils when accessing bulk foods. A scoop was left inside a bulk sugar container, which could lead to cross-contamination. Interviews with the Dietary Manager and another staff member revealed a lack of awareness and adherence to proper food safety protocols. The Dietary Manager acknowledged the risks associated with these practices, including the potential for freezer burn and food contamination, which could adversely affect the health of residents.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of three Certified Nursing Assistants (CNAs) who did not adhere to proper hand hygiene protocols while providing incontinence care to residents. Specifically, CNA D did not perform hand hygiene after removing soiled gloves and before donning clean gloves while caring for a resident with severe cognitive impairment and multiple health issues, including cerebral infarction and chronic kidney disease. This lapse in protocol occurred during the process of changing the resident's brief and cleaning the resident after a bowel movement. Similarly, CNA F failed to perform hand hygiene after removing gloves and before re-entering a resident's room to continue incontinence care. This resident, who was moderately cognitively impaired and dependent on care for all activities of daily living, was exposed to potential cross-contamination when CNA F did not change gloves after cleaning the resident and before handling clean items. The CNA also did not perform hand hygiene after leaving the room to retrieve supplies, further increasing the risk of infection. CNA L also neglected to perform hand hygiene after removing soiled gloves and before donning clean gloves while providing incontinence care to a resident with severe cognitive impairment and paraplegia. This resident required assistance for all activities of daily living and was always incontinent of urine and bowel. The CNA's failure to adhere to hand hygiene protocols during the care process, including after handling soiled briefs and before placing clean briefs, posed a risk of infection and cross-contamination.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in two residents. Resident #53, a female with severe cognitive impairment due to cerebral infarction and hemiplegia, was found with long, dirty, and chipped fingernails. Despite her condition, which required assistance with personal hygiene, her fingernails were not properly maintained. Similarly, Resident #74, a female with moderate cognitive impairment and physical debility, was found with discolored and dirty fingernails. She required extensive assistance with personal hygiene, yet her nail care was neglected. Interviews with facility staff revealed that both CNAs and LVNs were responsible for nail care, except in cases involving diabetic residents, where only nurses were allowed to perform nail care. The Director of Nursing (DON) stated that nail care should be provided every Sunday or as needed, particularly during shower times. However, the observations indicated a lapse in this routine care, as both residents were not diabetics and should have received regular nail care. The facility's policy on activities of daily living emphasized the need for services to maintain good grooming and hygiene for residents unable to perform these tasks independently, yet this was not adhered to in the cases of Resident #53 and Resident #74.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident #6 and Resident #83, were placed within their reach, which is a violation of their right to reside and receive services with reasonable accommodation of their needs. Resident #6, who has a history of falls, dementia, and severely impaired cognition, was observed in a low bed with the call light hanging off the bed rail, out of reach. Interviews with the resident and staff confirmed that the resident was unable to locate or reach the call light, which is crucial for preventing falls and ensuring assistance is available when needed. Similarly, Resident #83, who also has a history of falls, severely impaired cognition, and is on hospice services, was found with the call light looped and hung on the wall behind the bed, making it inaccessible. The resident was unaware of the call light's location, and staff interviews revealed that the call light should have been placed within reach to allow the resident to call for help if necessary. The staff acknowledged the importance of having the call light within reach to prevent falls and ensure the resident's needs are met. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator confirmed that both residents were at high risk of falls and should always have their call lights within reach. The facility's policy on resident call lights emphasizes the importance of a systems approach to safety, which includes ensuring call lights are accessible to residents to prevent injuries and meet their needs. However, the failure to adhere to this policy resulted in the deficiency observed during the survey.
Failure to Apply Splint as Ordered for Resident
Penalty
Summary
The facility failed to ensure that Resident #44 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the staff did not apply the resident's right hand splint as ordered by the physician on two consecutive days, 06/04/24 and 06/05/24. This oversight was observed during multiple instances where the resident was seen without the splint, despite the treatment administration record (TAR) being signed off as if the splint had been applied. Resident #44, a male with a history of aphasia, right-side hemiplegia, and cerebral vascular accident, was admitted to the facility with a care plan that included the use of a right hand splint to prevent further contractures. The care plan specified that the splint should be worn daily from 8 a.m. to 2 p.m. However, observations on the specified dates showed that the splint was not in place, and interviews with staff revealed a lack of clarity and communication regarding the responsibility for applying the splint. Interviews with various staff members, including CNAs and nurses, highlighted confusion about who was responsible for applying the splint. Some staff members were unaware of the resident's need for a splint, while others mistakenly believed it was not their responsibility. The Director of Nursing (DON) confirmed that nurses were responsible for ensuring the splint was applied and should not have signed off on the TAR if it was not in place. The facility's policy on resident mobility and range of motion emphasized the importance of interventions like splints to prevent a reduction in range of motion, which was not adhered to in this case.
Inadequate Supervision and Assistance for Resident Care
Penalty
Summary
The facility failed to provide adequate supervision and assistance to Resident #51, who required a two-person assist for incontinence care. The resident, a male with paraplegia and chronic respiratory failure, was dependent on staff for all activities of daily living (ADLs) and had severely impaired cognition. During an observation, a certified nursing assistant (CNA) was seen providing incontinence care to the resident without the required assistance, rolling the resident on his side and pulling him up in bed without help. This action was contrary to the resident's care plan and comprehensive MDS assessment, which indicated the need for a two-person assist. Interviews with the CNA and a licensed vocational nurse (LVN) revealed that the CNA often worked alone and would sometimes call for help if someone was available. The Director of Nursing (DON) stated that CNAs were instructed to ask for help with heavy residents and that the MDS should be checked first to determine the level of assistance required. The facility's policy emphasized resident safety and supervision as priorities, yet the failure to adhere to the two-person assist requirement placed the resident at risk for accidents and injury.
Failure to Label and Date Hydration Bag for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received appropriate treatment and services to prevent complications. Specifically, the facility did not label and date the hydration bag used for a resident's tube feeding pump. This oversight was observed during a survey, where it was noted that the hydration bag contained a colorless liquid without any label indicating its contents, the date it was hung, or the resident's name. The resident, who was dependent on tube feeding due to dysphagia and other medical conditions, was unable to provide information about the contents of the bag. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that it was standard protocol to label and date all enteral feeding bags with the contents, the date and time they were hung, and the resident's identifier. The failure to adhere to this protocol could lead to complications such as the use of incorrect hydration or an increased risk of infection. The facility's policy and recommendations from the American Society for Parenteral and Enteral Nutrition emphasize the importance of standardizing labels for all enteral formula containers to ensure safe practices.
Failure to Maintain Safe Sharps Disposal Practices
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible, specifically regarding the management of contaminated sharps disposal bins. During an observation, it was found that the sharps bin attached to the 300 Hall MA Medication Cart was past the full line, preventing the lid from closing completely. Additionally, eight pills were observed stuck between the plastic insert and the insert's lid, further contributing to the lid not closing properly. MA B, who was responsible for the cart, stated she was unaware of the issue and acknowledged that the full bin and medications posed a hazard for residents and staff. Similarly, the sharps bin attached to the 300 Hall Nurse Medication Cart was also found to be past the full line, with RN C acknowledging the potential hazard. Interviews with the ADON and the Administrator confirmed that the sharps bins should never be filled past the full line to prevent possible injury to staff or residents. The ADON and the Administrator both emphasized that medications should not be disposed of in the sharps bin and that the current state of the bins posed a potential risk. The DON confirmed that a staff member had recently been stuck by a needle due to a similar issue, and in-service training had been conducted. The facility's policy on safety and supervision of residents was reviewed, which stated that the environment should be as free from accident hazards as possible. The policy also outlined the responsibilities of staff in identifying and mitigating safety risks. Despite this, the facility failed to adhere to its own policy, resulting in the identified hazards.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for two residents. Resident #15, a female with diagnoses including hypertension, hypothyroidism, and breast cancer, did not receive her Metoprolol ER 50 mg tablet at the scheduled time of 9 am. Instead, the medication was administered at 11:25 am by LVN D, who acknowledged the delay and attributed it to a change in resident assignments after a staff member called off. This delay in medication administration could potentially affect the therapeutic outcomes intended by the physician's order. Similarly, Resident #20, a female with multiple diagnoses including insomnia, Parkinson's disease, and type 1 diabetes mellitus, did not receive her scheduled morning medications on time. MA B administered several medications, including Hydrocodone, Methocarbamol, Topiramate, Levetiracetam, and Trospium Chloride, at 11:54 am instead of the scheduled 9 am. MA B explained that the delay was due to being assigned more residents after another medication aide called off. The Director of Nursing confirmed that medications should be administered within a one-hour window to prevent negative effects and ensure efficacy, and acknowledged that the staff had been in-serviced on medication administration.
Failure to Properly Store and Dispose of Medications
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permitted unauthorized access to medications on one of the six medication carts reviewed. Specifically, eight pills were found stuck between the plastic insert of the sharps container and the lid on the 300 Hall MA Medication Cart, preventing the lid from closing properly. This was observed while residents were self-ambulating through the hall in their wheelchairs. MA B, who was responsible for the cart, stated she did not see the medications and denied disposing of them. She acknowledged that all staff were responsible for ensuring medications were secured and disposed of properly and that medications should not be disposed of in the sharps bin. The ADON and the Administrator confirmed that the medications should not have been on the lid of the sharps bin and posed a potential hazard to residents. The DON stated that the medications should be disposed of properly and not placed in the sharps bin. He changed out the sharps insert and disposed of the pills but was unable to identify what the pills were. He mentioned that staff are trained on how to dispose of medication properly but did not recall when the last training occurred. The facility's policy on the storage of medications indicated that drugs and biologicals should be stored in locked compartments and disposed of properly, but this policy was not followed in this instance.
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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