Brush Country Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 6500 Brush Country Rd, Austin, Texas 78749
- CMS Provider Number
- 675118
- Inspections on file
- 43
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Brush Country Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors observed a medication cart left unlocked and unattended near a nurses’ station while an LVN sat out of view and residents and staff walked by. The cart contained residents’ prescribed medications, OTC drugs, narcotics, and treatment supplies. Facility policy required all medication carts to be locked when not in use and never left unattended. In interviews, the LVN, DON, and ADM all confirmed their training and understanding of this policy and stated that the assigned nurse or med aide is responsible for locking the cart, with management monitoring through observation rounds, but none could explain why the cart was left unlocked.
Two residents did not receive their prescribed pain medications due to the facility's failure to order oxycodone and Percocet in a timely manner. One resident missed multiple doses and reported withdrawal symptoms and pain, while another was without pain medication for less than 24 hours. Staff interviews revealed there was no formal policy for medication ordering, and nurse management lacked a clear process for monitoring medication supplies.
Surveyors found that medications were not properly secured or stored at the correct temperature. The medication refrigerator was operating above the recommended range for several drugs, and a medication cart was left unlocked and unattended in a hallway. Staff interviews revealed confusion about monitoring responsibilities, and facility policy requiring locked storage and temperature checks was not followed.
A resident with chronic pain and multiple comorbidities did not receive prescribed Oxycodone for pain due to medication unavailability and lack of timely action by staff. Despite ongoing reports of severe pain, staff failed to complete pain assessments or ensure the medication was obtained, resulting in the resident seeking emergency care for pain relief.
Two residents sharing a room, both requiring assistance with incontinence care and other ADLs, did not have a privacy curtain in place, resulting in a lack of privacy during personal care. Staff and residents confirmed the absence of curtains, and facility leadership was unaware of the issue until it was identified during a survey. There was no documentation indicating that the residents or their families had requested no privacy curtains, despite facility policy requiring privacy to be maintained.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, resulting in a deficiency.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
Surveyors found that a resident did not receive an accurate assessment, as required. The inaccuracy in the assessment process was documented during the survey, but no further details about the resident's condition or history were provided.
A resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all assessed needs. Documentation and planning did not fully reflect the resident's requirements, resulting in a deficiency.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
Surveyors found that food served to residents was often unappealing, bland, and improperly prepared, with vegetables left sitting in water and served mushy and unseasoned. Meal trays were inconsistently arranged, portions were small, and food temperatures dropped due to open meal delivery carts. Staff interviews confirmed lapses in food preparation and delivery, especially with new cooks in training, and complaints about cold and unappetizing food were reported by the resident council.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Surveyors found that the facility did not have an effective training program in place for all new and existing staff members, resulting in staff not consistently receiving the required training.
A nurse left a computer screen displaying a resident's confidential medical information open and unattended in a hallway, allowing potential access by unauthorized individuals. Facility leadership confirmed that this action violated expectations and policy for safeguarding electronic protected health information.
A plan to meet a resident's most immediate needs was not created or implemented within 48 hours of admission. Surveyors found no documentation or evidence that this requirement was fulfilled for a newly admitted resident.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Several residents did not receive their scheduled 5:00 pm medications, including treatments for hypertension, diabetes, seizures, depression, and pain. MARs confirmed missed doses, and interviews revealed a lack of monitoring and communication regarding these omissions. The facility's policy required timely administration, but this was not consistently followed.
A resident with paraplegia and existing pressure ulcers did not receive consistent wound care or weekly skin assessments as ordered, resulting in missed treatments and worsening of wounds. Staff interviews and documentation revealed that wound care was not provided as required, and assessments were not completed, leading to significant deterioration of the resident's condition.
The facility failed to maintain the required RN coverage for at least 8 consecutive hours a day, 7 days a week, over an 8-day period. On several days, there were either no RNs on duty or less than the required hours of coverage. The DON was often the only RN scheduled, and the facility relied on telehealth services when he was unavailable. Concerns were raised about inadequate staffing, particularly on one day when only one nurse was available for all residents.
The facility failed to provide timely pharmaceutical services for two residents, resulting in missed and late medication doses. One resident did not receive several scheduled medications, including carvedilol and ciprofloxacin, while another missed doses of armodafinil and omeprazole. Both residents received multiple medications outside the professional standard window. Interviews revealed complaints about late medications and issues with internet connectivity affecting records.
A resident was discharged with incorrect medication intended for another resident, due to a failure in verifying medications against the resident's chart. The error was discovered by the family after leaving the facility, but before administration. The resident, with a history of serious health conditions, was prescribed Furosemide 20mg but received 40mg tablets. Facility staff acknowledged the error and attempted to rectify it by sending a prescription to the pharmacy.
The facility failed to document incidents and vital signs accurately for three residents, leading to potential errors in care. A resident's abuse allegation and another's injury were not recorded in progress notes, while vital signs for a third resident were marked as 'N/A' for two days. The facility's policy mandates documentation of all services, changes, and incidents.
The facility failed to ensure resident privacy as staff entered rooms without knocking, affecting five residents. Some residents felt uncomfortable and startled by this practice. Staff interviews confirmed the importance of knocking, but practical difficulties and lack of a formal policy contributed to lapses.
The facility failed to properly maintain oxygen equipment for three residents, leading to potential infection risks. Observations showed that oxygen tubing and humidifier bottles were not changed weekly as required, with some bottles being empty. Interviews revealed inconsistencies in policy implementation, and the facility's policy lacked specific guidelines for safe handling and maintenance of oxygen equipment.
The facility failed to follow food safety standards, with unlabeled and undated food items in storage and improperly thawed sausage at unsafe temperatures. Staff interviews revealed misunderstandings of food safety protocols, despite having food handler training. These deficiencies risked residents' health due to potential foodborne illness.
A resident with dysphagia and other medical conditions did not receive the prescribed mechanical soft diet, instead receiving a regular diet tray. Facility staff interviews revealed a failure to follow the protocol of checking meal trays against meal tickets, resulting in the resident not receiving the correct diet.
A resident was discharged without proper documentation and planning due to non-payment. Key sections of the discharge planning review were left blank, and there were no progress notes from the social worker. Staff interviews revealed a lack of communication and coordination regarding the discharge, and the facility's policy on preparing a resident for discharge was not followed.
A resident with multiple medical conditions and moderately impaired cognition was discharged a day earlier than the 30-day notice indicated, due to corporate pressure. The facility failed to follow its discharge policy, leading to improper discharge.
A resident and her legal representative did not receive the results of a care plan meeting within the required timeframe, despite multiple requests. The Social Worker cited various reasons for the delay, including a malfunctioning printer and being busy with other tasks.
Unlocked Medication Cart Left Unattended With Medications Accessible
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications on one of four medication carts (MC #1) were properly secured and accessible only to authorized personnel. During an observation at the nurses’ station, surveyors found MC #1 unlocked and unattended while a nurse sat inside the nurses’ station out of view of the cart, with residents and staff walking by. The unlocked cart contained residents’ prescribed creams, prescribed drugs, over-the-counter medications, narcotics, catheters, and breathing treatment medications. The facility’s written policy on storage of medications, dated 4/2019, stated that drugs and biologicals must be stored in locked compartments and that unlocked medication carts are not to be left unattended. In interviews, LVN A stated he had been trained on medication storage and acknowledged that the policy required staff to lock the medication cart anytime they walked away, even briefly, and that the nurse assigned to the cart was responsible for locking it, although any staff member who noticed an unlocked cart could lock it. He acknowledged that a resident might get into an unlocked cart and did not know why he had left MC #1 unlocked. The DON and the ADM both confirmed they had been trained on medication storage and described the same policy expectations that medication carts must always be locked when not in use, with the assigned nurse or medication aide responsible for securing the cart. They each reported that nursing management, including the DON and ADM, monitored compliance by walking the halls and observing carts, and neither could explain why LVN A did not lock the cart at the time of the observation.
Failure to Ensure Timely Ordering and Administration of Pain Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the timely ordering and administration of pain medications for two residents. For one resident, who had a history of congenital malformation of the nervous system, somatization disorder, and spinal fusion, the facility did not order her prescribed Percocet (oxycodone with acetaminophen) in a timely manner, resulting in her missing 18 doses over several days. Documentation showed that the resident experienced significant discomfort, including headaches, sore throat, burning sensations, and reported withdrawal symptoms. The resident refused alternative pain medications offered, such as tramadol and ibuprofen, citing adverse effects, and only agreed to take Tylenol at one point. Progress notes indicated ongoing somatic complaints and repeated requests for her prescribed medication, with delays attributed to issues in obtaining the necessary triplicate prescription forms for controlled substances. A second resident, with diagnoses including hip fracture and above-the-knee amputation, also experienced a lapse in receiving his prescribed oxycodone for pain management. The medication was not ordered in advance, resulting in the resident being without his pain medication for less than 24 hours. The resident reported a moderate pain level and was unaware that the facility had run out of his medication until informed by staff. Interviews with nursing staff revealed a lack of a formal policy for timely medication ordering, and staff typically ordered medications only a few days before they were due to run out. Administrative interviews confirmed the absence of a policy or systematic process for monitoring medication supplies and ensuring timely reordering. Nurse management was identified as responsible for overseeing medication ordering, but there was no clear method in place for monitoring this process. The administrator acknowledged that running out of pain medication could result in residents experiencing severe pain, and was only aware of one resident's medication lapse at the time of the survey.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and security of medications in two key areas: the medication refrigerator and a medication cart (MC #1). During observation, the medication refrigerator was found to be operating at 52°F, which is above the recommended storage temperature range of 36°F to 46°F for several medications stored inside, including Lantus, NovoLog, Trulicity, and Repatha. Staff interviews revealed that while there was a policy requiring daily temperature checks by the night shift, there was confusion among staff regarding who was responsible for monitoring and ensuring the refrigerator maintained the correct temperature. The Director of Nursing (DON) confirmed the required temperature range and acknowledged that the facility had not established clear monitoring responsibilities following a recent change in refrigerator equipment. Additionally, MC #1 was observed unattended and unlocked in a hallway, containing both prescription and over-the-counter medications. No staff were present in the vicinity at the time of observation. Interviews with medication aides and nursing staff confirmed that facility policy requires medication carts to be locked whenever unattended and that both nurses and medication aides are responsible for ensuring this. Staff acknowledged that leaving the cart unlocked could allow unauthorized access to medications. Review of the facility's medication storage policy confirmed that all drugs and biologicals must be stored in locked compartments and under proper temperature controls. Despite this, both the medication refrigerator and MC #1 were not secured according to policy at the time of the survey, and staff were unable to provide a clear explanation for these lapses. The findings were based on direct observation, staff interviews, and review of facility policies and medication storage guidelines.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, migraines with aura, and other medical conditions did not receive appropriate pain management services as ordered. The resident had a physician's order for Oxycodone 5 mg every 6 hours as needed for pain, but the medication was not available in the facility for an extended period. Documentation showed that the resident was only administered a limited number of Oxycodone tablets shortly after admission, and there was no evidence of the medication being provided during the month of September, despite ongoing reports of pain rated as high as 7 out of 10. The pharmacy records confirmed that the Oxycodone prescription was not filled or delivered until much later, and the facility's medication administration records and narcotic count sheets corroborated the lack of availability. On one occasion, the resident complained of severe abdominal pain and requested her prescribed pain medication, but staff were unable to provide it due to its unavailability. The nurse offered Tylenol, which the resident refused, and the resident subsequently requested to be transferred to the emergency room for pain management. Progress notes indicated that staff did not complete a pain assessment at the time of the complaint, nor did they contact the nurse practitioner or physician in a timely manner to resolve the medication issue. Interviews with staff revealed confusion and lack of clarity regarding the process for obtaining triplicate prescriptions for controlled substances, and there was no evidence that the necessary steps were taken to ensure the resident's pain medication was available as ordered. The facility's own policies required comprehensive pain assessments and prompt interventions consistent with professional standards of practice and the resident's care plan. However, these procedures were not followed, as evidenced by the lack of pain assessments, failure to monitor the effectiveness of interventions, and inadequate communication with providers and pharmacy. The deficiency resulted in the resident experiencing unmanaged pain and requiring emergency transfer for pain relief.
Failure to Provide Privacy Curtains for Residents Receiving Personal Care
Penalty
Summary
The facility failed to ensure that resident rooms were equipped to provide adequate privacy for two residents who shared a room. Both residents, a female with severe cognitive impairment and mobility limitations, and a male with paraplegia and an indwelling catheter, required assistance with incontinence care and other activities of daily living. Despite their need for personal care, there was no privacy curtain in their shared room, which was observed during multiple staff and resident interviews. Interviews with the residents revealed that the female resident was uncomfortable and embarrassed by the lack of privacy during personal care, especially as she shared the room with her male family member. The male resident stated he was not bothered by the absence of privacy curtains but acknowledged it might affect his roommate. Staff members, including CNAs and an LVN, confirmed that there were no privacy curtains in the room and that they sometimes attempted to use sheets to provide some privacy. However, none of the staff had reported the missing curtains to facility management prior to the survey. Facility leadership, including the Assistant Maintenance Director, Administrator, and DON, were unaware of the missing privacy curtains until it was brought to their attention during the survey. There was no documentation or care plan indicating that the residents or their families had requested the removal or absence of privacy curtains. The facility's policy required the promotion and maintenance of resident privacy, but this was not followed in the case of these two residents.
Failure to Follow Approved Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning and services provided to residents. Specific details about the residents involved, their medical history, or their condition at the time of the deficiency are not provided in the report. The deficiency centers on the inaccuracy of resident assessments, as observed and documented by surveyors during their review.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover the resident's assessed needs.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.
Failure to Serve Palatable, Attractive, and Properly Prepared Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and prepared in a manner that conserved nutritive value, flavor, and appearance. Observations revealed that lunch meal trays delivered to residents in one hallway were unappealing, with poor arrangement and small side portions. Test trays showed inconsistencies, with one tray being well-presented and another containing overcooked, mushy, and unseasoned broccoli. Additionally, vegetables were observed sitting in water for extended periods before serving, resulting in a watery and mushy texture. The meal delivery cart doors were left open during meal delivery, exposing trays and reducing food temperatures. Staff interviews confirmed that vegetables should not be left in water, and that proper portioning and seasoning were not consistently followed, especially by new cooks in training. Further interviews indicated that complaints had been received from the resident council regarding cold food, and staff acknowledged that delays in meal delivery and improper handling of food carts contributed to this issue. The Certified Dietary Manager (CDM) admitted to being distracted during training, which led to oversight in food preparation practices. The facility's policy requires that meals be nourishing, palatable, well-balanced, and served at safe and appetizing temperatures, but these standards were not consistently met during the survey period.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and/or maintain an effective training program for all new and existing staff members. This deficiency was identified based on observations and review of facility practices, which showed that staff did not consistently receive adequate training as required. The lack of a comprehensive and ongoing training program for staff members was directly observed and documented by surveyors during the review.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to maintain the confidentiality of a resident's personal and medical records. During an observation, the RN left the medication cart unattended with the computer screen open and facing the hallway, displaying confidential medical information including the resident's name and medications. The RN acknowledged that the screen was left open and that anyone passing by, including visitors or other residents, could have accessed the information. The RN also admitted to having received in-service training on HIPAA protocols but did not recall the date and did not follow the required procedures to lock the computer screen when not in use. Interviews with facility leadership, including the Administrator and Director of Nursing (DON), confirmed that the expectation was for all resident information to be kept confidential and for computer screens to be locked when not in use. The facility's policy on safeguarding electronic protected health information requires that workstations be protected from unauthorized access, including placing terminals away from high-traffic areas and automatically locking screens. The failure to follow these protocols resulted in the exposure of a resident's confidential medical information.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency was identified based on the absence of documentation or evidence that such a plan was developed and put into place for newly admitted residents. The lack of timely planning for immediate needs upon admission was observed during the survey.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Administer Scheduled Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of seven residents, as evidenced by the omission of scheduled medication doses. Multiple residents did not receive their prescribed medications at the scheduled 5:00 pm administration time on various dates. Medication Administration Records (MARs) confirmed that medications such as antihypertensives, antiepileptics, antibiotics, antidepressants, and pain management drugs were not administered as ordered. Residents and their family members reported missed doses, and staff interviews revealed a lack of awareness or documentation regarding these omissions. Residents affected had a range of medical conditions, including gastroesophageal reflux disease, hypertension, diabetes, seizure disorders, depression, and chronic pain. Care plans for these residents included specific interventions requiring timely administration of medications to manage their conditions. Despite these documented needs, the MARs showed repeated failures to administer medications as scheduled, and in some cases, associated assessments such as blood pressure or pain level checks were also omitted. Interviews with medication aides (MAs) and the nurse practitioner (NP) indicated that there was no consistent system in place to monitor or report missed medication doses. The NP stated that missed doses were not communicated to her, and the DON acknowledged ongoing issues with medication administration, noting that a staff member responsible for one of the affected halls had been terminated for poor performance. The facility's own policy required medications to be administered within one hour of the prescribed time, but this standard was not met for the residents reviewed.
Failure to Provide Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for a resident with significant risk factors, including complete paraplegia, muscle weakness, and a history of sepsis related to a sacral wound. The resident was admitted with a stage IV pressure ulcer to the sacrum and an unstageable pressure area on the left heel. Despite physician orders for specific wound care treatments and the need for weekly skin assessments, the facility did not complete weekly skin assessments or consistently provide ordered treatments to the resident's wounds over a period of several weeks. Documentation revealed that the resident did not receive wound care treatments as ordered on multiple occasions for both the sacral wound and the left heel. The treatment administration records showed missed treatments, and there was a lack of weekly skin assessments following the initial admission assessment. The wound care doctor was not made aware of the pressure area on the left heel, and the wound care nurse had left the facility, leaving gaps in wound care oversight. The resident's wounds worsened during this period, with the sacral wound increasing in size and the left heel developing into a full-thickness open wound with necrotic tissue. Interviews with staff confirmed that weekly skin assessments were not performed, and treatments were not administered as ordered. The resident reported not receiving care to the left heel and was unaware of the wound due to paralysis. The nurse responsible for documenting treatments admitted to mistakenly signing off on treatments that were not performed. Observations confirmed the presence of an old, dated dressing on the left heel and significant deterioration of the wound. Facility policies required regular skin assessments and documentation, which were not followed, leading to the identification of an Immediate Jeopardy situation.
Removal Plan
- Resident #1 received a head-to-toe assessment including skin by the DON, findings of a worsening left heel were relayed to Medical Director and new orders received to clean wound with normal saline, pat dry, apply alginate with silver and cover with non-adherent dressing daily.
- Findings were relayed to the Medical Director.
- Emotional Distress Assessment completed for Resident #1 by the Social Worker with no emotional distress observed.
- Resident #1's Care Plan was updated by Corporate MDS Nurse regarding wound care and observations to be performed by staff. All nursing staff were in-serviced including PRN, agency staff and all newly hired staff prior to their shift.
- Charge nurses on staff conducted a 100% skin audit on 78 residents overseen by the DON. Charge nurses were in-serviced on proper skin assessment by the DON prior to the conduction of assessments. No other residents were identified as having unidentified skin issues.
- Administrator/DON initiated Staff in-service for ALL NURSING STAFF on Prevention of Pressure Ulcers, Pressure Ulcers/Skin Breakdown - Clinical Protocol & Abuse and Neglect. DON trained by VP of Clinical Services prior to start of in-service. If staff are unable to attend any of the in-services, they will be required to complete them before starting their assigned shift to include PRN staff, agency staff and any new hires.
- The Medical Director has been involved in developing the Plan of Removal. These conversations are considered a part of the QA process.
- A QAPI meeting was held with attendance of the Company President, Director of Nursing & VP of Clinical Services.
- This plan will be monitored through completion by corporate staff.
- Plan of Removal completion with continuation of oncoming staff and follow up.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was observed over a period of 8 days from January 1, 2025, to January 8, 2025. During this time, there were days when no RN was on duty, and on other days, the RN coverage was less than the required 8 hours. Specifically, on January 2, 6, and 7, 2025, there were zero hours worked by an RN charge nurse, and on January 1, 3, 4, 5, and 8, 2025, the RN coverage was less than 8 hours. Observations on January 7 and 8, 2025, confirmed the absence of RNs on the staffing sign-in sheet for certain shifts, with only one nurse working a 6-hour shift on January 8, 2025. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the DON was often the only RN scheduled to work, and there was no dedicated RN charge nurse on certain days. The DON mentioned that when he was not present, the facility relied on an outside telehealth service for triage. The ADM stated that they strive to have an RN in the building for the required hours but acknowledged the challenges in maintaining this coverage. A confidential interview also highlighted concerns about inadequate nursing staff on January 1, 2025, with only one nurse providing care to all residents during the morning shift.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services, including the timely administration of medications, for two residents. Resident #1 did not receive several scheduled medications, including carvedilol, hydralazine, isosorbide dinitrate, and ciprofloxacin, on multiple occasions. Additionally, several medications were administered outside the professional standard window of one hour before or after the scheduled time. These medications included sodium bicarbonate, Abilify, sertraline, amlodipine besylate, lisinopril, hydralazine, isosorbide dinitrate, ciprofloxacin, Acidophilus, Vitamin D3, Mirtazapine, and Med pass. Resident #1 had a history of metabolic encephalopathy, breast cancer, dementia, aphasia, dysphagia, acute kidney failure, depression, gastro-esophageal reflux disease, and hypertensive heart disease. Resident #2 also experienced issues with medication administration. He did not receive his armodafinil and omeprazole as scheduled and received several other medications outside the professional standard window. These included Jardiance, Toprol XL, Cholecalciferol, Vitamin C, senna-docusate, torsemide, citalopram, lactulose, ferrous sulfate, potassium chloride ER, Rivaroxaban, metformin, and diltiazem. Resident #2 had a history of encephalopathy, atrial fibrillation, dysphagia, heart failure, depression, diabetes mellitus, edema, and hyperlipidemia. Interviews with the nurse practitioner and the Director of Nursing revealed that there were complaints from residents about late medications, and the facility had issues with internet connectivity, which affected the accuracy of medication administration records. The facility's policy on administering oral medications did not provide specific guidance on medication timing, contributing to the deficiencies in pharmaceutical services.
Medication Error During Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, resulting in the resident receiving incorrect medication. The resident, an elderly female with a history of metabolic encephalopathy, breast cancer, dementia, and other significant health issues, was discharged with a blister card of Furosemide 40mg tablets intended for another resident. This error was discovered by the resident's family after leaving the facility, but before any medication was administered. The resident was prescribed Furosemide 20mg tablets upon discharge, but instead received a higher dosage of 40mg tablets, which were meant for a male resident with different medical conditions. The facility's records showed that the resident's discharge medication list included the incorrect dosage, and the error was confirmed through interviews with the family and facility staff. The family provided photographic evidence of the blister card, which had the other resident's name and medication instructions. Interviews with facility staff, including the interim DON and ADM, revealed a lack of proper medication verification processes during discharge. The DON stated that medications should be checked against the resident's chart before dispensing, but this was not done in this case. The ADM acknowledged the error and mentioned that a prescription was sent to the pharmacy to correct the mistake. However, the family did not return the incorrect medication card to the facility. The incident raised concerns about potential adverse effects and a possible HIPAA violation due to the mix-up of resident information.
Deficient Documentation in Resident Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records of three residents, which could lead to errors in care and treatment. For Resident #1, an incident involving an allegation of abuse by two individuals was reported to the Administrator by a hospice social worker. However, there was no entry in the progress notes for the date of the incident, indicating a lack of documentation regarding the allegation and any subsequent plan of action. Resident #2, who has a diagnosis of dementia and moderate cognitive impairment, was involved in an incident where she pointed to a staff member and accused them of causing an injury. The resident had a tender and swollen finger, but the progress notes did not reflect any documentation of this self-reported injury of unknown origin. The Corporate RN acknowledged that the incident should have been documented to ensure follow-up care. For Resident #3, who has a history of coronary artery disease and other conditions, the treatment administration record for two consecutive days showed 'N/A' for vital signs, indicating that blood pressure, temperature, pulse, and respiratory rate were not recorded. The LVN confirmed this omission and noted the potential implications of not accurately recording vital signs. The facility's Charting and Documentation Policy requires that all services, changes in condition, and incidents be documented in the resident's medical chart to facilitate communication among the interdisciplinary team.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to uphold resident rights to personal privacy for five residents, as observed during a survey. Staff members, specifically CNAs, were noted entering residents' rooms without knocking, which is a breach of privacy. This practice was observed during meal tray deliveries, where CNAs entered the rooms of several residents without knocking, despite being trained on the importance of this protocol. Interviews with the residents revealed mixed feelings about the lack of knocking. Some residents expressed discomfort and a desire for staff to knock before entering, citing feelings of nervousness and being startled when staff entered unannounced. Others were less concerned but acknowledged that knocking would be preferable, especially in situations where they might be undressed or asleep. Staff interviews, including those with CNAs and the Director of Nursing, confirmed that the facility's policy requires staff to knock before entering a resident's room to respect their privacy and dignity. However, it was noted that there was no formal policy document regarding this practice. The staff acknowledged the importance of knocking and admitted to lapses in following this protocol, attributing it to practical difficulties such as carrying trays.
Oxygen Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to ensure the safe handling, humidification, cleaning, storage, and dispensing of oxygen for respiratory care services provided to three residents. Observations revealed that the oxygen tubing and humidifier bottles for Residents 9, 16, and 25 were not dated or changed weekly as required. Specifically, Resident 9's tubing and humidifier bottle were dated 7/14/24, Resident 16's were dated 7/3/24, and Resident 25's were dated 6/30/24 with the humidifier bottle being empty. These observations indicate a lack of adherence to the facility's policy of changing the tubing and humidifier bottles every seven days. Resident 9, a female with chronic obstructive pulmonary disease, congestive heart failure, and other conditions, had an order to apply oxygen as needed and to replace humidified water and tubing weekly. However, the tubing and humidifier bottle were not changed as per the order. Resident 16, a male with shortness of breath and other diagnoses, did not have an order for changing the tubing, which was not updated after his return to the facility. Resident 25, a female with limited physical mobility and other conditions, also had an order to change the humidifier water and tubing weekly, but this was not followed. Interviews with the Infection Control Practitioner (ICP), Director of Nursing (DON), Assistant Director of Nursing (ADON), and an LVN revealed inconsistencies in the understanding and implementation of the policy for changing oxygen tubing and humidifier bottles. The facility's policy, labeled Dynasty Health Care Group-Oxygen Administration, was found to be lacking in specific guidelines for the safe handling and maintenance of oxygen equipment. This deficiency placed residents at risk of developing respiratory infections due to potential contamination of the tubing and humidifier water.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation, as observed in their kitchen operations. During an inspection, it was noted that various food items in the walk-in refrigerator and freezer were not labeled or dated, including fruit cups, cooked ground meat, boiled eggs, drinks, chicken strips, hamburger patties, and English muffins. Additionally, breakfast sausage was found improperly thawed at a temperature of 63 degrees, which is above the safe temperature of 41 degrees or below. This improper handling and storage of food items placed residents at risk of foodborne illness. Interviews with kitchen staff revealed a lack of adherence to food safety protocols, despite having completed food handler training. One cook acknowledged the incorrect temperature of the sausage and disposed of it to prevent potential illness. Another staff member incorrectly stated the safe thawing temperature for meat, indicating a misunderstanding of food safety standards. The facility's Food Storage Policy and the FDA's Food Code were not followed, as evidenced by the lack of labeling, dating, and proper temperature control of food items, which could lead to bacterial growth and potential health risks for residents.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a physician-prescribed therapeutic diet to a resident who required a mechanical soft diet due to multiple medical conditions, including dysphagia, which poses a risk for choking. The resident was observed receiving a regular diet tray that did not match the prescribed mechanical soft diet, as evidenced by the meal consisting of a whole breaded chicken patty, spaghetti noodles, mixed vegetables, and a roll. This discrepancy was noted during dining services, and the resident confirmed receiving a regular diet for all meals. Interviews with facility staff, including an LVN, the DON, and the ADM, revealed that there was a protocol in place for nurses to check meal trays against meal tickets before serving them to residents. However, the staff did not know why the resident did not receive the correct diet. The facility's Tray Identification Policy required nursing staff to verify each food tray for the correct diet before serving, but this procedure was not followed, leading to the resident not receiving the appropriate mechanical soft diet as ordered.
Failure to Properly Document and Plan Resident Discharge
Penalty
Summary
The facility failed to ensure all residents were discharged per facility requirements, specifically for one resident who was discharged without proper documentation and planning. The resident, a female with multiple medical conditions including chronic kidney disease, diabetes, and depression, was discharged due to non-payment. The facility did not complete or document the discharge planning and summary in the resident's chart upon her discharge. Key sections of the discharge planning review were left blank, including the reason for discharge, recap of the resident's stay, and post-discharge medication list discussion with the resident or family. Additionally, there were no progress notes from the social worker on discharge planning and preparation. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge. The social worker stated she was not in the building when the resident was discharged, and the Assistant Director of Nursing (ADON) mentioned that none of the staff knew where the resident was going. The Nurse Practitioner, who signed off on the discharge, was not involved in the discharge planning and only became aware of the discharge on the day it occurred. The Director of Nursing (DON) and the Administrator acknowledged that the discharge planning review and summary were supposed to be completed but were not. The facility's policy on preparing a resident for transfer or discharge was not followed. The policy required a post-discharge plan to be reviewed with the resident or their representative and for nursing services to provide discharge information and inform appropriate departments of the discharge. The failure to adhere to these policies and procedures placed residents at risk of improper discharges and inadequate post-discharge care.
Failure to Provide Timely Discharge Notice
Penalty
Summary
The facility failed to provide appropriate timing of notice before transferring a resident. Specifically, the facility did not provide the required 30-day notice before discharging a resident with multiple medical conditions, including benign neoplasm of the pituitary gland, gout, muscle weakness, hyperlipidemia, depression, edema, chronic kidney disease, unspecified convulsions, type 2 diabetes, spinal stenosis, hypothyroidism, morbid obesity, and chronic pain syndrome. The resident, who had moderately impaired cognition, was given a 30-day discharge notice due to non-payment, but was discharged a day earlier than the notice indicated. The discharge occurred without proper coordination and communication among the facility staff, the resident, and the resident's family member. Interviews with facility staff revealed that the discharge was expedited due to pressure from the corporate office, which demanded the resident be discharged within 24 hours. The Nurse Practitioner was unaware of the discharge until the day it occurred and was instructed to write the discharge order on short notice. The Administrator acknowledged that the discharge process had been ongoing for 90 days but did not provide a clear explanation for the premature discharge. The facility's policy on preparing residents for discharge was not followed, leading to the improper discharge of the resident.
Failure to Provide Care Plan Meeting Results
Penalty
Summary
The facility failed to provide a copy of the care plan meeting results to a resident and her legal representative within the required timeframe. Resident #1, a cognitively intact female with multiple medical conditions, including Gastro-esophageal Reflux Disease, Irritable Bowel Syndrome, and Chronic Pain Syndrome, requested the results of a care plan meeting held on 01/25/24. Despite multiple requests from the resident's family member (FM), who is also the responsible party, the facility did not provide the requested documents. The initial request was made on 02/04/24, followed by a reminder on 02/16/24, but as of 03/05/24, the documents had not been furnished. Interviews with the Director of Nursing (DON) and the Social Worker (SW) revealed that the SW was responsible for communicating care plan details to residents and their families. The SW cited various reasons for the delay, including a malfunctioning printer, a vacation, and being busy with other tasks. Additionally, the SW expressed uncertainty about disclosing the care plan details due to HIPAA concerns, despite the FM being listed as the responsible party on the resident's face sheet. This failure to provide the requested care plan results could impact the resident's involvement in their care planning and overall well-being.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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