Cambridge Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Texas.
- Location
- 1106 Golfview, Richmond, Texas 77469
- CMS Provider Number
- 675901
- Inspections on file
- 34
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cambridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment, contractures, and dependence on staff for ADLs were observed lying in bed with Hoyer slings under their upper torsos, uncovered, with bed covers at the foot of the bed, while the room door was open and the privacy curtain not drawn. A CNA acknowledged leaving the room to obtain assistance with transferring them and stated they should have been covered for privacy and dignity. The ADON confirmed residents should be covered to promote dignity, and facility policy required maintaining body privacy and shielding residents from passers-by with a closed door or drawn curtain.
A resident with dementia, severe cognitive impairment, and documented need for substantial assistance with toileting was found wearing a pull-up over a brief that was heavily soiled with urine, with her clothing visibly wet. A CNA reported that the family had taken the resident to the bathroom and had double briefed her, and the CNA did not subsequently check the resident for toileting or incontinent care needs, despite stating that residents should receive incontinent care about every 2 hours. The family member reported routinely providing the resident’s care when present, double briefing at the resident’s request, and having previously complained that staff did not change the resident’s brief for hours, while the ADON acknowledged staff remained responsible to follow up on toileting even when family assisted.
Two residents did not receive care consistent with the facility’s infection control and incontinence policies. One cognitively impaired, fully incontinent resident was found in double briefs that were heavily soiled with urine, despite a care plan requiring disposable briefs and timely checks and changes; the assigned CNA did not verify toileting or incontinence needs after a family visit and relied only on asking if everything was okay. Another resident with intact cognition, total incontinence, and a colostomy was on enhanced barrier precautions, yet two CNAs provided incontinence care wearing only gloves, did not don gowns, used hand sanitizer instead of germicidal wipes to clean the bedside table, brought linen from another resident’s room, and performed perineal care using the same wipes in a back-and-forth motion rather than front-to-back with single-use wipes, contrary to EBP and infection control training.
A resident with hemiparesis, osteoporosis, reduced mobility, and prior femur fracture was care planned and documented on the MDS/Kardex as needing "staff assistance" for bed mobility, toileting, and bathing, but the care plan did not specify whether a 1‑person or 2‑person assist was required. Facility staff, including the MDS team and DON, reported that "staff assistance" was generally interpreted as a 1‑person assist and that the number of staff used was informally adjusted based on staff strength and the resident’s condition. During incontinent care using a mobility bar, a CNA provided a 1‑person assist; the resident rolled off the bed and sustained a comminuted intra‑articular distal femur fracture, with the resident later reporting that assistance for such care had alternated between one and two staff members.
A resident with hemiparesis, osteoporosis, reduced mobility, and a history of falls, who was care planned as dependent for bed mobility and at risk for falls, fell from bed during a bed bath and incontinence care provided by one CNA while using a mobility bar for turning. The resident reported that staff were not following protocol and that two staff were needed for turning, and staff interviews confirmed that assistance during bed baths and incontinent care alternated between one and two staff. After the witnessed fall, the resident initially complained of shoulder pain and later reported bilateral leg and knee pain; shoulder and lower-extremity x-rays were read as negative, but a subsequent CT scan at the hospital showed a comminuted intra-articular distal femur fracture. The family member stated they were not informed of the fall and requested hospital evaluation when the resident continued to complain of leg pain. The deficiency centers on the failure to keep the environment as free of accident hazards as possible and to provide adequate supervision during care, consistent with the facility’s fall management policy.
The facility failed to maintain clean and sanitary rooms and restrooms for multiple residents with significant cognitive and physical impairments. Surveyors observed a shared restroom with a glove on the floor and feces on a toilet seat riser on repeated checks, and another shared room with crumbs, utensils on the floor, dried brown substances in the toilet bowl, and soiled briefs left on the restroom floor. A family member reported routinely finding one resident’s room dirty, with an unmade bed and clothes on the floor, and stated she often cleaned the room herself. Housekeeping staff, the housekeeping supervisor, and the DON confirmed that housekeeping and CNAs shared responsibility for cleaning rooms, restrooms, and removing trash and soiled briefs, and acknowledged that unremoved trash and soiled items could contribute to infection. Despite a written homelike environment policy requiring cleanliness and order, these observations showed that the facility did not ensure thorough cleaning and sanitation in the affected rooms.
A resident with multiple comorbidities and intact cognition had PRN orders for Tylenol for pain and was documented as having significant pain on the MAR, but the MAR did not show that Tylenol was administered despite a nursing progress note stating that APAP was given and tolerated. The LVN later reported she had administered Tylenol and likely recorded it only in a personal paper tablet, and the DON confirmed that medications are expected to be documented on the MAR at the time of administration, resulting in incomplete and inaccurate clinical records.
A resident with profound intellectual disabilities and multiple complex medical conditions did not have PASRR evaluation recommendations incorporated into their assessment and care planning. The facility failed to submit a required NFSS request for specialized services following an IDT meeting, and staff interviews revealed a lack of awareness and communication regarding the recommendation for a prosthetic device. This resulted in the omission of necessary documentation and referral for specialized services.
A medication aide administered a phosphate-binding medication to a resident with end stage renal disease without ensuring it was given with food, as required by the physician's order and medication label. The resident had not eaten recently and no food was provided at the time of administration, resulting in a failure to follow prescribed medication administration procedures.
Surveyors found that an open, undated bag of macaroni and a disposable plastic cup left in a cornmeal container were present in the kitchen, contrary to facility policy requiring all opened food items to be dated and properly stored. Staff and management confirmed these actions were not in line with safe food handling practices and could lead to cross-contamination.
Two staff members failed to wear appropriate PPE while providing direct care to a resident with a tracheostomy on Enhanced Barrier Precautions, despite clear signage and facility policy requiring gown and glove use for high-contact care activities. Leadership was unaware of the lapse until shown video evidence, and both the DON and ADON/IP confirmed that PPE was required in these circumstances.
A resident with multiple comorbidities developed a Stage 3 sacral wound due to inadequate pressure ulcer care and prevention measures. The facility failed to implement effective interventions, resulting in worsening skin conditions. Observations showed a lack of proper offloading and timely incontinent care, and staff interviews revealed inconsistencies in wound care practices and documentation.
A resident with multiple health conditions, including spinal stenosis and diabetes, developed a sacral wound and MASD, but the facility failed to update the care plan to address these issues. Despite the resident's high risk for skin breakdown, the care plan was not revised to include the sacral wound, leading to a deficiency in care. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition.
A resident developed a Stage IV sacral pressure ulcer and a deep tissue injury on the left heel while under the care of a facility. Despite having a care plan, the facility failed to prevent the deterioration of the resident's condition, leading to debridement and hospitalization. The facility did not timely intervene or notify a wound care specialist, resulting in the resident developing sepsis due to MRSA and sacral osteomyelitis.
Failure to Maintain Privacy and Dignity for Two Dependent Residents
Penalty
Summary
The deficiency involves failure to maintain personal privacy and dignity for two residents who were dependent on staff for activities of daily living. One resident was an older female with hemiplegia and hemiparesis following a cerebral infarction, contractures of the upper and lower body, dysphagia, and a BIMS score of 0 indicating severely impaired cognition. Her care plan included staff participation in dressing due to an ADL self-care performance deficit. During observation, her room door was open, the privacy curtain was not drawn, and she was lying in bed on her back with the head of the bed lowered, wearing a gown with a Hoyer lift sling under her upper torso. She was uncovered, with bed covers at the foot of the bed, and was not interviewable. The second resident was an older female with dementia, osteoarthritis, anxiety, joint contractures, and a BIMS score of 3, also indicating severely impaired cognition, and was dependent on staff for ADLs. Her care plan included an intervention to close the curtain while providing care to protect her right to health, safety, and dignity. Observation showed her door open, curtain not pulled, lying on her back with the head of the bed lowered, wearing a gown with a Hoyer sling under her upper torso, and uncovered with covers at the foot of the bed. CNA A, who had been working at the facility for a year, entered the shared room and acknowledged that both residents should have been covered for privacy and dignity, stating she had left the room to get assistance with getting them out of bed. The ADON confirmed that residents should be covered and not exposed to promote dignity, and the facility’s Resident Rights/Dignity and Respect policy required maintaining privacy of the resident’s body and shielding residents from passers-by with a closed door or drawn curtain.
Failure to Provide Timely Incontinent Care and Maintain Continence Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who was continent on admission received services and assistance to maintain continence and appropriate incontinent care. The resident was an elderly female with diagnoses including anxiety, need for assistance with personal care, history of falls, osteoarthritis, and dementia, with a BIMS score of 3 indicating severely impaired cognition. Her quarterly MDS documented that she required substantial/maximal assistance with toileting hygiene and lower body dressing and was always incontinent of urine and bowel. Her comprehensive care plan identified an ADL self-care performance deficit related to cognitive deficit, dementia, and history of falls, with an intervention requiring staff participation with personal hygiene and oral care. On the day of observation, the resident was seen sitting in a recliner and was alert to name but not place or time. When asked, she stated she believed her brief was wet but then said she did not know, and there was no urine odor at that time. A CNA reported that she had taken the resident to the bathroom about 30 minutes earlier and that the resident could stand with one-person assistance. At the surveyor’s request, the CNA assisted the resident to the bathroom via wheelchair. When the resident stood from the recliner, the back of her pants was observed to be wet. In the bathroom, when the CNA pulled down the resident’s pants, the resident was found to be wearing a pull-up brief over another brief, and the inner brief was heavily soiled with urine, although the resident’s skin remained intact. The CNA stated that the resident was a “heavy wetter” and that it was the resident’s family member who had double briefed her. The CNA said she only took the family member to the bathroom and that the family member had taken the resident to the bathroom, and she did not check the resident to see if she required incontinent care or needed to use the bathroom. The CNA reported that she typically checked on residents needing assistance every 1½ to 2 hours and acknowledged the importance of providing incontinent care at least every 2 hours to avoid rashes and soiled clothing. The resident’s family member later reported that she had taken the resident to a dental appointment, returned her to the facility late morning, took her to the bathroom, and double briefed her at the resident’s request because the resident did not want her clothes to get wet. The family member also stated that she often did everything for the resident when present, had concerns that staff did not change the resident’s brief in a timely manner, and had previously reported to the facility that staff sometimes did not enter the room for hours to change the resident. The ADON stated that even when a family member says they will take a resident to the bathroom, staff should follow up to ensure the resident’s needs are met and that incontinent care should be provided at least every 2 hours, consistent with facility policies on incontinence and quality of life.
Failure to Follow Infection Control and Incontinence Care Practices for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program and to provide appropriate incontinence care for two residents. For one resident with dementia, severe cognitive impairment (BIMS score of 3), osteoarthritis, a history of falls, and total incontinence of bowel and bladder, the care plan required use of disposable briefs and checking and changing as indicated, with monitoring for signs and symptoms of UTI. On the survey date, this resident was observed sitting in a recliner, alert only to name, and stated she believed her brief was wet but was unsure. A CNA reported having taken the resident to the bathroom about 30 minutes earlier and stated the resident was checked every 1.5 to 2 hours. When the CNA assisted the resident to the bathroom at the surveyor’s request, the back of the resident’s pants was observed to be wet, and the resident was found wearing a pull-up brief over another brief that was heavily soiled with urine, although the skin remained intact. Further interviews revealed discrepancies in the timeline of care and who provided toileting assistance. The CNA stated that the resident’s family member had taken the resident to the bathroom and that the family member had doubled briefed the resident, and the CNA did not verify whether the family member had actually taken the resident to the bathroom or check the resident for incontinence. The CNA acknowledged she only asked if everything was okay and did not assess whether the resident needed incontinence care or toileting. The family member later reported that she had taken the resident to a dental appointment and returned her to the facility, took her to the bathroom once, and doubled briefed her because the resident did not want her clothes to get wet. The family member also reported ongoing concerns that staff did not change the resident’s brief in a timely manner and that she had previously notified the facility about long periods without staff entering the room. The resident was later evaluated at the hospital for altered mental status, with urinalysis showing bacteria in the urine and subsequent orders for a UA C&S and Nitrofurantoin for UTI. For another resident with intact cognition (BIMS score of 13), cerebral infarction, a femur fracture, reduced mobility, muscle weakness, and total incontinence of bowel and bladder with a colostomy, the care plan included checking as required for incontinence. The resident’s room had enhanced barrier precautions (EBP) signage and a PPE hanger with germicidal wipes, gloves, masks, and disposable gowns. During observed incontinence care, two CNAs washed their hands and donned gloves but did not wear disposable gowns despite the EBP signage. One CNA went into another resident’s room, took large towels from that room, and brought them into this resident’s room to use as linen. The same CNA removed items from the bedside table and attempted to disinfect the table using hand sanitizer instead of the available germicidal wipes. During perineal care, the CNAs used the same wipes repeatedly, cleaning the groin, perineal area, and buttocks back and forth rather than using one wipe at a time and wiping from front to back. Interviews with the CNAs confirmed that they did not follow EBP and infection control practices. One CNA stated she did not think she needed a gown and only realized after reading the EBP sign that a disposable gown was required to protect herself and the resident from bacteria. She acknowledged that taking linen from one resident’s room to another was not acceptable due to cross-contamination risk and that she used hand sanitizer on the bedside table because it was available, forgetting to use the germicidal wipes. She also stated she had been taught to wipe from front to back with one wipe at a time to prevent infection. The other CNA stated she knew residents on EBP required gowns and gloves and that linen should not be moved between rooms, and she acknowledged that perineal care should be done upward and away, not back and forth, to prevent introducing bacteria into the vaginal area. The ADON, serving as Infection Preventionist, confirmed that staff had been in-serviced on infection control, handwashing, cleaning and disinfecting surfaces with germicidal wipes, and EBP, and stated that staff should provide incontinence care at least every two hours, wear appropriate PPE for residents on EBP (including those with colostomies), avoid moving linen between rooms, and clean from front to back during incontinence care. Facility policies on infection control and incontinence required staff to minimize the spread of infections and provide appropriate treatment to prevent infections.
Failure to Specify Bed Mobility Assistance Level in Care Plan Resulting in Fall Injury
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with clear, measurable objectives and time frames for a resident’s bed mobility needs. The resident was an older female with multiple significant diagnoses, including cerebral infarction with hemiplegia/hemiparesis on the left non-dominant side, lack of coordination, reduced mobility, osteoporosis, muscle weakness, and a prior displaced comminuted fracture of the left femur. Her comprehensive MDS showed intact cognition (BIMS 14) and documented that she was dependent on staff for rolling left and right, with the helper doing all of the effort or requiring assistance of two or more helpers. The care plan and Kardex, however, only stated that she required “staff assistance” for bed mobility and did not specify whether she required a 1‑person or 2‑person assist. On the date of the fall, the resident’s care plan included problem areas such as ADL self‑care performance deficit related to functional decline and contractures, positioning support devices (HALO and 1/4 siderails), and risk for falls related to history of falls, hypotension, and generalized weakness. Interventions for bed mobility stated only that she required staff assistance for bed mobility (rolling left and right, sit to lying, lying to sitting), without clarifying the number of staff needed. The MDS and Kardex were based on section GG and also reflected that she was dependent for toileting, showering/bathing, and rolling, but again did not distinguish between 1‑person and 2‑person assist. Interviews with the MDS Coordinator, MDS Resource Coordinator, and DON confirmed that the facility’s practice was to interpret “staff assistance” as 1‑person assist, with the number of staff informally adjusted depending on the CNA’s strength and the resident’s condition on a given day, rather than being explicitly defined in the care plan. During the incident, a CNA provided a bed bath and incontinent care to the resident using the mobility bar (HALO). The CNA reported that after completing the bed bath, she positioned the resident on her right side, with the resident holding the mobility bar, and asked the resident multiple times if she had a firm grasp. As the CNA placed an adult brief under the resident, the resident rolled off the bed and landed on her left side. Progress notes documented that the resident fell from the bed while using the mobility bar, with vital signs stable and initial complaints of pain to the left side. Subsequent notes showed ongoing complaints of bilateral leg, knee, and ankle pain, and imaging eventually revealed a comminuted, mildly impacted, intra‑articular fracture of the distal left femur, requiring a leg immobilizer. The resident later stated that sometimes one staff member and sometimes two staff members assisted her with bed baths and incontinent care, and that the aide involved in the fall was not following protocol. Facility leadership acknowledged that the Kardex and care plan did not specify 1‑person versus 2‑person assist and that aides were expected to infer this from the generic “staff assistance” designation.
Failure to Prevent Fall and Injury During Bed-Level Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision during incontinence care, resulting in a resident’s fall and subsequent femur fracture. The resident was an older female with multiple significant diagnoses, including prior cerebral infarction with hemiplegia/hemiparesis on the left side, osteoporosis, reduced mobility, muscle weakness, lack of coordination, and a prior displaced comminuted fracture of the left femur. Her comprehensive and quarterly MDS assessments documented that she was dependent on staff for rolling left and right in bed and had a history of falls with major injury. Her care plan identified ADL self-care performance deficits, need for staff assistance with bed mobility and colostomy/incontinent care, and a requirement for two-person assistance with transfers using a Hoyer lift, as well as fall risk related to history of falls, hypotension, and generalized weakness. On the date of the incident, the resident was receiving a bed bath and incontinent care from one CNA. According to the ADON’s progress note, during the bed bath the resident used a mobility bar to turn and misjudged the width of the bed, causing her momentum to roll off the bed before staff could stop her, and she landed on the floor on her left side. The CNA later stated she had finished the bed bath and was positioning the resident on her right side to apply an adult brief while the resident held the mobility bar. The CNA reported asking the resident three times if she had a firm grasp on the bar, and as soon as she placed the brief under the resident, the resident rolled off the bed and landed on her left side in a seated position. The resident reported that the CNA was applying lotion to her legs before she was pushed out of bed, clarified that she did not believe it was intentional, and stated that the CNA was not following protocol. The resident also stated that there needed to be two people when turning her and that sometimes one staff member and sometimes two staff members assisted her with bed baths and incontinent care. Following the fall, nursing staff documented that the event was witnessed and that the resident initially complained of shoulder pain. Vital signs were taken, and an x-ray of the left shoulder was ordered and later read as showing no fracture or acute abnormality. Another nurse reported performing range of motion on both arms and legs, checking the resident’s head, and obtaining vital signs at the time of the fall but did not document this assessment because the resident was not on her assignment. Over the next days, the resident complained of bilateral leg, knee, and ankle pain, and the NP ordered STAT x-rays of both femurs, knees, and ankles, which were read as showing osteoporotic bones and osteoarthritis but no acute fractures or dislocations. The resident stated she complained of left leg pain for three days. Later, at the request of a family member due to ongoing leg/knee pain, the resident was sent to the hospital, where a CT scan of the left lower extremity revealed a comminuted, mildly impacted, intra-articular fracture of the distal femur. The family member reported not being informed of the fall and only learning of it before insisting on hospital evaluation. The facility’s fall management policy stated that residents are to receive appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs, but the report findings describe that the facility failed to prevent the fall during care and to keep the environment as free of accident hazards as possible for this resident.
Failure to Maintain Clean and Sanitary Resident Rooms and Restrooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, specifically by not thoroughly cleaning and sanitizing resident rooms and restrooms in the 100 hall. For one resident with severe cognitive impairment, osteomyelitis, diabetes with neuropathy, muscle weakness, and frequent incontinence, and another resident with severe cognitive impairment, Alzheimer’s disease, heart failure, and occasional incontinence, surveyors observed their shared restroom on multiple occasions. The restroom contained a pink latex glove on the floor beside the toilet and a toilet seat riser with a dry brown substance on the seat, later identified as feces. These conditions were observed both when the residents were out of the room and when they were present, and the feces remained on the toilet seat riser over several observations. Two additional residents, one with intact cognition but dementia, diabetes, polyneuropathy, and muscle weakness, and another with moderate cognitive impairment, diabetes, CKD stage 3A, anemia, and muscle weakness, were also found to be living in an unclean environment. Their shared room had crumbs and a white plastic spoon on the floor, and the restroom toilet bowl had a dried brown substance. A pair of soiled briefs was observed on the restroom floor in the corner. A family member of one of these residents reported that every time she visited, the room was dirty, the bed was not made, and the resident’s clothes were on the floor, and that she often ended up cleaning the room herself, sometimes finding the room dirty even when visiting twice in one day. Interviews with housekeeping staff and facility leadership confirmed that housekeeping staff were responsible for cleaning resident rooms and restrooms, sanitizing tables, cleaning toilets, and removing trash, and that CNAs shared responsibility for removing trash and bagging soiled briefs. The housekeeper assigned to the 100 hall acknowledged that trash and soiled clothing lying around in resident rooms could be hazardous and could lead to infection. The housekeeping supervisor and DON stated that housekeeping staff did not clean when food was being served on the hall and that some rooms required cleaning twice a day, with CNAs expected to notify housekeeping when residents removed dirty briefs. Despite these stated responsibilities and policies, including a homelike environment policy requiring cleanliness and order, the observed conditions in the four residents’ rooms and restrooms demonstrated that the facility failed to ensure thorough cleaning and sanitation. The facility’s homelike environment policy dated October 2009 stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including cleanliness and order. However, the persistent presence of feces on toilet surfaces, dried brown substances in toilet bowls, soiled briefs on restroom floors, and general room clutter and debris showed that this policy was not effectively implemented in the affected rooms on the 100 hall.
Incomplete MAR Documentation for PRN Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident receiving pain management. The resident was an older female with multiple significant diagnoses, including cerebral infarction with resulting hemiplegia/hemiparesis, reduced mobility, osteoporosis, muscle weakness, and a history of a displaced comminuted fracture of the left femur. Her comprehensive and quarterly MDS assessments showed intact cognition (BIMS 14) and documented that she received scheduled and PRN pain medications and non-medication interventions for pain. Physician orders included monitoring pain every shift using a 1–10 scale and PRN orders for Meloxicam and Tylenol 325 mg, two tablets by mouth every six hours as needed for mild pain. Following a fall from bed on 1/6/26, a progress note documented that she complained of pain to her left side and was medicated for discomfort. On 1/8/26, the Medication Administration Record (MAR) documented a pain level of 8 for the resident on the night shift (Nocs), but there was no corresponding documentation on the MAR that Tylenol 325 mg was administered that day. A progress note entered on 1/9/26 by an LVN stated that the resident, status post fall, complained of knee pain during the shift and was medicated once with APAP 325 mg as ordered, which she tolerated well. In an interview, the LVN reported that she gave Tylenol when the resident reported pain of 8, that the resident’s pain decreased and she likely went to sleep, and that failure to document on the MAR was probably an oversight, despite having noted it in her paper tablet. The DON stated that her expectation was that nurses document medication administration on the MAR at the time it is given. Facility documents, including the LVN job description and the documentation policy, describe the requirement to complete charting and maintain a concise account of treatment, care, and resident response, underscoring that the missing MAR entry for the administered Tylenol constituted incomplete and inaccurate clinical documentation.
Failure to Incorporate PASRR Recommendations and Submit NFSS Request
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident's assessment, care planning, and transition of care. Specifically, the facility did not submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within 20 days after the Interdisciplinary Team (IDT) meeting, as required. This omission was identified for one resident who was PASRR positive for intellectual disability and had a recommendation for a prosthetic device documented in the Person-Centered Service Plan (PCSP). Record review showed that the resident had multiple complex diagnoses, including profound intellectual disabilities, cerebral palsy, contractures, and was totally dependent on activities of daily living. The resident's care plan acknowledged the PASRR assessment and the need for specialized services, but there was no evidence in the clinical record that the NFSS form was completed or submitted. Interviews with facility staff revealed a lack of awareness and communication regarding the PCSP recommendation for a prosthetic device, with the MDS coordinator and RN both stating they were not aware of the recommendation at the time of the meeting. The physical therapist also indicated that no device was recommended during the PASRR meeting. The facility's policy requires that all residents be properly screened using PASRR and that referrals for specialized services be made to the appropriate state agencies. However, in this case, the process was not followed, and the required documentation and referral for specialized services were not completed. Staff interviews confirmed that the failure to submit the NFSS could prevent residents from receiving necessary services for their wellbeing.
Failure to Administer Medication as Ordered with Required Food
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications as ordered for a resident with end stage renal disease and type 2 diabetes mellitus with chronic kidney disease. Specifically, the medication Sevelamer Carbonate, prescribed to be taken with meals to control phosphorus levels, was administered by a medication aide without food, contrary to the physician's order and the instructions on the medication container. During observation, the medication aide gave the resident two tablets of Sevelamer Carbonate in the resident's room where no food or snacks were present. The resident confirmed that he had eaten lunch much earlier and would not have dinner until later, and the aide did not inquire about the availability of snacks or offer food at the time of administration. The medication administration record showed the medication was documented as given at that time, and the aide later acknowledged not following the special instructions due to being observed during the process. Interviews with the facility pharmacist, hemodialysis nurse, nurse practitioner, and director of nursing confirmed that Sevelamer Carbonate requires administration with food for proper absorption, as indicated by the physician's order and medication label. The facility's policy also requires medications to be administered as prescribed, including any special instructions. The failure to administer the medication with food constituted a deviation from both the physician's order and facility policy.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
During a kitchen inspection, surveyors observed that a half-used bag of uncooked enriched macaroni was left open and undated in the dry storage area. Additionally, a disposable plastic cup was found left inside a large container of cornmeal. These practices were not in accordance with the facility's food storage policy, which requires all opened containers to be dated and sealed or covered during storage. Interviews with dietary staff, the dietary manager, and the administrator confirmed that all food items should be dated upon opening and that leaving a disposable cup in a food container is not permitted due to the risk of cross-contamination. The facility's own policy, last revised in July 2014, specifies that opened containers must be dated and properly sealed or covered. The observed failures in food storage and handling could place residents at risk of cross-contamination and foodborne illness.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions for a resident requiring such measures. Specifically, two staff members, identified as Unknown A and Unknown B, did not wear the appropriate personal protective equipment (PPE) while providing direct care to a resident with a tracheostomy who was on Enhanced Barrier Precautions. Video monitoring screenshots showed that one staff member did not wear a mask or gown, and the other did not wear a gown during high-contact care activities. The resident involved had significant medical conditions, including anoxic brain damage, respiratory failure, type 2 diabetes with hyperglycemia, Alzheimer's disease, chronic kidney disease stage 3, tracheostomy status, persistent vegetative state, unspecified dementia, and aphasia. The care plan for this resident specifically required the use of Enhanced Barrier Precautions due to the tracheostomy, and signage was posted on the resident's door outlining the required PPE for high-contact care activities. Despite these measures, staff failed to comply with the established protocols. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed that staff are required to don and doff PPE when providing care to residents on Enhanced Barrier Precautions. Both leaders were unaware that staff had failed to use the required PPE and acknowledged that such lapses could result in the spread of infection. Review of the facility's infection control policy further supported the requirement for PPE use during high-contact care activities for residents on Enhanced Barrier Precautions.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for a resident, leading to the acquisition of a Stage 3 sacral wound. The resident, who was bedfast and had multiple comorbidities including spinal stenosis, diabetes, and congestive heart failure, was admitted with a red area on the groin or buttock. Despite being at high risk for pressure ulcers, the facility did not implement effective interventions to prevent skin breakdown or promote healing of existing wounds. The care plans for the resident did not adequately address the sacral wound, and there was a lack of documentation and timely intervention for the moisture-associated skin damage (MASD) and incontinence-associated dermatitis (IAD) observed in the groin area. Observations revealed that the resident was often found in a supine position without proper offloading measures, and there were significant gaps in the documentation of repositioning and incontinent care. The Braden Scale assessments indicated a high risk for pressure ulcers, yet the facility did not consistently follow through with necessary preventive measures. Interviews with staff revealed inconsistencies in wound care practices and communication. The wound care nurse and other staff members were aware of the resident's skin issues but failed to document and address them adequately. The wound care doctor noted that the sacral wound worsened after the resident's return from the hospital, and there was a lack of adherence to repositioning and offloading recommendations. The facility's failure to provide timely and effective care placed the resident at risk for further skin breakdown, infection, and pain.
Failure to Update Care Plan for Resident with Sacral Wound and MASD
Penalty
Summary
The facility failed to ensure that the care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for a resident who had a sacral wound and moisture-associated skin damage (MASD) to the groin. The care plan did not accurately address the sacral wound, which was a significant oversight given the resident's condition and risk factors. The resident, a male with multiple diagnoses including spinal stenosis, dysphagia, Type 2 Diabetes, congestive heart failure, and chronic kidney failure, was bedfast and at high risk for skin breakdown. Despite the presence of a sacral wound and MASD, the care plan was not updated to reflect these conditions. The care plan dated 4/1/2024 only addressed the risk of skin breakdown due to incontinence, and subsequent care plans failed to include the sacral wound, even as it progressed. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's skin conditions. The Wound Care Nurse was aware of the sacral wound and MASD but did not ensure the care plan was updated. The Director of Nursing and Executive Director were also unaware of why the care plan did not address the sacral wound, indicating a breakdown in the facility's processes for updating care plans in response to significant changes in a resident's condition.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a Stage IV sacral pressure ulcer and a deep tissue injury on the left heel for a resident who was admitted without pressure ulcers. The resident, who had multiple medical conditions including encephalopathy, hypertension, and cognitive impairment, developed these pressure injuries while under the care of the facility. Despite having a care plan that included interventions such as an air mattress, repositioning, and skin assessments, the resident's condition worsened, leading to debridement and hospitalization. The facility did not timely intervene when the resident's Stage IV pressure ulcer continued to deteriorate. The resident was not sent to the hospital promptly and was only suggested for hospice care. Additionally, the facility failed to notify a wound care specialist physician about the worsening condition of the pressure ulcer, resulting in a lack of evaluation and modification of the wound treatment for 12 days. This inaction contributed to the resident's development of sepsis due to MRSA, sacral osteomyelitis, and the worsening of the sacral pressure ulcer. The facility's records indicate that there were inconsistencies in the completion of prescribed treatments, such as the use of a low air loss mattress and preventive skin care. The resident's weight loss and nutritional intake were also inadequately monitored, which may have contributed to the deterioration of the pressure ulcers. The lack of timely and appropriate interventions placed the resident at risk of further skin breakdown, infection, and pain.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
