Capstone Healthcare Of Hughes Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Hughes Springs, Texas.
- Location
- 215 Fm 161 Business South, Hughes Springs, Texas 75656
- CMS Provider Number
- 676154
- Inspections on file
- 29
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Capstone Healthcare Of Hughes Springs during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, and homelike environment by allowing ongoing roof leaks and damaged ceiling tiles in resident rooms, the dining room, and common areas. Surveyors observed bulging, stained, and loose tiles, visible insulation, and a stained light fixture in the dining area, as well as stained and missing tiles in multiple resident rooms, with one opening exposing the roof and at least one tile appearing damp. Several residents reported recent episodes of water dripping from the ceiling into their rooms and in front of the ice machine, and a family member described trash cans being used to catch leaking water and tiles falling in a high-traffic area. The former maintenance supervisor and other staff stated that the roof had been a long-standing problem, with repeated patching, structural concerns above the ice machine, soaked insulation, and ceiling tiles falling during storms, while administrative staff acknowledged intermittent leaks and recognized that such conditions could negatively affect residents’ sense of dignity and homelike surroundings.
The facility failed to create comprehensive care plans for three residents, neglecting to address specific needs such as depression, aggression, wound care, and dietary requirements. This oversight involved a resident with depression and aggressive behavior, another with multiple wounds lacking enhanced barrier precautions, and a third with severe cognitive impairment and dietary needs. The absence of detailed care plans could lead to inadequate care and increased risks for the residents.
The facility failed to provide palatable and appetizing food, serving burnt dinner rolls to residents during a lunch meal. The Dietary Manager noticed the rolls were burnt but did not instruct staff to discard them or offer an alternative. Staff interviews confirmed the issue, and the facility's policy requires food to be nourishing and attractive.
A long-term care facility failed to maintain an effective infection prevention and control program, as observed in two cases. A CNA did not perform hand hygiene or change gloves appropriately while providing care to a resident, leading to potential cross-contamination. Additionally, a resident on Enhanced Barrier Precautions (EBP) did not have proper signage, and a Treatment Nurse did not wear a gown during wound care. These actions violated the facility's policies and CDC guidelines, increasing the risk of infection.
A resident in a LTC facility was denied the reheating of food brought by family due to facility policy, impacting his dignity and quality of life. The resident, who had intact cognition and required assistance for ADLs, canceled his supper tray expecting to eat the reheated food. The CNA, following dietary and nursing staff instructions, informed the resident of the policy after the fact, leaving him without a meal and upset. Staff interviews confirmed the policy against reheating outside food due to safety concerns, acknowledging the resident's right to have his preferences respected.
A facility failed to ensure proper infection control practices during incontinent and urinary catheter care for a resident with severe cognitive impairment and multiple medical conditions. A CNA did not perform hand hygiene or change gloves appropriately, leading to potential cross-contamination. Staff interviews confirmed the CNA's actions violated infection control policies, increasing the risk of infections for the resident.
The facility failed to ensure proper labeling and storage of medications, resulting in expired drugs being found in the medication storage room. Staff interviews revealed no designated person or schedule for checking expiration dates, leading to the presence of expired Zinc Tablets, Acetaminophen Suppositories, and Bisacodyl Suppositories. This oversight could result in the administration of ineffective medications to residents.
The facility failed to prevent resident-to-resident altercations, resulting in physical aggression between residents. In one incident, two residents engaged in a physical altercation over an ashtray, while in another, a resident slapped his roommate over a dispute about clothing. Both incidents were witnessed by staff, but the facility did not prevent the altercations, highlighting a deficiency in protecting residents from abuse.
The facility failed to maintain the kitchen ceiling in good repair, with observations of stained and damaged ceiling tiles above food preparation areas. Staff confirmed the issue had persisted for months, posing a risk of food contamination.
The facility failed to treat several residents with dignity and respect, including forcing a resident to use a bedside commode, removing food from a resident's plate without permission, not providing knives for cutting meat, and standing over a resident while feeding her. These actions led to significant discomfort and embarrassment for the residents.
The facility failed to provide a safe, clean, and homelike environment for four residents. Three residents had brown water stains on their bedroom ceiling tiles, causing anxiety and discomfort. Another resident was required to use a bedside commode despite having a functional bathroom commode, leading to embarrassment and a lack of privacy. The maintenance director and staff were aware of these issues but did not address them in a timely manner.
The facility failed to document vital signs and access site assessments for a resident after dialysis, leading to potential risks of missed complications and inadequate care. Interviews and record reviews revealed inconsistencies in post-dialysis assessment protocols and documentation.
The facility failed to ensure proper behavior monitoring for four residents prescribed psychotropic medications, including Zoloft, Lexapro, Ativan, Buspirone, Depakote, and Sertraline. This lack of monitoring could prevent the residents from receiving the intended therapeutic benefits of their medications.
The facility failed to secure a medication cart properly, leaving two insulin pens unsupervised and the cart unlocked. Staff interviews confirmed the cart contained various medications, including narcotics, and emphasized the importance of locking it to prevent unauthorized access.
A resident's MDS assessment inaccurately coded Cilostazol, an antiplatelet medication, as an anticoagulant. The MDS Coordinator admitted to the error, and interviews revealed a lack of consistent auditing processes to ensure assessment accuracy, potentially affecting resident care and facility funding.
The facility failed to ensure accurate PASRR screening for a resident with mental health disorders, leading to the risk of the resident not receiving needed assessments and specialized services. The MDS Coordinator did not verify the accuracy of the PASRR Level 1 assessment, which incorrectly stated that the resident had no mental illness despite a diagnosis of bipolar disorder.
The facility failed to update the comprehensive care plans for two residents to reflect their current medical needs and physician orders. One resident's care plan did not include the current blood thinner medication, while another resident's care plan did not reflect his dietary needs and fluid restrictions. The MDS Coordinator, social service representative, and DON acknowledged lapses in the process of updating care plans after meetings.
A facility failed to ensure proper infection control during wound care for a resident with a chronic venous ulcer. The Wound Care Nurse did not use hand gel or wash hands after removing gloves multiple times, despite handling soiled dressings. This breach in protocol was confirmed by both the WCN and the Director of Nursing, posing a risk of infection to the resident.
Ongoing Roof Leaks and Damaged Ceilings Undermine Safe, Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment, specifically related to an ongoing leaking roof and damaged ceiling tiles in resident rooms, the dining room, and common areas. Surveyors observed multiple bulging, stained, and loose ceiling tiles in the dining room, including two bulging tiles with large brown, apparently damp stains in the far back corner above a metal cabinet, additional stained tiles in the main dining area, and a light fixture with a brown stain inside the fixture. Near the nurse’s station and in front of the ice machine leading into the dining room, several ceiling tiles had brown stains and rings of various sizes, and one tile in the hallway was loose with visible insulation. These conditions were directly observed during the survey and were associated with water intrusion from the roof. In resident rooms, surveyors observed stained, missing, and previously leaking ceiling tiles. In one shared room, a resident reported that about three weeks earlier the ceiling along the outside wall had leaked, with multiple tiles damaged and water visibly dripping into the room; some tiles had been replaced, but one tile above the roommate’s bed remained with a large brown stain covering most of the tile. Another resident stated that the roof leaked in front of the ice machine and that water sometimes dripped into his room from the ceiling; his room contained two tiles with small brown stains near the head of his bed. A third resident in the same shared room confirmed that the corner of the ceiling near the head of her bed had leaked about three weeks earlier, with water dripping into the room and leaving more than half of one tile stained brown. In another room, two ceiling tiles were missing in one corner along the outside wall, exposing the roof, and one remaining tile was stained; in yet another room, two tiles had large faint stains, with one appearing still damp. Staff, residents, and a family member described a long-standing roof problem and repeated episodes of leaking, particularly in front of the ice machine and in the dining room. The former Maintenance Supervisor, who had worked at the facility for three years, stated that the roof had been an ongoing issue, that he had repeatedly patched it with a flexible tar-like substance, and that there was a structural issue above the ice machine where iron beams were rusting through. He reported that residents on one hall, especially in one specific room, had to be moved due to leaks, that insulation in the dining room ceiling became soaked and dripped for days, and that tiles in the area leading into the dining room would fall because the roof could not be properly repaired. A housekeeper and a CNA both reported that tiles had fallen in the dining room and in front of the ice machine, that trash cans and floor blankets were used to catch and manage leaking water, and that the roof had been leaking for years. Administrative staff, including the MDS Coordinator, ADON, DON, and Administrator, acknowledged that the roof had leaked at times, that tiles had fallen or been replaced after storms, and that stained, missing, and leaking tiles could negatively affect residents’ feelings, mood, and perception of their home environment. The facility’s own policies on resident rights and homelike environment required a safe, clean, sanitary, and dignified environment, which contrasted with the observed and reported conditions.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #29, who had a history of depression and aggressive behavior, did not have a care plan that addressed his aggression towards his roommate or interventions for his depression. Despite being aware of his depression and recent aggressive incidents, the facility did not have a trauma-informed care assessment or a comprehensive plan to manage his mental health needs. Resident #41, who had multiple wounds and was at risk for pressure ulcers, did not have a care plan that included enhanced barrier precautions or interventions for his skin concerns. The facility's staff, including the MDS nurse and RN, acknowledged that the care plan was incomplete and that the necessary precautions were not documented. This lack of documentation and planning could lead to inadequate care and increased risk of infection for the resident. Resident #8, who had severe cognitive impairment, anxiety, depression, and anorexia, did not have a care plan that addressed her DNR code status, diet, or use of a plate guard. The MDS Coordinator admitted to missing these care areas when creating new care plans after a software change. The absence of a comprehensive care plan for Resident #8 meant that her specific needs and interventions were not clearly outlined, potentially impacting her quality of care.
Facility Serves Burnt Rolls to Residents
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for all residents in a confidential group meeting and during a lunch meal review. On April 1, 2025, ten anonymous residents reported being served hard, burnt dinner rolls at the noon lunch meal. The Dietary Manager acknowledged that the rolls were burnt and had been served despite noticing their condition before service. The manager admitted that burnt bread had been served previously due to an unevenly cooking oven, and no alternative was provided to the residents. Interviews with staff, including CNAs and the Director of Nursing, confirmed the issue of burnt rolls being served, with some residents only eating the top portion of the bread. The Dietary Manager and the Administrator both recognized the importance of serving palatable food and acknowledged the failure to provide an alternative to the burnt rolls. The facility's Food and Nutrition Services policy, revised in October 2017, mandates that each resident is provided with a nourishing, palatable, well-balanced diet, and that food trays are inspected to ensure the food appears palatable and attractive.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. One significant issue involved a CNA who did not perform hand hygiene or change gloves appropriately while providing incontinent and urinary catheter care to a resident. The CNA handled various items in the resident's room, including the bed, bedding, and urinary catheter bag, without changing gloves or sanitizing hands after cleaning feces from the resident. This lack of proper infection control practices was acknowledged by the CNA, who admitted to being nervous, and was confirmed by other staff members who recognized the potential for cross-contamination and increased infection risk. Another deficiency was observed with a different resident who was on Enhanced Barrier Precautions (EBP) due to open wounds. The facility failed to display appropriate signage indicating the need for EBP and the use of personal protective equipment (PPE) outside the resident's room. Additionally, a Treatment Nurse did not wear a gown while performing wound care on this resident, contrary to the facility's policy and CDC guidelines. Interviews with staff revealed a lack of clarity and adherence to the EBP protocols, which could lead to cross-contamination and infection. The facility's policies on infection prevention, hand hygiene, and perineal care were not followed, as evidenced by the actions of the staff. The report highlights the failure to implement proper infection control measures, such as changing gloves and performing hand hygiene when moving from contaminated to clean areas, and ensuring the use of PPE during high-contact care activities. These deficiencies were acknowledged by various staff members, including the DON and Interim Administrator, who recognized the potential for increased infection risk due to these lapses in protocol.
Resident's Food Reheating Request Denied, Affecting Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity by denying his request to have food brought by his family reheated. The resident, who had intact cognition and required assistance for most activities of daily living, was upset when a CNA refused to reheat his food due to facility policy. The resident had canceled his supper tray, expecting to eat the food brought by his family, and was left without a meal when the CNA informed him of the policy after the fact. The CNA explained that the dietary staff and nurse had informed her that reheating food from outside was not allowed due to infection control concerns and the inability to regulate food temperature. The resident expressed his frustration and discomfort, feeling that the CNA's actions made him feel unnecessary and uncomfortable. Despite being offered alternative snacks, the resident was upset and cried over the situation. Interviews with staff, including the RN, Social Services Assistant, Dietary Manager, DON, and Interim Administrator, confirmed the facility's policy against reheating outside food due to safety concerns. The staff acknowledged the resident's right to have his food preferences respected and recognized that not accommodating his request could negatively impact his quality of life and satisfaction. The facility's policies emphasized balancing resident choice with safety, but in this instance, the resident's preferences were not met, leading to the deficiency.
Inadequate Infection Control During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during the provision of incontinent and urinary catheter care for a resident with severe cognitive impairment and multiple medical conditions, including dementia, diabetes, and chronic kidney disease. The resident, who was dependent on staff for most activities of daily living, had an indwelling urinary catheter and was always incontinent of bowel. The care plan for the resident included specific interventions for catheter care and bowel incontinence management. During an observation, a CNA did not perform hand hygiene or change gloves appropriately while providing care to the resident. The CNA handled a fall mat from the floor, assisted in repositioning the resident, and performed incontinent care without changing gloves or sanitizing hands. The CNA then proceeded to provide urinary catheter care and continued to touch various surfaces and items in the resident's room without changing gloves or performing hand hygiene. Interviews with staff, including another CNA, an LVN, an RN, and the DON, confirmed that the CNA's actions were against the facility's infection control policies and procedures. The staff acknowledged that the failure to change gloves and perform hand hygiene could lead to cross-contamination and increase the risk of infections, such as urinary tract infections, for the resident. The facility's policies on perineal care, catheter care, and hand hygiene emphasize the importance of preventing infections through proper hand hygiene and glove use.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, specifically regarding expiration dates. During an observation, it was found that the medication storage room contained expired medications, including an unopened bottle of Zinc Tablets 50mg with an expiration date of March 2025, a package of Acetaminophen Suppositories 650 mg with an expiration date of December 10, 2024, and an opened box of Bisacodyl Suppositories 10mg with an expiration date of February 28, 2025. These expired medications were found in the medication storage room and refrigerator, indicating a lack of proper monitoring and management of medication expiration dates. Interviews with facility staff, including the Medication Aide (MA), Assistant Director of Nursing (ADON), Registered Nurse (RN), Director of Nursing (DON), and the Administrator, revealed that there was no designated person responsible for checking expiration dates, nor was there a set schedule for these checks. The staff acknowledged that expired medications should not be stored in the facility as they could be mistakenly administered to residents, potentially leading to reduced therapeutic effects. The facility's policy indicated that nursing staff were responsible for maintaining medication storage, but the lack of a systematic approach to checking expiration dates contributed to the presence of expired medications in the storage room.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving four residents. Resident #1 and Resident #2 were involved in an altercation in the smoking area over an ashtray, which escalated to both residents slapping each other. Despite the presence of a staff member, the altercation was not prevented, and both residents engaged in physical aggression. The incident was witnessed by a laundry aide, who reported that neither resident sustained visible injuries, although Resident #1 had bruising on her arm from being grabbed by Resident #2. In another incident, Resident #4 and Resident #5, who were roommates, were involved in a physical altercation. Resident #4 approached and slapped Resident #5 after being accused of taking his pants. This incident was witnessed by two CNAs, who intervened to separate the residents. No injuries were reported, but the altercation highlighted the facility's failure to prevent resident-to-resident aggression. The facility's records indicate that both incidents were discussed in QAPI meetings, and in-service training on resident-to-resident altercations and behavior awareness was conducted. However, the facility's inability to prevent these altercations and ensure the safety of its residents constitutes a deficiency in protecting residents from abuse.
Failure to Maintain Kitchen Ceiling in Good Repair
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. Observations revealed brown staining on approximately six ceiling tiles above the area of the tea maker machine, juice machine, and food processor. One ceiling tile had a rounded dropped appearance with loose particles hanging directly above the tea maker and food processor. Additionally, there was a gap around the fire sprinkler head and a crack in the ceiling tile near the air vent. These conditions were observed during the initial tour and subsequent observations, indicating ongoing issues with the ceiling tiles in the kitchen area. Interviews with the Dietary Manager (DM) and Maintenance Supervisor confirmed that the ceiling tiles had been in disrepair since around the beginning of the year. The Maintenance Supervisor had attempted to fix the leak by applying tar on the roof, but the problem persisted during heavy rains. The DM expressed concerns about potential cross-contamination from the particles hanging from the ceiling tiles. The Maintenance Supervisor acknowledged that the damaged ceiling tiles could lead to contamination of food and drinks. The Administrator (ADM) was aware of the issue and was waiting for a repair quote from a roofing company. The facility's policy on food safety and sanitation emphasized the importance of maintaining sanitary conditions to prevent foodborne illnesses, which was not adhered to in this case.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat several residents with respect and dignity, leading to multiple deficiencies. Resident #31 was forced to use a bedside commode instead of the working bathroom commode in her room, causing her significant discomfort and embarrassment. Despite her repeated requests to fix the bathroom commode, the facility did not take timely action, and staff were aware of her dissatisfaction with the situation. The maintenance supervisor confirmed that the bathroom commode was functional but was not being used due to previous plumbing issues caused by the resident flushing wipes. The facility did not provide a specific timeframe for resolving the issue, and the resident continued to feel uncomfortable and undignified using the bedside commode. Resident #18 experienced a lack of respect during a meal when the DON removed an egg roll from her plate without asking for her permission or explaining the reason beforehand. The resident felt humiliated and likened the experience to having food taken away from a dog. Staff interviews revealed that proper protocol was not followed, as they should have explained the situation to the resident before removing the food item. The DON claimed to have explained the situation and offered a substitute, but the resident's account and staff interviews indicated otherwise. Residents #38 and #33 were not provided with knives to cut their meat during meals, leading to frustration and difficulty eating. Both residents expressed their dissatisfaction with the plastic utensils provided and the lack of assistance in cutting their meat. Staff interviews confirmed that the kitchen did not routinely provide knives, and it was up to the staff to assist residents with cutting their food. Additionally, Resident #30 was fed by a CNA who stood over her instead of sitting at eye level, which could have made the resident feel rushed and uncomfortable. The ADON and ADM confirmed that staff were expected to sit while assisting residents with meals to ensure their dignity and comfort.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for four residents. Resident #1, Resident #29, and Resident #41 had brown water stains on their bedroom ceiling tiles. Resident #1's room had three ceiling tiles with brown water stains above his bed and one near the closet, with buckets placed underneath. Resident #41's room had three slightly bowing ceiling tiles with brown water stains near the window and two above the head of his bed. Resident #29's room had an 18-to-20-inch semicircular brown water stain on the ceiling. The maintenance supervisor acknowledged the issue but had not addressed it, and the DON and ADM were unaware of the problem. Resident #29 expressed anxiety about the potential for black mold due to the water stains and reported the issue to maintenance weeks prior without resolution. Resident #31 was not allowed to use the working commode in her room and was instead required to use a bedside commode. This situation arose because Resident #31 had a history of flushing excessive toilet paper and wipes, causing plumbing issues. Despite the bathroom commode being fixed, the facility continued to restrict its use, citing concerns about the septic system. Resident #31 expressed discomfort and embarrassment about using the bedside commode, feeling it lacked privacy. The maintenance director confirmed the bathroom commode was functional but had not been reinstated for Resident #31's use. The DON and ADM were aware of the situation but had not provided a clear plan for resolving it. Interviews with staff, including CNAs and the maintenance director, revealed that the bedside commode was intended as a temporary measure, but no specific timeframe for its removal was established. The ADM mentioned plans to involve occupational therapy to address Resident #31's compulsive behavior with toilet paper, but no immediate actions were taken. The facility did not have a policy related to maintaining a safe, comfortable, and homelike environment, contributing to the ongoing issues experienced by the residents.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure dialysis services were provided consistently with professional standards of practice for a resident who required such services. Specifically, the facility did not document vital signs and an assessment of the access site after the resident returned from dialysis. This failure was identified through interviews and record reviews, which revealed that the necessary post-dialysis assessments were not performed or documented for the resident, who had end-stage renal disease and required regular dialysis treatments. The resident's care plan indicated that the resident had dialysis related to renal failure and required monitoring of the access site every shift. However, the facility's dialysis communication form did not include sections for post-dialysis vital signs and access site assessments. Record reviews showed that the resident's dialysis communication forms and progress notes lacked documentation of post-dialysis assessments, and the resident confirmed that nursing staff did not check his blood pressure or pulse after dialysis sessions. Interviews with nursing staff and the Director of Nursing (DON) revealed inconsistencies in the understanding and implementation of post-dialysis assessment protocols. The RN stated that post-dialysis assessments were important to monitor for complications, but the facility did not have clear guidelines on where to document these assessments. The DON acknowledged the importance of post-dialysis assessments but was unsure if nursing staff were required to check vital signs after dialysis. This lack of clear guidelines and documentation could lead to missed complications and inadequate care for residents receiving dialysis.
Failure to Monitor Behavior for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic drugs due to inadequate behavior monitoring. Specifically, four residents were affected: Resident #2, Resident #11, Resident #16, and Resident #41. These residents were prescribed various psychotropic medications, including Zoloft, Lexapro, Ativan, Buspirone, Depakote, and Sertraline, without proper behavior monitoring to assess the effectiveness and necessity of these medications. This lack of monitoring could prevent the residents from receiving the intended therapeutic benefits of their medications. Resident #2, a male with diagnoses including bipolar disorder, dementia, and recurrent depressive disorders, was prescribed Zoloft. Despite the care plan indicating the need for behavior monitoring, no such monitoring was documented. Similarly, Resident #11, a male with a history of recurrent depressive disorders, was prescribed Lexapro without documented behavior monitoring, even though his care plan required it. Both residents had no orders for behavior monitoring noted in their consolidated physician orders. Resident #16, a male with diagnoses including depression, alcohol abuse, generalized anxiety disorder, and recurrent depressive disorders, was prescribed Ativan, Buspirone, and Lexapro. Despite care plans indicating the need for behavior monitoring, no such monitoring was documented. Resident #41, a male with Alzheimer's disease, dementia, and depression, was prescribed Depakote and Sertraline. His care plan required behavior monitoring, but no such monitoring was documented. Interviews with facility staff revealed a misunderstanding of the requirements for behavior monitoring, with some staff believing it was only necessary for antipsychotic and antianxiety medications. The facility's policy on medical utilization and prescribing emphasized the need for periodic re-evaluation and monitoring of conditions and symptoms for which medications are prescribed, but this was not adhered to in these cases.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured properly for one of four nurse medication carts. Specifically, LVN D left two insulin pens unsupervised on top of the nursing cart and subsequently left the cart unlocked with the keys in it while attending to a resident's blood glucose check. This incident was observed on multiple occasions, and attempts to contact LVN D for further clarification were unsuccessful. Interviews with various staff members, including a CMA, RN, LVN, DON, and the Administrator, revealed that the medication cart contained several medications, including as-needed medications, insulins, and narcotics. Staff members acknowledged the importance of locking the cart to prevent unauthorized access and potential harm to residents. However, the DON and Administrator were unable to provide specific details on the potential consequences of a resident accessing the cart. The facility's policy on medication storage, which mandates that medication carts be locked when not under direct observation, was not followed in this instance.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of a resident, specifically in the case of a male resident with peripheral vascular disease, acute embolism, and thrombosis. The resident's MDS assessment incorrectly coded Cilostazol, an antiplatelet medication, as an anticoagulant. This error was identified during a review of the resident's records, which showed that the resident was taking Cilostazol for acute embolism and thrombosis, but there were no current orders for other anticoagulants like Plavix or Eliquis. The MDS Coordinator admitted to marking the wrong button during the assessment and acknowledged that there was no monitoring system in place to catch such errors. Interviews with the MDS Coordinator, DON, and ADM revealed that the MDS Coordinator was responsible for the accuracy of the MDS assessments, but there was no consistent auditing process to ensure accuracy. The DON and ADM both emphasized the importance of accurate MDS assessments for proper care and facility funding. However, the facility did not have a specific policy on the accuracy of assessments, relying instead on RAI guidelines. The lack of a robust monitoring and auditing system contributed to the inaccurate coding of the resident's medication, potentially affecting the resident's care and the facility's funding.
Failure to Ensure Accurate PASRR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure that individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening. Specifically, the facility did not review Resident #2's PASRR Level 1 assessment for accuracy. Resident #2, who was diagnosed with bipolar disorder, had the mental health question answered as 'no' on the PASRR screening. This oversight could place residents at risk of not receiving needed assessments, individualized care, and specialized services to meet their needs. The resident's records indicated diagnoses of bipolar disorder, dementia, and recurrent depressive disorders, and the MDS assessment showed moderate cognitive impairment and active diagnoses of bipolar disorder and depression. Despite these indicators, the PASRR Level 1 Screening incorrectly stated that there was no evidence of mental illness. Interviews with facility staff revealed that the MDS Coordinator was responsible for PASRRs and admitted to inputting the referring entity's referral paperwork into the system without verifying its accuracy. The MDS Coordinator acknowledged awareness of Resident #2's bipolar disorder diagnosis but did not consider the resident PASRR positive due to the presence of dementia. The Director of Nursing (DON) and the Administrator (ADM) also confirmed that there was no process in place to ensure the accuracy of PASRR referrals from the referring entity until the incident with Resident #2. The ADM stated that a new process had been implemented to review referrals before submission, but this was only after the deficiency was identified. The facility did not have a PASRR policy until the date of the interview.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plans for two residents were not updated to reflect their current medical needs and physician orders. Resident #1's care plan did not include the current blood thinner medication, Cilostazol, that he was prescribed, instead listing outdated medications Plavix and Eliquis. This oversight occurred despite the resident's medical records indicating the correct medication and diagnosis for acute embolism and thrombosis of the right lower extremity. The MDS assessment also confirmed that Resident #1 had moderate cognitive impairment and was taking an anticoagulant during the assessment period, yet the care plan was not updated accordingly. The MDS Coordinator acknowledged that the care plan should have been updated to reflect the current medication orders but admitted that changes were not always made after care plan meetings. The DON and social service representative also confirmed that the care plans should be revised to accurately reflect the resident's needs but noted lapses in the process of updating care plans after meetings. Resident #11's care plan was similarly outdated and did not reflect his current dietary needs and fluid restrictions. Despite being on a mechanically altered diet with increased protein intake and a liberal fluid restriction of 1200 milliliters a day, these details were not included in his care plan. The resident's medical records and physician orders clearly indicated these dietary requirements, but the care plan was not updated to reflect them. The MDS Coordinator, social service representative, and DON all acknowledged that the care plan should have been updated to include these details. The MDS Coordinator admitted that it was her responsibility to ensure care plans were current but noted that changes were not always made after care plan meetings. The social service representative also confirmed that if she was not directly told to update a problem on a care plan during the meeting, it could get missed. The DON emphasized that care plans should be revised to accurately reflect the resident's needs and guide their care, but noted lapses in the monitoring process to ensure care plans were updated. The ADM also confirmed that care plans should be updated to reflect current physician orders and that monitoring of care plan revisions happened during IDT meetings. However, the facility's Care Area Assessment policy indicated that care plans should be individualized and updated based on clinically significant events, which was not consistently followed in these cases.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to ensure an infection prevention and control program during wound care for a resident with a chronic venous ulcer. The Wound Care Nurse (WCN) did not practice proper infection control measures by failing to use hand gel or wash hands after removing gloves multiple times during the dressing change procedure. This lapse in protocol was observed during a wound care dressing change, where the WCN removed gloves and put on new ones without sanitizing hands, despite handling soiled dressings and other materials. The resident involved was an elderly male with a history of peripheral vascular disease, acute embolism, thrombosis, and a non-pressure chronic ulcer on the right calf. The resident's care plan required daily wound treatment, and the resident was noted to have moderate cognitive impairment but was generally independent in personal hygiene and dressing. During the dressing change, the WCN acknowledged the failure to wash hands or use hand gel after glove removal, which she admitted could place the resident at risk for infection. Interviews with the WCN and the Director of Nursing (DON) confirmed the breach in infection control protocol. The WCN admitted to not using hand gel or washing hands during the procedure and recognized the potential risk of infection this posed to the resident. The DON stated that hand washing or using hand gel is necessary after removing soiled gloves to prevent the spread of contaminants, especially during procedures involving soiled dressings. Facility policies also mandated hand washing after removing contaminated gloves, which was not followed in this instance.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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