Carrollton Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carrollton, Texas.
- Location
- 1618 Kirby Rd, Carrollton, Texas 75006
- CMS Provider Number
- 675972
- Inspections on file
- 43
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Carrollton Health And Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively impaired resident with multiple comorbidities independently obtained ice from an ice cooler after a nurse opened the lid on her cup, without staff assistance or intervention. Staff interviews revealed that this resident sometimes got her own ice, even though residents were not supposed to access the ice cooler due to cross-contamination and infection control concerns. Nursing and CNA staff acknowledged that they attempted to assist and redirect the resident, but she was still able to reach the cooler and serve herself ice, contrary to the facility’s infection prevention expectations.
Surveyors identified that staff failed to consistently follow required procedures for controlled medication disposal and documentation. One med aide reported she would waste refused controlled meds directly into a sharps container, with or without a witness, and was unsure of the associated risks, despite facility expectations for witnessed wasting using a drug buster. On another cart, a discrepancy was found between the Lorazepam blister card and the controlled drug count sheet for a resident after a med aide administered a dose but did not immediately update the count sheet, resulting in a one‑tablet variance. Other nursing staff and the DON described policies requiring two licensed or registered personnel to document destruction and immediate updating of count sheets when controlled meds are removed.
Surveyors found that three cognitively impaired residents with dementia and depression-related diagnoses were not protected from environmental hazards. One resident had a can of Lysol spray stored on a chest in his room, and another had an aerosol air freshener can on her nightstand; an RN acknowledged residents were not supposed to have these items because they were dangerous. A third resident, who had dementia and conduct disorder, was observed in bed after inserting a phone charging cord directly into an electrical outlet without the plug attached, despite a posted sign asking staff to assist with plugging in her phone. Staff, including an RN and CNA, stated they should have connected the phone for the resident, and the DON confirmed that staff should have plugged in the charger and that the resident could have harmed herself by doing it independently, contrary to the facility’s Resident Rights policy requiring a safe environment.
Surveyors found that nebulizer masks and nasal cannulas for four cognitively impaired residents with COPD, chronic respiratory failure, or chronic kidney disease were left unbagged on nightstands, oxygen concentrators, and an oxygen tank between uses, despite physician orders for PRN or continuous O2 and staff acknowledgment that such equipment should be stored in plastic bags when not in use to prevent contamination. The facility’s oxygen administration policy did not address bagging respiratory devices.
Surveyors found that three cognitively impaired, high-fall-risk residents with diagnoses such as lack of coordination, muscle weakness, and unsteadiness on feet did not have accessible call systems as required by their care plans and facility policy. One resident in bed had no call light and instead relied on a bell attached to a bedside table placed across the room, while two other residents had call lights either on the floor behind the bed or hanging from the head of the bed, all out of reach. Staff, including a CNA, RN, DON, and an LVN, acknowledged that call lights should be within residents’ reach so they can call for assistance, and that residents sometimes pulled out or knocked off the call lights.
A resident with severe cognitive impairment and a right heel wound did not receive wound care as ordered on two scheduled days. Nursing staff reported being too busy to complete the treatments and failed to notify the DON or oncoming nurses, contrary to facility policy. This resulted in a lapse in following professional standards for pressure ulcer prevention and care.
A nurse failed to close the door or pull the privacy curtain while changing a resident's feeding tube supplies, leaving the resident's abdomen exposed to the hallway. The resident, who is non-verbal and severely cognitively impaired, attempted to cover himself and later indicated a preference for privacy during care. The nurse acknowledged forgetting to provide privacy, and facility policy requires maintaining resident dignity and privacy during personal care.
A resident with severe cognitive impairment and a history of falls was found on the floor by a CNA, who failed to notify a nurse and moved the resident without a licensed assessment, contrary to facility policy. The incident was only reported after the responsible party observed it on video and contacted the facility, resulting in a delayed assessment and documentation.
A medication cup containing calmoseptine ointment was left unsecured and unattended in a resident's room, despite the resident's severe cognitive impairment and lack of orders to self-administer medications. Nursing and CNA staff were either unaware of the ointment's presence or did not secure it, and facility policy required all medications and treatments to be locked and accessible only to authorized personnel.
Staff failed to follow infection control protocols during care for two residents, including not changing soiled gloves or performing hand hygiene during incontinent care and feeding tube supply replacement. Supplies were improperly stored on a dirty linen cart, and staff moved between contaminated and clean tasks without proper glove changes or handwashing, despite recent in-service training on infection control procedures.
Three residents with mobility needs were observed using wheelchairs with cracked right armrests and exposed foam, despite having care plans that included wheelchair mobility. Staff interviews revealed inconsistent reporting of needed repairs, with CNAs and RNs relying on verbal communication rather than the required electronic maintenance system. The Maintenance Director and Administrator confirmed that no repair requests had been entered and that there was no policy or procedure for equipment repair.
A nurse failed to administer medications as ordered for a resident with a G-tube, including giving a chewable aspirin instead of a capsule, substituting an over-the-counter calcium supplement, and administering Geritol instead of Maalox. The nurse did not check for the correct medications or consult with other staff, leading to multiple medication errors during a single medication pass.
A resident with significant medical needs did not receive medications as ordered when an RN administered incorrect forms and substitutes of prescribed drugs via G-tube, resulting in a medication error rate of ten percent. The RN failed to follow proper medication administration protocols, including giving a chewable aspirin instead of a capsule, crushing a tablet that should not have been crushed, and substituting Geritol for Maalox, without notifying the DON or obtaining physician approval.
A resident with multiple health conditions experienced a delay in diagnosis and treatment of pneumonia due to the facility's failure to obtain a chest X-ray and results in a timely manner. The X-ray was ordered as routine, leading to delays by the contracted provider, and the facility lacked a specific policy for managing X-ray orders and results, contributing to the deficiency.
A registered nurse failed to disinfect a blood pressure cuff between uses on multiple residents and did not perform hand hygiene after stoma care or before administering G-tube medications to a resident with significant medical needs. The nurse also inadequately cleaned reusable equipment, contrary to facility policy and prior training, resulting in a breakdown of infection prevention and control procedures.
A resident with severe cognitive impairment was hit by a CNA in response to the resident's aggressive behavior, resulting in a red handprint on the resident's thigh. The CNA admitted to the action, which violated the facility's abuse and neglect policy. The incident was reported to the DON and ADM, and the facility had addressed the issue before the state's investigation.
The facility failed to ensure the proper administration of parenteral fluids for two residents, as their IV dressings were not changed according to physician orders. This oversight placed the residents at risk of infection.
A resident's call light was found out of reach on two separate occasions, despite facility policy and staff acknowledgment that it should always be accessible. The resident has significant medical conditions, and staff interviews confirmed the oversight.
A resident with a gastrostomy tube was found in unsanitary conditions, with dried formula spills and trash in their room. Interviews revealed a lack of proper cleaning and communication among staff, leading to a failure in maintaining cleanliness and infection control.
A facility failed to ensure accurate MDS assessments, leading to a resident being incorrectly documented as having a wound infection. The error was due to prepopulated data from a previous assessment and a lack of review for accuracy, as confirmed by interviews with staff and a review of the resident's records.
The facility failed to act on the Pharmacist Consultant's recommendation to update a resident's Lidocaine patch order to include 12 hours on and 12 hours off. The resident continued to receive the patch daily without removal instructions, and the DON was unaware of the oversight. The facility lacked a policy for Drug Regimen Review.
The facility failed to ensure that a resident was free from significant medication errors by administering Losartan Potassium outside of physician-recommended parameters on four occasions. Despite the resident's blood pressure being below the safe range, medication aides administered the drug, contrary to the care plan and medication administration policy.
A resident with severe cognitive impairment was found with an unsupervised medication cup in her room, indicating a failure in proper medication storage and administration. Staff acknowledged the issue, and the DON confirmed the responsible nurse was an agency nurse.
A facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment from eloping. The resident, who had a history of elopement, left the building without staff being aware and was found approximately 2/10ths of a mile away. Despite previous incidents, there were no current special supervision precautions in place, and staff were unaware of the resident's potential to elope.
Resident Self-Access to Ice Cooler in Violation of Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident from independently accessing ice from an ice cooler, contrary to infection control expectations. The resident was an adult woman with epilepsy, Down syndrome, major depressive disorder, and mild intellectual disabilities, and had a BIMS score of 07, indicating severe cognitive impairment. On the observed date, the ADON assisted the resident by opening the lid on her cup, after which the resident walked toward the area near the dining room, poured a can of soda into her cup, and placed the cup and lid on top of the ice cooler. The resident stated she obtained ice for her cup herself, indicating staff did not assist her with getting ice from the cooler. Staff interviews confirmed that this resident sometimes got ice from the cooler on her own and that other residents did not. RN A stated that staff tried to assist the resident with getting ice when they saw her walking around, as she might be going to the cooler, but acknowledged that the resident did sometimes get ice herself. CNA B also indicated that the resident often got her own ice, despite residents not being supposed to do so. The ADON confirmed she had opened the resident’s cup but did not anticipate the resident would go to get ice, and acknowledged that the resident would forget staff instructions to ask for help. Staff, including RN A, CNA B, the DON, and the ADM, all identified that residents were not supposed to get their own ice due to concerns about contamination and infection control, yet the resident was still able to access the ice cooler independently.
Failure to Accurately Account for and Properly Dispose of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate system for disposition and accounting of controlled medications and to ensure staff competency in these processes. During medication pass on one hall, a medication aide (MA A) reported she had never experienced a resident refusing narcotics or controlled medications, but stated that if a resident refused, she would waste the medication directly into the sharps container on her cart, with or without a witness. She stated she did not think a witness was needed and was unsure of the risk of wasting without a witness. MA A also stated that the controlled medication count sheet should always be documented immediately after administration to prevent forgetting and causing a discrepancy, and reported she had not received in‑service training on controlled medication counting and disposal since starting work in September 2025. On another hall, observation of a medication cart managed by a second medication aide (MA B) revealed a discrepancy between the Lorazepam card and the controlled drug count sheet for one resident: the medication card showed 18 tablets while the count sheet showed 19. MA B stated he had administered Lorazepam to the resident earlier that morning but forgot to document the count sheet immediately because he became busy, and acknowledged that failure to document right away could lead to suspicion of drug diversion. The resident confirmed receiving all medications that morning and did not notice any missed dose, and the MAR reflected Lorazepam administration at 0700. Other staff, including an LVN and the DON, described facility expectations that controlled medications be wasted only with a witness, using a drug buster rather than a sharps container, and that count sheets be updated as soon as a controlled medication is removed from the cart. Facility policy required two licensed or registered personnel to document destruction of medications and to dispose of medications in a manner that renders them unusable.
Failure to Maintain Resident Rooms Free of Environmental Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain residents’ environments free from accident hazards to the extent possible for three residents with cognitive impairment and mental health diagnoses. One male resident with dementia, severe cognitive impairment, and depression was observed with a can of Lysol spray sitting on top of a 5‑drawer chest in his room. A female resident with major depressive disorder, moderate cognitive impairment, and an impaired cognitive function care plan was observed with a can of aerosol air freshener spray on top of her nightstand. When shown these items, RN A stated that residents were not supposed to have these cans in their rooms because they were a biohazard and dangerous for the residents. Another female resident with dementia, conduct disorder, and severe cognitive impairment, who also had a care plan for impaired cognitive function, was observed lying in bed while pointing to a phone charger cord that she had inserted directly into an electrical outlet without the charging plug attached; the plug was observed separately on top of her 5‑drawer chest. A sign above the outlet requested that staff assist the resident by ensuring her phone was plugged in and turned on. During an interview and observation, RN A and CNA L acknowledged that staff should have connected the resident’s phone to the charger after placing her in bed, and stated the resident could injure herself if she attempted to charge the phone on her own. The Administrator and DON were informed of the situation, and the DON stated staff should have plugged in the charger for the resident and that the resident could have harmed herself by plugging the charging cord directly into the outlet. The facility’s Resident Rights policy stated that residents have a right to a safe, clean, comfortable, and homelike environment and that the facility must ensure residents can receive care and services safely and that the physical layout does not pose a safety risk.
Improper Storage of Respiratory Equipment Between Uses
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards of practice and residents’ care plans by not properly storing nebulizer masks and nasal cannulas when not in use. For one resident with COPD and severe cognitive impairment, surveyors observed a nebulizer mask ordered for PRN Ipratropium-Albuterol treatments sitting unbagged on the nightstand. For another resident with COPD, chronic respiratory failure, and severe cognitive impairment, a breathing treatment mask ordered for PRN Ipratropium-Albuterol was also observed unbagged on the nightstand. Both instances occurred despite physician orders for respiratory treatments and the residents’ need for respiratory equipment. Two additional residents with severe cognitive impairment were observed with nasal cannulas not stored in bags when not in use. One male resident with COPD had a nasal cannula hanging unbagged on his oxygen concentrator, and he reported that he had not used the oxygen device in a few days and did not use it much. Another male resident with chronic kidney disease and an order for continuous oxygen at 2 L/min via nasal cannula had his nasal cannula hanging unbagged on an oxygen tank attached to his wheelchair. Nursing staff, including an RN and an LVN, acknowledged during interviews that nebulizer masks and nasal cannulas should be placed in plastic bags when not in use to prevent contamination and infection, and the DON similarly stated that these items needed to be bagged to avoid residents getting an infection. The facility’s written oxygen administration policy did not address bagging respiratory devices when not in use.
Inaccessible Call Systems for Multiple Cognitively Impaired, High-Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents had access to a functioning call system from their beds and bathrooms/bathing areas, as required by facility policy. For three residents with severe cognitive impairment and documented fall risk, surveyors found that call systems were not within reach. One resident, an elderly female with lack of coordination, history of falling, and a care plan intervention specifying that the call system be within reach, was observed lying in bed without a call light. Instead, she had a bell attached to a bedside table that was placed across the room near a chest of drawers, out of her reach. Staff, including an RN and a CNA, acknowledged that the resident used the bell to contact staff, that she was unable to self-transfer and required staff assistance, and that staff should have placed the bedside table near her. The RN stated the resident had a history of yanking the call light cord out of the wall and destroying it. Two additional residents, both elderly males with severe cognitive impairment, muscle weakness or lack of coordination, unsteadiness on feet, and care plans identifying them as fall risks with interventions to keep call lights within reach, were also found without accessible call lights. One resident’s call light was observed on the floor behind the bed, and the other’s was hanging down from the head of the bed, both out of reach. A CNA observed that these residents often knocked the call lights off the bed and stated she would use a clip to secure them, acknowledging that call lights needed to be within reach so residents could call for assistance. The DON confirmed that all staff were responsible for ensuring call lights were within residents’ reach, and an LVN covering the hall also stated that call lights should be within reach so residents could call for help. The facility’s written policy required that each resident be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor.
Failure to Provide Scheduled Wound Care and Communicate Missed Treatments
Penalty
Summary
A resident with multiple diagnoses, including hypertension, dementia, and muscle weakness, was admitted with an open lesion on the right heel. The care plan specified that wound care was to be administered to the right heel on Monday, Wednesday, and Friday, as ordered by the physician. Documentation and observation revealed that wound care was not provided as scheduled on two occasions, with dressings on the heel dated several days prior to the surveyor's observation. The resident was noted to have severe cognitive impairment and required assistance with personal care. Interviews with nursing staff revealed that wound care was missed on the scheduled days because the responsible RNs were too busy and failed to complete the treatments. Both RNs admitted they did not inform the oncoming nurse or the DON about the missed wound care, as required by facility protocol. The DON confirmed she was not made aware of the missed treatments and stated that the expectation was for nurses to report and ensure completion of wound care if unable to perform it themselves. Facility policy required that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection, with nursing staff responsible for administering treatments as ordered. The failure to provide wound care as scheduled and to communicate missed treatments to supervisory staff constituted a lapse in following professional standards of practice and facility policy, resulting in a deficiency related to the prevention and treatment of pressure ulcers.
Failure to Provide Privacy During Wound Care
Penalty
Summary
A registered nurse (RN) failed to provide privacy and maintain the dignity of a resident during a routine change of gastroenterology (feeding tube) supplies. The RN entered the resident's room, did not close the door, and did not pull the privacy curtain, resulting in the resident's abdomen being exposed and visible from the hallway throughout the procedure. The resident, who is non-verbal due to severe cognitive impairment and a history of cerebral vascular disease, aphasia, and dysphagia, attempted to cover himself by pulling up the sheet and adjusting his gown. The resident later indicated through non-verbal communication that he did not like having the door open during care and preferred it to be closed. During interviews, the RN acknowledged forgetting to ensure privacy and admitted awareness of the facility's policy and training regarding residents' rights to privacy, dignity, and respect. The Director of Nursing confirmed that privacy and dignity should be maintained during all nursing care, including closing the door and pulling the privacy curtain. Facility policy requires that residents be treated with dignity and that their bodies be shielded from view during personal care activities.
Failure to Follow Fall Reporting and Assessment Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow facility policy and procedure after finding a resident on the floor in her room. The CNA did not report the incident to the nurse in charge and instead assisted the resident up from the floor, placed her in a wheelchair, and took her to the dining room for breakfast. The resident was not assessed by a licensed nurse prior to being moved, contrary to facility policy which requires a nurse assessment before moving any resident found on the floor. The resident involved was an elderly female with a history of hypertension, non-Alzheimer's dementia, cerebrovascular accident, and repeated falls. She had severe cognitive impairment, used a wheelchair for mobility, and required assistance with transfers and activities of daily living. Her care plan specified that she was at risk for falls and required one-person assistance for transfers, use of a gait belt, and immediate nurse notification if a fall or injury occurred. Despite these interventions, the CNA did not follow the care plan or facility policy when the resident was found on the floor. Interviews and record reviews confirmed that the CNA was aware of the policy to leave residents in place and notify a nurse if found on the floor, but did not comply. The incident was only discovered when the resident's responsible party observed the event on a camera and notified the facility. The nurse was not informed until after the responsible party's call, at which point the resident was assessed and appropriate documentation was completed. The failure to follow established procedures resulted in the resident not being assessed for injuries in a timely manner.
Unsecured Medication Ointment Left in Resident Room
Penalty
Summary
A deficiency occurred when a medication cup containing a pink ointment, identified as calmoseptine ointment, was found unsecured and unattended on top of a dresser in a resident's room. The resident had severe cognitive impairment, was unable to make decisions, and required staff assistance for activities of daily living. There were no physician orders for the resident to self-administer medications. During observations and interviews, nursing staff acknowledged the ointment was likely used for the resident's skin care, but did not remove it from the room or secure it. Certified nursing assistants interviewed were unaware of the ointment's presence or use, and one stated she did not use any cream during care. Further interviews with licensed nursing staff and the Director of Nursing confirmed that all treatments, including ointments, were supposed to be stored in a locked treatment cart and only accessed by authorized personnel. The facility's policy required drugs and treatments to be administered only upon a licensed provider's order and to be securely stored. The failure to secure the ointment and restrict access to authorized personnel constituted a breach of the facility's medication storage protocols.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by direct observations of staff not following established protocols during resident care. One certified nursing assistant (CNA) did not perform hand hygiene or change soiled gloves during incontinent care for a female resident with severe cognitive impairment, hypertension, diabetes, and dementia. The CNA also used supplies stored on a dirty linen cart and failed to wash hands or use sanitizer after completing care, returning contaminated items to the cart. The CNA acknowledged awareness of proper procedures but attributed the lapse to nervousness during survey observation. Additionally, a registered nurse (RN) did not change gloves or perform hand hygiene while replacing feeding tube supplies for a male resident with cerebral vascular disease, aphasia, dysphagia, and hypertension. The RN wore personal protective equipment but moved between contaminated and clean tasks without changing gloves or sanitizing hands, and left the room without performing hand hygiene. The facility's infection control policy requires handwashing after direct resident contact, after removing gloves, and after handling potentially contaminated items, but these procedures were not followed during the observed care. Interviews with staff and the Director of Nursing (DON), who also serves as the infection control preventionist, confirmed that staff had recently received in-service training on infection control, including glove changes and hand hygiene. Despite this training, staff did not adhere to the required protocols during care, as observed by surveyors. The DON acknowledged the importance of these practices and that failure to follow them could result in the spread of germs.
Failure to Maintain Wheelchairs and Ensure Hazard-Free Equipment
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were properly maintained and free of hazards for three residents reviewed for essential equipment. Observations revealed that each of these residents was using a wheelchair with a cracked right armrest and exposed foam while seated in the dining room. All three residents had care plans that included wheelchair mobility, and their medical histories included conditions such as dementia, cerebral vascular accident, heart failure, hypertension, weakness, and unsteadiness. At the time of observation, none of the residents had skin problems or tears on their arms. Interviews with staff indicated that the process for reporting wheelchair repairs was inconsistent. CNAs typically reported needed repairs verbally to the nurse in charge, while RNs stated that staff were supposed to inform the maintenance department. The Maintenance Director explained that repairs should be entered into the electronic maintenance system, but acknowledged that staff often failed to do so, making it difficult to track and address needed repairs. A review of the electronic maintenance system showed no entries for wheelchair armrest repairs during the relevant period, and the Administrator confirmed that there was no policy or procedure in place for equipment repair at the facility.
Failure to Administer Medications as Ordered via G-Tube
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to accurately administer medications to a resident with a history of cerebrovascular accident, hemiplegia, muscle weakness, and cognitive confusion, who required assistance for activities of daily living and received medications via G-tube. The RN did not follow physician orders for three separate medications during a medication pass. Specifically, the RN administered a chewable aspirin (ASA) 81 mg via G-tube instead of the ordered ASA 81 mg capsule, without checking the medication room or consulting other staff for the correct form of the medication. Additionally, the RN administered an over-the-counter Calcium D supplement instead of the prescribed Calcium D oral tablet 600-400 mg, and did not mix the medication properly before administering it through the G-tube. The RN also failed to administer the ordered Maalox (aluminum/magnesium suspension) and instead gave Geritol 5 ml. These actions were observed during the medication pass, and the RN acknowledged not following the correct procedures, citing being busy and running behind as reasons for the errors. Interviews with the RN and the Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered as prescribed and that staff should notify the DON if medications are unavailable. The RN admitted to not following the established medication administration process, including verifying medication availability and consulting with the DON or physician before substituting medications.
Medication Error Rate Exceeds Five Percent Due to Incorrect Administration and Substitution
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication pass, resulting in a ten percent error rate for one resident. Specifically, a registered nurse (RN) did not administer medications as ordered for a male resident with a history of cerebrovascular accident, hemiplegia, muscle weakness, and cognitive confusion. The resident required assistance with activities of daily living and received medications via G-tube. During observation, the RN did not have the prescribed ASA (aspirin) 81 mg capsules available and instead administered a chewable form of ASA through the G-tube. The RN also incorrectly crushed and administered a Calcium D oral tablet that was not intended to be crushed, and substituted Geritol for the prescribed Maalox suspension. These actions were not in accordance with the physician's orders or facility policy, which requires medications to be administered as prescribed. Interviews with the RN revealed a lack of adherence to medication administration protocols, including failure to notify the DON when medications were unavailable and administering substitute medications without physician approval. The RN acknowledged being busy and running behind, which contributed to the errors. The resident was able to respond to some questions and indicated feeling safe and cared for at the facility.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to provide or obtain timely radiology services as ordered by a physician for a resident who was admitted with multiple diagnoses, including coronary artery disease, hypertension, and pneumonia. The resident, who was cognitively alert but experienced short periods of confusion and required assistance with activities of daily living, had a chest X-ray ordered due to a new onset cough. Despite the physician's order, the chest X-ray was not completed on the same day, and there was a delay in both obtaining the X-ray and receiving the results. Nursing documentation showed that the X-ray was ordered as routine, which allowed the contracted X-ray company to delay the service. Staff interviews revealed that the X-ray company often did not prioritize routine orders and sometimes refused to come on weekends, resulting in further delays. The nurse responsible for ordering the X-ray continued to follow up, but the company cited being too busy as a reason for the delay. The physician assistant and DON were both aware of the delay, and the physician assistant attempted to change the order to STAT, but the X-ray company did not process the change in a timely manner. The delay in obtaining the chest X-ray led to a delay in diagnosing and treating the resident's pneumonia. The facility did not have a specific policy or procedure in place for managing X-ray orders and test results, which contributed to the lack of timely follow-up and coordination with the X-ray provider. The deficiency was identified through record review and staff interviews, which confirmed that the facility did not ensure prompt diagnostic services as required.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN) during the care of a resident with multiple medical conditions, including a history of stroke, hemiplegia, and muscle weakness. The RN did not disinfect the blood pressure cuff between uses on different residents and failed to perform hand hygiene after providing stoma care and before administering medications via a G-tube. The RN was observed using the same blood pressure machine on multiple residents without cleaning it and did not wash her hands or use hand sanitizer after removing gloves and gown following direct care contact. Additionally, the RN used tweezers to clean the resident's stoma and returned them to a cup on the bedside table after only cleaning them with normal saline, rather than disinfecting them as required. The facility's policies and the infection control preventionist confirmed that equipment should be disinfected between residents and that hand hygiene should be performed before and after resident contact and medication administration. Despite having received prior in-service training on these procedures, the RN did not follow established infection control protocols during the observed care.
Resident Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who hit a resident on the outer left thigh, leaving a red handprint. The incident occurred when the resident, who had severe cognitive impairment and was known to be resistive to care, reportedly hit the CNA, prompting the CNA to retaliate by hitting the resident. This action was contrary to the facility's policy and training on abuse and neglect, which the CNA had received. The resident involved was an elderly male with a history of dementia, stroke, and aphasia, and had a care plan that included interventions for being resistive to care. The care plan advised staff to leave the room, approach the resident later, or seek assistance from another staff member when the resident was resistive. Despite these guidelines, the CNA reacted physically to the resident's behavior, resulting in the abuse incident. Interviews with staff revealed that the CNA reported the incident to a Medication Aide (MA), who then informed the Director of Nursing (DON) and the Administrator (ADM). The CNA admitted to hitting the resident as a reaction to being hit first. The facility's policy on abuse and neglect was clear that any form of abuse, including physical retaliation, was unacceptable. The incident was identified as past noncompliance, and the facility had addressed the issue before the state's investigation began.
Failure to Change IV Dressings as Per Physician Orders
Penalty
Summary
The facility failed to ensure the proper administration of parenteral fluids consistent with professional standards of practice and physician orders for two residents. Resident #52, a [AGE] year-old female with a history of joint replacement surgery and infection, had a PICC line dressing that was not changed as per the physician's order. The dressing was last changed on 03/29/24, but it was not changed on 04/05/24 as required. During an interview, Resident #52 confirmed that her dressing had not been changed in the last week, and the nurse assigned to her was unaware of the missed dressing change. Similarly, Resident #3, a [AGE] year-old female with a history of a pelvic fracture and elevated white blood cell count, had a mid-line dressing that was not changed as per the physician's order. The dressing was last changed on 03/31/24, but it was not changed on 04/03/24 as required. During an interview, Resident #3 confirmed that her dressing had not been changed recently, and the nurse assigned to her was also unaware of the missed dressing change. The Director of Nursing (DON) stated that the expectation was for nurses to check PICC lines every shift, flush before and after medication, and change the dressing every 7 days or as needed if soiled. However, the DON was unaware of when the dressings for Resident #3 and Resident #52 were last changed. The facility's failure to follow physician orders for dressing changes placed the residents at risk of developing an infection.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a critical aspect of accommodating resident needs and preferences. Specifically, Resident #45, a [AGE] year-old female with diagnoses including metabolic encephalopathy, acute kidney failure, and adjustment disorder with anxiety, was found on two separate occasions with her call light placed out of reach on top of the light above her bed. This was observed on 04/09/24 and 04/10/24 while the resident was sleeping in her room. Interviews with staff, including an LVN and the DON, confirmed that the call light should always be within the resident's reach to ensure they can call for assistance when needed. The LVN admitted to not noticing the call light's placement during her morning check, and the DON stated that it was the responsibility of the assigned Angel, CNAs, or nurses to ensure the call light was accessible. The facility's policy, revised on 08/03/21, also mandates that the call device be placed within the resident's reach before leaving the room.
Failure to Maintain Clean and Homelike Environment for Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident with a gastrostomy tube. The resident's feeding pump and surrounding area were observed to be dirty, with dried formula spills on the floor and pole, and trash behind the oxygen tank and under the bed. The resident, who has severe cognitive impairment and relies on a feeding tube, was found in these unsanitary conditions during multiple observations. Interviews with the assigned nurse, housekeeper, and housekeeping director revealed a lack of proper cleaning and communication. The nurse admitted to not noticing the dirty g-tube poles and floor, while the housekeeper acknowledged the difficulty in removing dried formula and not cleaning under the bed regularly. The housekeeping director was unaware of the trash accumulation and expected his staff to clean thoroughly and report any issues. The Director of Nursing confirmed that nurses were responsible for cleaning the g-tube poles and housekeepers for the floors, highlighting a failure in maintaining cleanliness and infection control.
Inaccurate MDS Assessment for Wound Infection
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for one resident reviewed for MDS assessment accuracy. Specifically, a quarterly MDS assessment for a resident was incorrectly coded to indicate a wound infection when no such infection was present. This error was identified through a review of the resident's face sheet, physician's orders, and interviews with the resident, the Director of Nursing (DON), an LVN, and two MDS Coordinators. The resident's face sheet and physician's orders did not show any indication of a wound infection, and interviews confirmed that the resident did not have any wounds or infected wounds during the relevant period. The error occurred because the MDS assessment section for wound infection was automatically prepopulated from a previous assessment and was not corrected before completion. The MDS Coordinator responsible for the assessment admitted to not catching the error. The facility's policy requires that each individual who completes a portion of the assessment certify its accuracy, but there was no process in place to review completed MDS assessments for accuracy. This lack of oversight led to the inaccurate documentation of the resident's condition, which could potentially affect the level of care provided.
Failure to Act on Pharmacist Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the Pharmacist Consultant were acted upon for a resident reviewed for unnecessary medications and medication regimen review. The Pharmacist Consultant recommended updating the Lidocaine External Patch 4% order to include instructions to wear the patch for 12 hours on and then 12 hours off. However, this recommendation was not implemented, and the resident continued to receive the patch daily without an order for removal. The Director of Nursing (DON) was unaware that the recommendation had not been acted upon and admitted that reviewing the Pharmacist Consultant's recommendations was primarily her responsibility. The facility did not have a policy for Drug Regimen Review, and the DON could not provide any guidance being used. The resident involved was a [AGE] year-old female with diagnoses including a disorder of muscles and multiple sclerosis. Her comprehensive MDS indicated moderate cognitive impairment. The resident's physician's orders and Medication Administration Record (MAR) reflected the use of the Lidocaine patch daily without removal instructions. The failure to act on the Pharmacist Consultant's recommendation could place residents at risk for possible adverse side effects and decreased quality of life. The DON assumed that when pharmacy reviews were placed in the binder, they were completed, but this was not the case for the resident in question.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically for one resident who was administered Losartan Potassium outside of the physician-recommended parameters. Resident #45, a [AGE] year-old female with diagnoses including unspecified dementia and essential hypertension, was given Losartan Potassium on four occasions when her blood pressure readings were below the prescribed thresholds. These instances occurred on 03/05/24, 03/10/24, 03/20/24, and 03/21/24, with different medication aides administering the medication despite the resident's blood pressure being out of the safe range specified by the physician's orders. The resident's care plan and medication administration records indicated that the medication should be held if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was less than 60, but these guidelines were not followed in the noted instances. Interviews with the medication aides and the Director of Nursing (DON) revealed a lack of adherence to the medication administration policy. One medication aide stated that he always checked the parameters before administering the medication and would notify the nurse if the vitals were out of range, but could not recall the documentation code for not administering the medication. The DON acknowledged that two medication aides had administered the medication out of parameters and that one aide was terminated for this reason. The DON also admitted that she was responsible for monitoring the residents' Medication Administration Records (MARs) but was unable to review all of them due to the high number of residents. The facility's Medication Administration policy, dated May 2007, mandates that medications must be administered according to the written orders of the attending physician, which was not adhered to in this case.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and administered properly, as evidenced by an incident involving a resident with severe cognitive impairment. The resident was found with a medication cup containing a white pill on her bedside table, which she stated she would take when she was ready. This medication was supposed to be administered by the nursing staff, but it was left unsupervised in the resident's room, contrary to the facility's policy and standard medication administration practices. Multiple staff members, including a medication aide, a licensed vocational nurse, and a certified nursing assistant, observed the pill in the resident's room and acknowledged that medications should not be left unsupervised. The Director of Nursing confirmed that the nurse responsible was an agency nurse and reiterated that all nurses, including agency staff, are oriented to the facility's procedures. However, the facility's Medication Administration policy did not address the need for resident supervision until the medication is taken, contributing to the deficiency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with severe cognitive impairment from eloping. The resident, who had a history of elopement, was able to leave the building without staff being aware and was found approximately 2/10ths of a mile away from the facility early in the morning. The resident had a diagnosis of schizophrenia, cerebral infarction, PTSD, aphasia, and required assistance with personal care. Despite being placed on 15-minute checks after a previous elopement incident, there were no current special supervision precautions in place at the time of the incident. The resident's elopement assessment completed after the incident scored him as high risk for elopement, but prior assessments had scored him as low risk. Interviews with staff revealed that they were unaware of the resident's potential to elope and had not observed any exit-seeking behavior prior to the incident. The facility's failure to maintain adequate supervision and implement effective elopement precautions led to the resident's unsupervised departure from the facility, placing him at risk for harm or serious injury.
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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