Cascades At Galveston
Inspection history, citations, penalties and survey trends for this long-term care facility in Galveston, Texas.
- Location
- 3702 Cove View Blvd, Galveston, Texas 77554
- CMS Provider Number
- 675254
- Inspections on file
- 37
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Cascades At Galveston during CMS and state inspections, most recent first.
Nursing staff lacked adequate competency and training in controlled medication management, leading to multiple discrepancies and unsafe practices. For one resident with seizure disorder and severe cognitive impairment, an RN’s control count sheet for Lacosamide did not match the actual volume on the cart, and the RN reported no recent skill check‑off or training on medication administration or control counts. For another resident with dementia and pain management needs, a tramadol blister pack was found with a punched, half‑exposed tablet, and the same RN stated she did not know how to handle the situation and had not been trained on control counts. For a third resident receiving PRN acetaminophen‑codeine for pain, an LVN’s control sheet showed one more tablet than was present in the blister pack; the LVN admitted administering a dose without signing it out on the control sheet or MAR and indicated she had not received medication administration training beyond brief floor orientation, despite facility policy requiring nursing leadership to ensure staff competency.
Multiple failures in pharmacy services were identified, including inaccurate controlled drug counts, improper handling of damaged blister packs, and incomplete documentation. One resident receiving Lacosamide via G-tube had a control count sheet that did not match the actual volume in two bottles, and the RN who discovered the discrepancy reported no recent training on med administration or controlled counts. Another resident with PRN tramadol for pain had a blister pack with a punched-open seal and a half-exposed tablet, and the RN did not know the appropriate action. A third resident receiving PRN acetaminophen-codeine had a mismatch between the blister pack count and the control sheet because an LVN administered a dose but failed to sign it out on the control sheet or MAR. The DON reported limited time for comprehensive nurse training, the facility’s policy required MAR initials after each medication, and a requested drug diversion policy was not provided.
A resident with convulsions, hypertension, traumatic brain injury, severely impaired cognition (BIMS 3/15), and extensive to total ADL needs was found to have no active care plan after the existing plan was cancelled in the electronic record. The MDS Coordinator stated she did not cancel the plan and believed her supervisor did so, and she was unaware of the cancellation until the surveyor requested the care plan, despite having recently completed the quarterly MDS without reviewing it. The DON and Administrator reported they did not know why the plan was cancelled, confirmed that the care plan is used to guide care and communicate with providers and nursing staff, and acknowledged that every resident should have a current, quarterly-updated care plan, while also noting the facility had no specific care plan policy and followed the RAI manual instead.
A resident with multiple comorbidities, severe cognitive impairment, and on hospice care had PRN oral morphine ordered for pain. While counting the resident’s prefilled morphine syringes on the medication cart, an LVN dropped one syringe on the floor, then picked it up and placed it back with the other syringes instead of wasting it, thereby contaminating the entire group. In interviews, the LVN acknowledged the syringe was contaminated and should have been destroyed with another nurse, and the DON confirmed that the dropped syringe and the remaining syringes were considered contaminated, constituting a breach of the facility’s medication administration policy requiring adherence to infection control procedures. The requested infection control policy was not provided by administration at exit.
The facility did not include required staffing level information in its facility-wide assessment, and the assessment was not used to inform nursing staff schedules. Instead, staffing decisions were based on PPD, census, and national averages, without considering individual resident needs as outlined in facility policy.
The facility did not provide enough nursing staff to meet residents' needs, resulting in a resident remaining in a urine-soaked brief, another unable to get out of bed for an entire day, and a third experiencing long waits for incontinent care. Staffing assignments showed fewer CNAs present than scheduled, and staff interviews confirmed that care was delayed or missed due to inadequate staffing levels.
Multiple medication carts were found unattended and unlocked, with keys left accessible and a variety of prescription and OTC medications, including narcotics, stored inside. Nursing staff and the acting DON confirmed that facility policy requires all medication carts to be locked when not in use, but this was not followed, resulting in unsecured access to medications.
A resident with severe cognitive impairment and multiple medical conditions was not provided with a care plan that addressed her G-J tube feeding and pleasure feeding needs, despite clear physician orders and hospital discharge instructions. The care plan did not include protocols for pureed snacks with SLP or trained caregiver supervision, nor did it reflect the resident's tube feeding requirements.
Two residents were found to have roaches in their rooms, with one resident experiencing repeated infestations involving her bed, wheelchair, and personal items. Staff and maintenance confirmed ongoing pest issues despite regular pest control treatments, and food was often found left in the affected rooms, contributing to the problem. Housekeeping and maintenance staff acknowledged that pest control efforts had not been effective in eliminating the roaches.
Three residents were inaccurately assessed during the MDS process, including one whose bed grab bars were incorrectly coded as restraints, another who was documented as having a catheter that had already been removed, and a third who was assessed as having a catheter despite its prior discontinuation. Staff interviews, observations, and record reviews confirmed these inaccuracies, which resulted in incorrect documentation of the residents' actual conditions.
Two residents with complex medical needs did not have comprehensive care plans addressing their indwelling urinary catheter and oxygen therapy, despite clear documentation and physician orders indicating these interventions. Staff interviews and record reviews confirmed the absence of these care plans, which are required to guide care and ensure all needs are met.
A resident with multiple chronic conditions was sent to the hospital for altered mental status and tested positive for THC, but the physician was not notified of this significant change. Staff interviews revealed gaps in communication and review of hospital records, and the facility's policy requiring timely notification of clinical changes was not followed.
The facility did not update the care plans for two residents after they were hospitalized for altered mental status and tested positive for substances not prescribed to them, including benzodiazepines and THC. Despite these significant findings, care plans were not revised to address substance use, and staff interviews confirmed that this information was not incorporated into resident care planning.
Two residents experienced significant medication errors related to blood pressure management. One resident received Midodrine despite a high SBP, contrary to physician orders. Another resident was given Toprol X and Spironolactone when blood pressure readings indicated they should be held. The medication aide admitted to overlooking the orders, and the ADON acknowledged the incomplete documentation and potential health risks.
The facility failed to maintain accurate medication records for two residents, leading to improper administration of blood pressure medications. For one resident, the MAR did not consistently reflect whether Midodrine was given or held, and blood pressure logs were incomplete. Another resident received Spironolactone and Toprol X despite blood pressure readings indicating they should be held. Staff interviews revealed acknowledgment of these errors, highlighting the need for improved adherence to physician orders and documentation practices.
The facility failed to notify the physician and implement orders for a resident's G-tube care, leading to complications and hospital intervention. Staff were unaware of the physician's orders for an abdominal binder and did not properly manage the G-tube, resulting in pain and soiling at the site.
A facility failed to implement a physician's order for an abdominal binder and did not provide proper gastrostomy tube care for a resident, leading to hospitalization for G-Tube replacement. Additionally, medications were improperly administered via the G-Tube, placing the resident at risk for complications.
A facility failed to maintain a medication error rate below 5 percent, resulting in a 16 percent error rate. An LVN administered the wrong dose of Lactulose, used an incorrect volume of water for g-tube flushing, and did not elevate a resident's head during medication administration, contrary to physician orders and facility policy.
The facility, licensed for 150 beds, failed to employ a qualified full-time social worker for four months, despite job postings and interviews. An LVN was placed as acting social services, and residents expressed confusion over the delay in hiring a qualified social worker.
The facility failed to conduct a comprehensive and accurate assessment of a resident's functional capacity, missing critical information about hospice care and dental status. The resident, with multiple diagnoses including ovarian cancer and major depressive disorder, reported issues with her dentures that were not addressed in a timely manner. Staff interviews revealed gaps in MDS documentation and follow-up.
The facility failed to update a resident's MDS assessment within 14 days after the resident was discharged from hospice care. The resident, who had multiple diagnoses including diabetes and ovarian cancer, discharged herself from hospice due to restrictions on visiting her own physician. The facility did not reassess her condition following this significant change, as required by the RAI manual.
The facility failed to complete and transmit a Death in Facility MDS for a resident who passed away, due to the absence of a permanent MDS Coordinator and reliance on remote staff. The oversight led to the resident's assessment not being recorded in the EMR within the required timeframe.
The facility failed to ensure that a resident's Death in Facility assessment accurately reflected her date of death. The resident had severe cognitive impairments and multiple medical conditions. The Regional MDS RN acknowledged the need to review the resident's EMR to determine if a corrected or modified Death in Facility MDS was necessary.
A resident with COPD and other health issues was transported to a doctor's appointment without a portable oxygen tank, despite being on continuous oxygen therapy. Upon arrival, the resident's oxygen saturation was critically low, requiring immediate intervention. The facility's staff, including the ADON and the resident's nurse, acknowledged the oversight, which was due to a lack of communication and verification of the resident's needs before transport.
Inadequate Nursing Competency and Medication Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had appropriate competencies and skills to manage controlled and other high‑risk medications for multiple residents. For one male resident with convulsions, hypertension, traumatic brain injury, severely impaired cognition, and extensive to total ADL needs, surveyors found a discrepancy between the control count sheet and the actual volume of Lacosamide oral solution on the medication cart. The control sheet documented 480 mL, while two bottles on the cart contained a total of 510 mL (one unopened 400 mL bottle and one 110 mL bottle). The RN responsible for the cart stated she did not know what to do about the discrepancy, suggested it might be a documentation or measurement error, reported she had not received any skill check‑off on medication administration or control counts since starting three weeks earlier, and did not respond when asked what could have happened if the resident did not receive the prescribed seizure medication dose. A second male resident with dementia, hypertension, diabetes, moderately impaired cognition, and supervision to partial assistance with ADLs had an active care plan for pain management and an order for PRN tramadol. During a controlled substance count on the same medication cart, surveyors observed that one tramadol blister in the resident’s card had a punched seal with the tablet half exposed. The RN stated the seal was punched and she did not know what to do, and also reported she had not received training on medication administration or control counts. The DON later stated that if a tramadol blister pack seal was broken, the nurse should waste the medication with another nurse and sign the control sheet, and that if the medication in the opened blister was not taken out and destroyed, it could have gone missing and would have been reportable for drug diversion. A third female resident with obesity, hypertension, diabetes, intact cognition, and independence to supervision with ADLs had a care plan for pain medication therapy and an order for PRN acetaminophen‑codeine. Review of the control count sheet showed 16 tablets documented, but surveyors found only 15 tablets in the blister pack on a different medication cart. The LVN assigned to that cart stated she had administered one tablet earlier that afternoon and forgot to sign it out on the control sheet or the MAR, and when asked when she should have signed the control book and MAR, she shrugged her shoulders. She reported having no medication administration training since starting three weeks earlier, aside from three days of floor orientation. The DON acknowledged that the LVN should have signed out the medication immediately when it was pulled and administered, and also stated that comprehensive nursing training had not been completed due to ongoing staffing needs, despite the facility’s written policy requiring nursing leadership to establish and monitor competency requirements and training for nursing staff.
Medication Control, Documentation, and Packaging Failures in Pharmacy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, administering, and accounting of medications for multiple residents. For one resident with convulsions, hypertension, and traumatic brain injury, the control count sheet for Lacosamide oral solution (10 mg/mL, 20 mL via G-tube twice daily) documented 480 mL, while two bottles on the medication cart contained a total of 510 mL (one unopened 400 mL bottle and one 110 mL bottle). The RN conducting the count identified the discrepancy but stated she did not know what to do, suggested it might be a documentation or measurement error, and reported she had not received any skill check-off on medication administration or controlled drug counts since starting work three weeks earlier. The resident’s quarterly MDS showed severely impaired cognition and extensive to total assistance needs, and the resident had no current care plan after the prior plan was canceled. For a second resident with dementia, hypertension, and diabetes mellitus, who had a care plan identifying risk for pain and an order for tramadol 50 mg by mouth every six hours as needed for pain, surveyors observed that one tramadol blister pack on the medication cart had a punched-open seal with the tablet half exposed. The RN present stated she did not know what to do about the partially opened blister and reported she had not received training on medication administration or controlled drug counts. The DON later stated that if a tramadol blister pack seal was broken, the medication should be wasted with another nurse and documented on the control sheet, and also stated they were not sure if the medication in the opened blister was the original medication and that if not destroyed, the medication could come up missing and would be reportable for drug diversion. For a third resident with obesity, hypertension, and diabetes mellitus, who had intact cognition and a care plan for pain management with analgesic medications, the order summary showed acetaminophen-codeine 300-30 mg, one tablet by mouth every four hours as needed for pain. The control count sheet for this controlled medication showed 16 tablets, but the blister pack contained only 15 tablets. The LVN stated she had administered one tablet at 1:30 p.m. and forgot to sign it out on the control sheet or the MAR, and when asked when she should sign the control book and MAR, she shrugged her shoulders and reported she had not had any training on medication administration since starting at the facility, aside from three days of floor orientation. The facility’s written policy required the individual administering medication to initial the MAR after giving each medication and before administering the next one, and the surveyor’s request for a drug diversion policy was not fulfilled. The DON acknowledged that if controlled medications are not signed out when pulled, it would look like drug diversion and stated she had not had time for comprehensive nursing training while covering multiple roles.
Cancelled Care Plan Leaves Resident Without Comprehensive Person-Centered Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical and cognitive needs. The resident was an adult male with diagnoses including convulsions, hypertension, and traumatic brain injury, and a Quarterly MDS showed a BIMS score of 3/15, indicating severely impaired cognition, with extensive to total assistance required for ADLs. Record review showed that this resident’s care plan was cancelled on 01/19/26, leaving him with no current care plan in place. The MDS Coordinator reported that she did not cancel the care plan and stated it had been cancelled by her supervisor, the MDS Supervisor, and that she was unaware it had been cancelled until the surveyor requested the care plan. The MDS Coordinator stated that care plans were reviewed quarterly in conjunction with MDS completion and acknowledged she had completed the quarterly MDS earlier in the month but had not reviewed the care plan. She did not provide an explanation of how care would be provided without a care plan. The surveyor was unable to reach the MDS Supervisor by telephone. In an interview, the DON stated that care plans were the responsibility of the MDS Coordinator and that she did not know why the care plan had been cancelled, while acknowledging that the care plan was used to provide care for residents and that its absence could have affected this resident’s care. The Administrator similarly stated that the resident should have had a current care plan and that it was used to communicate with providers and nursing staff. The DON also reported that the facility did not have a care plan policy and followed the RAI manual, and that every resident should have had a care plan updated quarterly.
Improper Handling of Prefilled Morphine Syringes Breaches Infection Control
Penalty
Summary
The deficiency involves a failure to maintain an infection prevention and control program when handling a resident’s prefilled morphine syringes. The resident was an elderly female with diabetes mellitus, hypertension, and a history of cerebral infarction, with a BIMS score of 8/15 indicating severely impaired cognition, requiring extensive to total assistance with ADLs, and on hospice care with a terminal prognosis related to CVA. Her care plan included close observation for pain and administration of pain medication as ordered, and her orders included PRN oral morphine sulfate concentrate. During observation of the medication cart, an LVN was counting the resident’s prefilled morphine syringes when one syringe fell to the floor. The LVN picked up the fallen syringe and placed it back with the other nine syringes instead of wiping or destroying it, thereby contaminating the remaining syringes. In interview, the LVN acknowledged the syringe that fell became contaminated and that she should have wasted it with another nurse. The DON stated the syringe that fell should have been wasted and that placing it back with the others contaminated all of them, identifying this as an infection control issue. The facility’s medication administration policy required staff to follow established infection control procedures, and when the infection control policy was requested from the administrator, it was not provided upon exit.
Facility Assessment Lacks Staffing Level Information
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included information regarding the level of staff needed to meet the needs of each resident during both day-to-day operations and emergencies. Record review of the facility assessment dated 4/30/25 revealed that it did not contain details about staffing levels required to provide competent care for residents. The facility's policy states that the assessment should inform staffing decisions and consider staffing needs for each shift, but this was not reflected in the actual assessment document. During an interview, the Administrator acknowledged uncertainty about whether the facility assessment included staffing level information and confirmed that the assessment was not used when creating the nursing staff schedule. Instead, staffing decisions were based on the facility's PPD (per patient day) and census, with a CNA-to-resident ratio of 1:15. The Administrator also referenced the facility's star rating and national staffing averages but did not indicate that individual resident needs or the facility assessment were used to determine staffing levels.
Insufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents involving three residents. One resident, who was legally blind, had dementia, and was dependent on staff for personal and toileting hygiene, was found by a family member in the evening with her hair, gown, and bed soaked in urine, and her room had a strong odor. Documentation showed that incontinent care was only provided once earlier in the day, and staff assignments indicated fewer CNAs present than scheduled. Interviews with staff could not clarify the care provided during the shift in question. Another resident, who had hemiplegia, hemiparesis, and required a two-person assist with a mechanical lift for transfers, reported that he was unable to get out of bed for 24 hours due to insufficient staff. Staffing records confirmed that fewer CNAs were present than scheduled, and a nurse was working as a CNA. The resident stated that delays in getting out of bed occurred when the facility was short-staffed, and a CNA confirmed that staffing ratios made it difficult to meet residents' preferences for getting up. A third resident, who was dependent on staff for transfers and toileting hygiene, reported waiting more than two hours for assistance with incontinent care during the evening shift, leading him to remove his own brief to prevent skin breakdown. Resident council records and staff interviews indicated ongoing concerns about insufficient staff, particularly at night, with residents reporting infrequent care and long wait times. The facility's assessment did not include information on the level of staff needed to meet each resident's needs, and scheduling was based primarily on census and PPD, without clear consideration of resident acuity.
Failure to Secure Medication Carts and Store Drugs in Locked Compartments
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments as required, as observed during medication storage inspections of four out of six medication carts. On multiple occasions, medication carts were found unattended and unlocked, with residents, visitors, and staff in close proximity. Specifically, Medication Cart #1 was left unlocked on hall 100 while the assigned nurse was on break, and the ADON confirmed that the cart should have been locked at all times when unattended. The nurse responsible for the cart acknowledged the oversight and stated that the cart contained various prescription and over-the-counter medications, including PRNs, insulin, blood pressure medications, pain and anxiety medications, antiepileptics, and OTC drugs. Although narcotics were said to be locked, the nurse admitted that they should have been secured under two locks, not one. Further observations revealed that Medication Carts #2, #3, and #4 were also left unlocked and unattended, with the keys placed on top of each cart and visible to anyone nearby. These carts contained a range of prescription medications, including heart, depression, diuretic, antinausea, diabetes, inhalation, anti-yeast, and OTC medications, as well as narcotics. At another time, Medication Cart #1 was again found unlocked, with several drawers open and no staff in sight. The cart contained a laptop, a cell phone, and keys hidden under the phone, along with a variety of prescription and OTC medications, insulin syringes, and lancets. Interviews with nursing staff and the acting DON confirmed that facility policy required medication carts to be locked at all times when unattended or out of direct sight of nurses. Staff acknowledged responsibility for ensuring the carts were secured and recognized that the failure to do so could result in medications being accessed by unauthorized individuals. The acting DON stated that the nurses had not followed the facility's medication storage policy, which mandates that all medications and biologicals be stored in locked compartments, with controlled substances separately locked.
Failure to Develop and Implement Person-Centered Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed all identified needs for a resident with complex medical conditions. Specifically, the care plan did not include the resident's requirement for G-J tube feeding with small amounts of pureed textured snacks for pleasure, to be administered under the supervision of a Speech-Language Pathologist (SLP) or a trained caregiver. This omission was identified despite the resident's comprehensive assessment and physician orders clearly indicating the need for such interventions. The care plan also did not reflect the resident's G-J tube status or the specific feeding protocols outlined in the hospital discharge summary and physician orders. The resident in question was an elderly female with multiple diagnoses, including gastronomy status, dyskinesia of the esophagus, dysphagia (pharyngeal phase), metabolic encephalopathy, and acute pulmonary edema. Her admission Minimum Data Set (MDS) assessment indicated severe cognitive impairment and that eating was not attempted due to medical or safety concerns. Although the Care Area Assessment (CAA) triggered the need for care planning related to feeding tube care, the actual care plan failed to address the resident's specific nutritional and feeding needs as documented in her medical records and physician orders.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the rooms of two residents. One resident, a female with cerebral palsy, congenital ear malformation, and a mood disorder, was found by a nurse to have roaches crawling on her bedroom floor, bed, and wheelchair while she was sitting in her wheelchair. The nurse and a CNA observed roaches on the blanket the resident was sitting on and on her wheelchair, prompting them to remove her from the room for cleaning. The resident's care plan indicated she was dependent on staff for meeting her needs and had communication difficulties due to a hearing deficit and unclear speech. Progress notes and staff interviews confirmed repeated sightings of roaches in her room, with food crumbs frequently found on the floor and bed, and the resident often refusing to allow staff to remove her meal trays. Another resident was observed to have a small live roach on the floor near the doorway of his bedroom. During interviews, housekeeping staff confirmed the presence of roaches and stated that despite regular spraying, the pests continued to return. The Director of Maintenance reported treating the affected room on several occasions and consistently finding German roaches, especially when moving furniture and checking outlets. Pest control invoices and records showed that the facility had pest control services performed monthly and additional treatments were requested for the affected rooms, but the problem persisted, particularly in the room of the first resident. Staff interviews revealed that the pest control measures in place were not effective in eliminating the infestation, especially in rooms where food was present and not promptly removed. The ongoing presence of roaches was documented through observations, staff reports, and pest control invoices, indicating a failure to ensure the facility was free of pests and rodents as required.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to accurately assess the status of three residents during the Minimum Data Set (MDS) process, resulting in incorrect documentation of their conditions. For one resident with a history of hemiplegia, chronic kidney disease, and above-the-knee amputation, the MDS incorrectly coded the use of bed grab bars as restraints, despite observations and interviews confirming the bars were used to assist with bed mobility and did not restrict movement. The care plan also indicated the grab bars were for safe repositioning, and staff confirmed the coding was inaccurate. Another resident with schizoaffective disorder, hypertension, and a history of traumatic brain injury was incorrectly documented on the MDS as having an indwelling catheter. Progress notes and staff interviews revealed the resident had removed the catheter prior to the assessment and refused reinsertion, with no physician order for a catheter present at the time of the MDS. Observations confirmed the absence of a catheter or drainage bag, and staff familiar with the resident's care verified he did not have a catheter during the assessment period. A third resident, admitted with diagnoses including intracranial hemorrhage, chronic kidney disease, and urinary retention, was assessed on the admission MDS as having a catheter, although observations and staff interviews confirmed she did not have one upon return from the hospital. Documentation showed the catheter had been discontinued prior to readmission, and no evidence of a catheter was found during the assessment. The MDS coordinator relied on nurse documentation and resident observation but failed to accurately reflect the resident's current status.
Failure to Develop and Implement Comprehensive Care Plans for Indwelling Catheter and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the management of an indwelling urinary catheter and oxygen therapy. For one male resident with multiple diagnoses, including metabolic encephalopathy, peripheral vascular disease, osteoporosis, atrial fibrillation, and acute urinary retention, there was no care plan addressing his indwelling urinary catheter following a recent hospitalization and procedure. Despite clear documentation in hospital records, physician orders, and nursing notes regarding the presence and management of the catheter, the resident's care plan did not include this information at the time of review. Interviews with facility staff confirmed the absence of a care plan for the catheter, and staff acknowledged that such a plan was necessary to guide care. Another female resident with complex medical needs, including a tracheostomy, chronic kidney disease, pressure ulcer, hypertension, encephalopathy, urinary retention, gastrostomy, muscle weakness, dysphagia, diabetes, chronic pain, and chronic respiratory failure, was also found to have an incomplete care plan. Although physician orders and the Minimum Data Set (MDS) assessment indicated that she was receiving continuous oxygen therapy via tracheostomy, her care plan did not address this intervention. Observations confirmed the resident was on oxygen, and staff interviews revealed awareness of her oxygen use but also acknowledged the lack of a corresponding care plan. The facility's policy requires the interdisciplinary team to develop comprehensive, person-centered care plans based on resident assessments. In both cases, the care plans failed to include measurable objectives and time frames for the identified needs, specifically the indwelling urinary catheter and oxygen therapy. This omission was confirmed through record review, staff interviews, and direct observation, demonstrating a failure to ensure that care plans accurately reflected the residents' current conditions and required interventions.
Failure to Notify Physician of Positive THC Test After Hospitalization
Penalty
Summary
The facility failed to notify a resident's physician following a significant change in condition, specifically after the resident tested positive for THC at the hospital. The resident, an adult female with a history of lumbar fracture, paraplegia, asthma, and COPD, was sent to the hospital for altered mental status. Hospital records indicated a positive THC drug screen and a diagnosis of THC overdose, with additional documentation of a history of marijuana use. The resident did not have a physician order for THC, and her care plan did not address substance abuse. Interviews with facility staff revealed that while some staff were aware of the resident's altered mental status and suspected drug ingestion, there was no evidence that the physician was notified of the positive THC result. The DON at the time was not employed during the incident, and the Interim DON stated she was not verbally notified by the hospital nor did she review the hospital report. The admissions nurse was identified as responsible for reviewing hospital records, but there was no confirmation that this occurred. Nursing staff reported inconsistent access to hospital discharge paperwork, and the physician confirmed she was not made aware of the positive drug test. Facility policy required timely communication of significant changes in resident status to the medical staff, including pertinent information from recent hospitalizations. Despite this, the positive drug test and related hospital findings were not communicated to the resident's physician, resulting in a failure to ensure the physician was informed of a significant clinical change.
Failure to Revise Care Plans After Positive Drug Screens
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents after significant changes in their condition were identified. Both residents were sent to the hospital for altered mental status and subsequently tested positive for substances not prescribed to them. Despite these findings, neither resident had their care plan updated to address substance abuse or the new information from their hospitalizations. One resident, a male with hepatic encephalopathy, alcohol cirrhosis, and other significant diagnoses, was admitted with moderate cognitive impairment. He was sent to the hospital for altered mental status, where a urine drug screen was positive for benzodiazepines and THC, neither of which were prescribed. The care plan did not reflect any interventions or monitoring related to substance abuse, and staff interviews confirmed that this information was not incorporated into his care planning. The second resident, a female with paraplegia and chronic respiratory conditions, was also sent to the hospital for altered mental status. Hospital records indicated a THC overdose, with a positive urine drug screen for THC. Like the first resident, her care plan did not address substance use, and staff interviews revealed that the hospital report was not reviewed or acted upon in terms of care planning. The lack of care plan revision was acknowledged by facility leadership and nursing staff.
Medication Errors in Blood Pressure Management
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. For one resident, the facility did not hold the medication Midodrine as ordered by the physician when the resident's systolic blood pressure (SBP) was above 100. Despite the blood pressure reading being 145/88, the medication was administered, contrary to the physician's instructions. This oversight was acknowledged by the medication aide, who admitted to overlooking the order and recognized the potential for adverse effects on the resident's health. Another resident was affected by the improper administration of blood pressure medications, Toprol X and Spironolactone. These medications were given even when the resident's blood pressure readings were within the parameters that required the medications to be held. Specifically, the medications were administered when the diastolic blood pressure (DBP) was 58 and the SBP was 105, both of which were below the threshold for administration. The medication aide admitted to possibly overlooking the parameters and acknowledged the potential consequences of such errors. The facility's policy on pharmacy services emphasizes the accurate and safe administration of medications, yet these incidents highlight a failure to adhere to physician orders and established protocols. The Assistant Director of Nursing (ADON) confirmed the expectations for staff to follow physician orders and acknowledged the incomplete documentation in the blood pressure log. The ADON also recognized the potential risks associated with these medication errors, including the possibility of adverse health effects for the residents involved.
Deficient Medication Documentation and Administration
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the documentation of medication administration for two residents. For Resident #1, the Medication Administration Record (MAR) for May 2024 did not consistently reflect whether the medication Midodrine was given or held, despite specific physician orders to hold the medication if systolic blood pressure (SBP) was above 100. Additionally, there was a lack of documentation in the blood pressure log for several dates, and no explanation was provided in the nurse's notes for why blood pressure readings were not recorded or why the medication was not held when required. Resident #2's MAR also showed discrepancies in medication administration. The medications Spironolactone and Toprol X were administered on specific dates when the blood pressure readings indicated they should have been held according to physician orders. The nurse's notes lacked documentation explaining why these medications were given despite the blood pressure parameters indicating they should be held. This oversight in documentation and adherence to physician orders could potentially lead to adverse effects on the residents' health. Interviews with staff, including a medication aide and the Assistant Director of Nursing (ADON), revealed acknowledgment of the errors in medication administration and documentation. The medication aide admitted to possibly overlooking orders, which could result in incorrect medication administration, potentially causing residents' blood pressure to drop or rise inappropriately. The ADON confirmed that medications should not be given when blood pressure readings are within the parameters to hold them and emphasized the importance of documenting reasons for holding medications in the progress notes or MAR.
Failure to Notify Physician and Implement Orders for G-Tube Care
Penalty
Summary
The facility failed to immediately consult with the resident's physician regarding the dysfunction or malfunction of a gastrostomy tube (G-tube) for a resident. The resident had a diagnosis of Gastrostomy Status and Gastro-Esophageal Reflux Disease (GERD). The facility did not implement the physician's order for an abdominal binder to protect the G-tube and its site due to an inadequate supply. This failure resulted in the resident requiring discharge to the hospital for G-tube replacement. The facility also failed to notify the physician of complications related to the resident's G-tube site pain and the administration of medications via the G-tube. An LVN administered medications by forcefully pushing them into the G-tube instead of allowing them to flow by gravity, placing the resident at immediate risk for potential harms such as G-tube blockage and aspiration. The resident was observed not wearing the prescribed abdominal binder, and the G-tube site was found to be soiled and painful. Interviews with facility staff revealed a lack of awareness and communication regarding the physician's orders for the abdominal binder and the proper care of the G-tube. The staff did not routinely check the resident's orders each shift, and there was a failure to notify the physician of the complications and the inability to implement the prescribed abdominal binder. The facility's failure to follow physician orders and properly manage the resident's G-tube care led to significant complications and the need for hospital intervention.
Failure to Implement Physician's Orders and Proper G-Tube Care
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not implement the physician's order for an abdominal binder, which was indicated to prevent complications of the gastrostomy tube. This failure resulted in the resident requiring discharge to the hospital for G-Tube replacement. Additionally, the facility did not provide proper gastrostomy tube site care, leading to the resident experiencing pain and a visibly soiled dressing with dark red substance at the gastrostomy tube site. The resident was often seen pulling on the gastrostomy tube, and the staff was unaware of the abdominal binder order, which was not implemented due to the facility not having the proper size available. The facility also failed to use the proper technique and safety precautions for administering medications via the G-Tube. An LVN administered medications by plunger pushing them into the gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms such as G-Tube blockage and aspiration. The LVN did not check the tube placement by auscultating for bowel sounds or visualizing the site to ensure the tube had not become dislodged or infected. The LVN also did not follow the physician's order to flush the feeding tube with water before and after administering medications. Furthermore, the facility did not notify the physician of the complications related to the G-Tube and the failure to implement the abdominal binder. The staff, including the DON and Administrator, were aware of the physician's order but did not take appropriate actions to ensure the resident received the necessary care. The facility's failure to implement the physician's orders and provide proper care placed the resident at immediate risk for complications, including infection and hospitalization. The facility's deficiencies were identified during a survey, and an Immediate Jeopardy was declared, indicating the severity of the situation.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate below 5 percent, resulting in a 16 percent error rate. This was observed during a medication administration pass involving one resident and one LVN. The LVN administered the wrong dose of Lactulose and flushed the resident's g-tube with an incorrect volume of water. Additionally, the LVN did not elevate the resident's head during medication administration, increasing the risk of aspiration. These actions were not in accordance with the physician's orders and the facility's policy for administering medications through an enteral tube. The resident involved had a diagnosis of Gastrostomy Status and Gastro-Esophageal Reflux Disease (GERD) and required an abdominal feeding tube. The resident's care plan specified the need for proper g-tube care, including checking tube placement and flushing with the correct volume of water. However, the LVN failed to follow these protocols, leading to the resident experiencing pain and discomfort during the medication administration process. Interviews with the LVN and the DON revealed that the LVN had been trained but did not follow the correct procedures for g-tube medication administration. The LVN admitted to pushing medications with force instead of using gravity flow and did not report complications related to the g-tube. The DON confirmed that the head of the bed should have been elevated and that pushing medications with force could cause harm to the resident. The facility's policy and training records were reviewed, and it was noted that additional training would be provided to address these deficiencies.
Failure to Employ a Full-Time Social Worker
Penalty
Summary
The facility, licensed for 150 beds, failed to employ a qualified full-time social worker despite having a capacity of more than 120 beds. The facility had been without a social worker for four months since the last social worker's employment ended on 11/23/23. The job description for the social worker position required a high school diploma or a bachelor's degree in social work along with an LCSW or LMSW. Despite job postings from 1/18/24 to 3/28/24 and a reposting from 3/11/24 to 4/10/24, the position remained vacant. The HR representative confirmed that an LVN was placed as acting social services in the interim. The Administrator, who joined on 1/16/24, acknowledged the vacancy and stated that several interviews had been conducted, but the candidates were not licensed. The Administrator also mentioned that they were waiting for corporate approval to have a social worker from a sister facility assist for 2-3 days. During a resident council meeting, four residents confirmed that the facility had not had a social worker for the last five months and that a nurse was acting in that capacity. The residents expressed confusion over the delay in hiring a qualified social worker.
Failure to Conduct Comprehensive Assessments
Penalty
Summary
The facility failed to conduct a comprehensive, accurate, and standardized assessment of Resident #27's functional capacity upon admission and periodically thereafter. Specifically, the facility did not assess the resident for hospice care and the lack of natural teeth in her oral cavity. Resident #27, a female with multiple diagnoses including diabetes, ovarian cancer, and major depressive disorder, was admitted on hospice with a DNR status. However, her Admission MDS did not reflect her hospice status, and her oral/dental status was marked as unable to examine. The resident later discharged herself from hospice services and reported issues with her dentures, which were not addressed by the facility in a timely manner. Interviews with staff revealed that the facility had been without a full-time MDS coordinator for some time, and the newly hired MDS coordinator was still in training. The Regional MDS Coordinator and a remote MDS coordinator had been assisting with assessments, but there were gaps in the documentation and follow-up. The resident's care plan did not reflect her current needs, and there was no significant change MDS assessment completed. The facility's policy on MDS accuracy was not specific, and the staff relied on the RAI manual. This lack of comprehensive assessment and follow-up could lead to unmet medical needs for the residents.
Failure to Update MDS Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to conduct a comprehensive, accurate, standardized, and reproducible assessment of Resident #27's functional capacity within 14 days after a significant change in the resident's condition. Specifically, the facility did not update Resident #27's MDS assessment within 14 days of the resident being discharged from hospice care. This oversight was identified through observation, interview, and record review. Resident #27, a female with multiple diagnoses including diabetes, ovarian cancer, major depressive disorder, and mobility issues, had a care plan indicating she was on hospice for a terminal prognosis. However, she discharged herself from hospice because the hospice company restricted her from visiting her own physician, and the facility did not reassess her condition following this significant change. Interviews with the MDS Coordinator and the Regional MDS Coordinator revealed that the resident should have been assessed for a significant change in status after being discharged from hospice. The Regional MDS Coordinator acknowledged the oversight and indicated that a modification would be made. The facility's policy on the accuracy of MDS assessments was requested but not provided, with the Administrator and Regional MDS Coordinator stating that the facility followed the RAI manual. According to the Long-Term Care Facility RAI Manual, a Significant Change in Status Assessment (SCSA) must be completed within 14 days from the determination date of the significant change in status, which was not done in this case.
Failure to Complete and Transmit Death in Facility MDS
Penalty
Summary
The facility failed to ensure resident assessments were completed within the required 7 to 14 days and transmitted to the CMS system for a resident who had passed away. Specifically, the facility did not complete a Death in Facility MDS for the resident, who had been admitted with diagnoses including dementia, drug-induced systemic lupus, hypertension, hyperlipidemia, and chronic hepatitis C. The resident expired at the facility, but no death in facility or discharge MDS was recorded in the electronic medical record (EMR) within the required timeframe. Interviews with the Regional MDS RN and MDS Coordinator B revealed that the facility had been without a permanent MDS Coordinator, and the assessments were being completed remotely. The Regional MDS RN, who was responsible for oversight, admitted that they did not know why the death in facility MDS had not been completed or initiated. MDS Coordinator B, who worked remotely, also did not know why the death in facility MDS was missed and depended on the information in the facility's EMR, which was found to be incorrect. The review of the resident's records confirmed that the Death in Facility MDS was not completed or transmitted within the required timeframe. The Regional MDS RN acknowledged that the assessment should have been completed within 14 days of the resident's death. The lack of a permanent MDS Coordinator and reliance on remote staff contributed to the oversight and failure to meet regulatory requirements for timely and accurate resident assessments.
Inaccurate Death in Facility Assessment
Penalty
Summary
The facility failed to ensure that a resident's Death in Facility assessment accurately reflected her date of death. The resident, an elderly female with severe cognitive impairments and multiple medical conditions including hyperlipidemia, dementia, dysphagia, peripheral vascular disease, and combined systolic and diastolic heart failure, was readmitted to the facility and later expired. The nursing clinical progress notes documented her death and the pronouncement by a hospice RN, but the Death in Facility MDS did not accurately reflect the date of death. The Regional MDS RN acknowledged that the MDS assessments were completed based on the census line provided by the facility and that there had not been an in-house, in-person MDS person at the facility. The Regional MDS RN indicated that they would need to review the resident's electronic medical record (EMR) to determine if a corrected or modified Death in Facility MDS was necessary. The facility's failure to ensure the accuracy of the resident's assessment could place residents at risk for inadequate care, services, and dignity in death.
Failure to Provide Continuous Oxygen During Resident Transport
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy. The resident, who had a history of Chronic Obstructive Pulmonary Disease (COPD) and other serious health conditions, was transported to a doctor's appointment without a portable oxygen tank. Upon arrival at the appointment, the resident's oxygen saturation level was critically low at 73%, and he experienced difficulty breathing. The clinic nurse had to administer oxygen to stabilize the resident's condition. Interviews and record reviews revealed that the resident was on continuous oxygen therapy as per physician orders, which required oxygen to be administered at 5L/min via nasal cannula. Despite this, the resident was transported without the necessary oxygen support. The Assistant Director of Nursing (ADON) and the resident's nurse, LVN A, acknowledged that the resident should have been transported with a portable oxygen tank, as he was oxygen-dependent. However, due to a lack of communication and oversight, the resident left the facility without the required oxygen support. The transporter, who was responsible for taking the resident to the appointment, assumed the resident was ready for transport and did not verify the need for a portable oxygen tank. The transporter stated that it was the nurse's responsibility to ensure all necessary items were provided before transport. The facility's administrator was unaware of the resident's continuous oxygen requirement and the oversight that led to the resident being transported without oxygen. This incident highlighted a significant lapse in the facility's procedures for ensuring residents receive necessary medical support during transport.
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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