Cedar Creek Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bandera, Texas.
- Location
- 159 Montague Ave, Bandera, Texas 78003
- CMS Provider Number
- 675929
- Inspections on file
- 22
- Latest survey
- December 21, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Cedar Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Three residents experienced failures in pharmaceutical services, including missed documentation of narcotic administration by nursing staff and improper handling of a punctured Lorazepam blister pack. Nurses admitted to missing documentation due to workload, and staff were unclear on procedures for wasting controlled substances, leading to discrepancies between narcotic counts and records.
Surveyors found that food temperatures were not consistently documented, containers of food lacked discard dates, an air conditioner vent in the kitchen was unclean, and raw proteins were stored above fully cooked foods in the freezer. The CDM and staff acknowledged these lapses, which were not in line with facility policy or FDA Food Code standards.
A registered nurse left a medication cart laptop unlocked and unattended, displaying confidential information about a resident while entering another room for a medication pass. Facility leadership confirmed that the laptop should have been locked to protect resident privacy, as required by HIPAA and facility policy.
A resident with moderate cognitive impairment and a history of dementia and cataracts was found to have prescribed eye drops left at bedside by an RN, allowing unsupervised access to the medication. There was no assessment or documentation authorizing self-administration, and facility policy requires medications to be administered only by licensed personnel. The DON and ADM were unaware of any self-administration assessment for the resident.
A resident with moderate cognitive impairment and multiple medical conditions had a personal refrigerator that was not consistently maintained at or below 41°F, and temperature documentation was incomplete for several days. The facility did not enforce its policy on safe food storage for items brought in by family or visitors.
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Residents complained about cold and flavorless food, with meals often being late and trays sitting in the hall for extended periods. During meal service observation, food items required reheating, and a test tray revealed cold green beans, lukewarm turkey, and overcooked tater tots. The Dietary Supervisor and Administrator acknowledged potential negative impacts on residents' quality of life.
The facility failed to provide suitable snacks to residents outside scheduled meal times, particularly at bedtime, affecting diabetic residents who did not receive snacks labeled for their needs. Interviews revealed confusion among staff about responsibility for maintaining the resident refrigerator, which contained outdated food items. The facility lacked a clear protocol for offering snacks, and there was no follow-up to ensure snacks were distributed, contributing to the deficiency.
The facility failed to follow professional standards for food service safety. During a meal service, the cook and dietary aide did not wash their hands between tasks, violating the hand washing policy. The cook also used bare hands to handle food, contrary to the no-glove policy. These actions could risk foodborne illness.
The facility failed to maintain an effective infection prevention and control program, with staff observed not sanitizing equipment or performing proper hand hygiene. An ADON used unsanitized equipment on multiple residents, while an LVN did not wash hands between glove changes during wound care. These practices were acknowledged as breaks in infection control, posing potential risks of infection transmission.
Two residents in a facility were administered insulin without proper privacy measures, as observed by surveyors. One resident was injected with insulin in full view from the hallway, while another had her blood sample taken and insulin administered with the door open and no privacy curtain used. Both residents were moderately cognitively impaired and had type 2 diabetes. The nursing staff acknowledged the oversight, and the DON emphasized the expectation of providing privacy during care.
A facility failed to implement a comprehensive care plan for a resident requiring oxygen therapy. Despite medical orders for specific oxygen use, the care plan lacked details on the amount, duration, and frequency of oxygen therapy. Observations showed the resident using oxygen at 3 liters per minute, which was not documented. Interviews with staff confirmed the care plan should have been updated to reflect the resident's needs.
A resident with severe cognitive impairment and mobility issues was not provided with a fall mat as ordered by the physician, posing a risk for falls. The fall mat was observed folded against the wall instead of being placed beside the bed. Staff interviews revealed confusion about responsibility for ensuring the mat's use, with the DON acknowledging the oversight.
A resident's oxygen nasal cannula was improperly stored and not replaced as needed, leading to a deficiency in respiratory care. The nasal cannula was found on the floor and in an open drawer, contrary to facility policy requiring it to be stored in a protective bag. Interviews with the ADON and DON confirmed the oversight, highlighting the importance of proper storage to prevent infections.
The facility failed to ensure proper storage of drugs and biologicals, with a resident found with a jar of mentholated ointment on their nightstand and a medication cart left unlocked and unattended. The DON confirmed that residents are not allowed to self-medicate and that medication carts should remain locked to prevent unauthorized access.
A facility failed to maintain complete medical records for a resident with severe cognitive impairment, as the guardianship paperwork had expired and no renewal was found. The resident, who requires total assistance with ADLs and has multiple diagnoses, was observed frequently yelling and was not interviewable. The administrator relied on the social services worker to update the paperwork, who confirmed it was her responsibility and planned to contact the guardian for the updated document.
The facility failed to maintain effective pest control in the kitchen, as a live roach was observed near the oven. Despite recent pest control treatment, heavy German Cockroach activity was noted, and recommended targeted service was not documented. The facility's pest control policy was not effectively implemented.
The facility failed to maintain a pest-free environment, with German cockroaches observed in various areas, including the kitchen, for about a year. Staff interviews confirmed sightings, but the pest control log lacked documentation of these incidents. The pest control service inspection reported heavy cockroach activity and recommended targeted treatment and structural repairs.
A resident with moderate cognitive impairment was reportedly left on the floor by a nurse after a fall, and staff members failed to report the incident to the administrator within the required timeframe. Staff assumed the DON would handle the situation, but the DON did not report it, believing the fall did not occur. The facility's policy for immediate reporting of suspected abuse or neglect was not followed.
The facility failed to provide scheduled showers for three residents due to staffing issues on the 2-10 PM shift. A resident with cerebral infarction and hemiplegia had to repeatedly request a shower, while two other residents did not receive showers for an entire month. Staff interviews confirmed the issue was due to inadequate staffing, and the facility's administrator was aware and working on hiring more staff.
The facility failed to maintain privacy and confidentiality for residents when an LVN entered two rooms without knocking and another LVN left a computer screen open in a hallway displaying a resident's personal information. These actions violated the facility's policies on resident privacy and confidentiality.
A facility failed to implement a comprehensive care plan for a resident with a left-hand contracture, lacking interventions to maintain or improve mobility. The resident, with a history of cerebral infarction and hemiplegia, did not receive necessary therapy or devices due to financial constraints and the absence of a restorative program. Staff interviews confirmed the lack of restorative aides and devices, and the care plan did not include measures to address the contracture, resulting in a deficiency.
A resident with a left-hand contracture did not receive appropriate care to maintain or improve mobility. Despite having a history of cerebral infarction and hemiplegia, the resident lacked devices or therapy for the contracture. The care plan did not address the contracture, and staff interviews revealed a lack of awareness and action. Financial constraints and the absence of a restorative program contributed to the deficiency.
A facility failed to create a comprehensive care plan for a resident with peripheral vascular disease and multiple wounds. The resident's baseline care plan did not address her specific medical needs, including wound care for her condition. Despite receiving treatment, the comprehensive care plan was not completed, and necessary interventions were not documented, as confirmed by staff interviews.
Failure to Ensure Accurate Documentation and Handling of Controlled Substances
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for three of eight residents reviewed. For one resident with chronic pain and moderate cognitive impairment, a registered nurse administered Hydrocodone-Acetaminophen as ordered but did not document the administration on the resident's narcotic sheet. This discrepancy was identified during shift change when the narcotic count did not match the number of medications in the cart. The nurse admitted that documentation was sometimes missed due to being busy, but confirmed the medication was given. Another resident with chronic pain, cancer, and moderate cognitive impairment had Tramadol administered by an LVN, but the administration was not documented in the Medication Administration Record (MAR) on two occasions, despite being recorded on the narcotic sheet. The LVN acknowledged forgetting to document in the MAR due to workload and recognized the importance of accurate documentation to track medication administration and prevent errors. A third resident with severe cognitive impairment and anxiety had a blister pack of Lorazepam punctured, but instead of wasting the dose as required, the pack was taped shut. Staff were unsure of the correct procedure, but another nurse clarified that punctured narcotic blister packs should be destroyed and witnessed by two nurses. The facility's policies required immediate removal and destruction of compromised medications and proper documentation of all administered and wasted controlled substances.
Deficiencies in Food Storage, Preparation, and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, specifically related to food storage, preparation, and documentation. There were several instances where food temperatures were not documented for breakfast, lunch, and dinner over multiple days, as required by facility policy. The Certified Dietary Manager (CDM) acknowledged that it was the cook's responsibility to record these temperatures, but he was overseeing the process and was unaware that the documentation was incomplete. Additionally, containers of jalapeno peppers, ketchup, and tartar sauce in the refrigerator were found without discard dates, contrary to professional standards and FDA Food Code requirements. Further observations revealed that the air conditioner vent in the kitchen, located above closed cereal containers, had visible black substances on it and had not been cleaned. The CDM was unsure who was responsible for cleaning the vent but agreed it needed attention. In the freezer, raw chicken was stored above pizza dough and cookie dough, which is not compliant with food safety standards that require raw proteins to be stored below fully cooked foods to prevent cross-contamination. Staff interviews confirmed awareness of these standards, but lapses in practice were evident. Record reviews showed that the facility's policies required regular cleaning of the dietary department and equipment, as well as daily documentation of food temperatures before meal service. However, the food storage policy did not specify the need for dating food products with expiration or discard dates, as outlined in the FDA Food Code. Despite these deficiencies, the Director of Nursing (DON) reported no pattern of gastrointestinal issues among residents in the past six months, based on infection control surveillance records.
Unsecured Laptop Screen Exposes Resident Information
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a laptop on a medication cart unlocked and unsupervised, displaying confidential resident information, while entering a resident's room during a medication pass. This incident was observed and confirmed through interviews with facility administration, who acknowledged that the laptop should have been locked to protect resident privacy in accordance with HIPAA requirements. The facility's policy on resident rights also states that residents have the right to secure and confidential personal and medical records. The failure to lock the computer screen allowed for the possibility that resident information could be seen or accessed by unauthorized individuals passing by. The report does not specify the identity or medical history of the resident whose information was exposed, nor does it provide details about their condition at the time of the incident.
Medication Storage and Administration Protocol Not Followed
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a resident's prescribed eye drop medication at the bedside, allowing the resident to access and potentially self-administer the medication unsupervised. The resident, a male with dementia and a cataract diagnosis, had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. The medication, Prolensa Ophthalmic Solution, was ordered to be administered once daily for cataract surgery. During an interview and observation, the RN acknowledged that the medication should not have been left at the bedside, even though the resident might be capable of self-administration. Further investigation revealed that there was no documentation or assessment indicating that the resident was authorized or capable of self-administering his medications. The Director of Nursing (DON) and Administrator were unaware of any such assessment or care plan. Facility policy requires that only licensed or legally authorized personnel administer medications and that medications are not left with residents unless proper assessment and documentation are in place. This lapse in medication storage and administration protocol led to the cited deficiency.
Failure to Maintain and Document Safe Refrigerator Temperatures for Resident Food Storage
Penalty
Summary
The facility failed to implement and enforce a policy regarding the use and storage of foods brought in by family and other visitors for residents. Specifically, the facility did not ensure that a resident's personal refrigerator maintained a temperature at or below 41 degrees Fahrenheit, as required by facility policy. Temperature logs showed that for several days, the refrigerator was above the recommended temperature, and for a subsequent period, temperatures were not documented at all. This lapse was identified through observation, interview, and record review. The resident involved was an older adult with a history of constipation, protein-calorie malnutrition, and nausea, and had moderate cognitive impairment as indicated by a BIMS score of 12 out of 15. Despite the resident reporting no illness from consuming food stored in her refrigerator, the facility's failure to monitor and document refrigerator temperatures as per policy constituted a deficiency in ensuring safe and sanitary food storage for residents.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. During an initial tour, two residents complained about the food being cold and lacking flavor, with one resident noting that the food was not of restaurant quality. Confidential interviews during a Resident Meeting confirmed that the food was frequently cold and lacked taste, with several residents noting that meals were often late and trays sat on the hall in carts for over 15 minutes before being handed out. The carts used for delivering trays to the dining room were open type, providing no insulation other than dome covers. During an observation of meal service, the cook had to reheat several items to bring them up to the required temperature on the steam table. The last cart went out over an hour later than the scheduled meal service time, and the Administrator was observed checking each plate, allowing heat to escape. A test tray delivered to the state survey room revealed that the green beans were cold, the turkey was lukewarm, and the tater tots were overcooked and hard. The Dietary Supervisor and Administrator acknowledged that residents could experience weight loss and a diminished quality of life if food was served cold and not palatable.
Failure to Provide Snacks and Maintain Refrigerator
Penalty
Summary
The facility failed to ensure that residents received suitable and nourishing meals and snacks outside of scheduled meal service times, particularly at bedtime. During a Resident Meeting, it was revealed that snacks were not offered at bedtime unless specifically requested by the residents. Three out of seven residents, who were diabetic, reported not receiving any snacks labeled with their names, indicating a lack of attention to their dietary needs. This oversight could potentially affect all residents, especially those with specific dietary requirements such as diabetics, by increasing the risk of unplanned weight loss and medication side effects. Interviews with various staff members, including the Dietary Supervisor (DS), Maintenance Director, and Administrator, highlighted a lack of clarity regarding responsibility for maintaining the resident refrigerator and distributing snacks. The DS showed the surveyor a refrigerator containing outdated and undated food items, and there was confusion among staff about who was responsible for cleaning and maintaining the refrigerator. The DS assumed that nursing staff were responsible for distributing snacks, while the Maintenance Director and Administrator believed that housekeeping should maintain the refrigerator. Further observations and interviews revealed that the facility did not have a clear protocol for offering snacks to residents, particularly those with dietary needs such as diabetics. The DS mentioned that a list of diabetic residents was requested, and snacks were prepared for them, but there was no follow-up to ensure these snacks were distributed. The facility lacked a policy for snacks, and the existing policy for cleaning the refrigerator was outdated, contributing to the deficiency in providing adequate nutrition and care to the residents.
Failure to Follow Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a lunch meal service. The cook did not wash his hands between tasks, such as taking food temperatures, writing notes, flipping through pages, gathering serving utensils, and washing thermometers. Similarly, the evening cook, who was serving as a dietary aide, was observed preparing dessert items and covering bowls with plastic wrap without washing her hands. These actions were in violation of the facility's hand washing policy, which mandates frequent hand washing to prevent cross-contamination. Additionally, the cook was observed using his bare hands to place rolls on plates during meal service, contrary to the facility's no-glove policy on the steam table. The Dietary Department Glove Standard Protocol specifies that there should be no bare hand-to-food contact in the kitchen, and utensils like tongs should be used to handle ready-to-eat food items. The failure to follow these protocols could place residents at risk for foodborne illness, as the facility did not ensure proper hand hygiene and food handling practices.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and equipment sanitation. During observations, the Assistant Director of Nursing (ADON) was seen administering medications to residents without sanitizing the blood pressure cuff and pulse oximeter between uses. The ADON also failed to perform proper hand hygiene after administering medications to two residents, which was acknowledged as a break in infection control by the ADON during an interview. In another instance, a Licensed Vocational Nurse (LVN) did not perform proper hand hygiene before entering a resident's room and during wound care procedures. The LVN was observed changing gloves multiple times without washing or sanitizing hands in between, and used scissors that were not sanitized prior to use. The LVN admitted to not being trained about washing or sanitizing hands between glove changes and acknowledged the potential for cross-contamination due to these practices. The Director of Nursing (DON) confirmed the expectation for staff to perform proper hand hygiene between glove changes and highlighted the risks of improper hand hygiene, including the spread of bacteria and infection. Despite the facility's policies on hand hygiene and infection control, these practices were not followed, leading to potential risks of infection transmission among residents.
Failure to Ensure Privacy During Insulin Administration
Penalty
Summary
The facility failed to ensure privacy and dignity for two residents during insulin administration. Resident #11, a moderately cognitively impaired female with type 2 diabetes, was observed receiving an insulin injection without privacy measures in place. The Licensed Vocational Nurse (LVN) administering the injection did not close the bedroom door or pull the privacy curtain, leaving the resident exposed to view from the hallway. Despite the resident stating it did not bother her, the LVN acknowledged forgetting to provide privacy, recognizing it as a dignity issue. Similarly, Resident #27, also moderately cognitively impaired and diagnosed with type 2 diabetes, was administered insulin without adequate privacy. The LVN left the bedroom door open and did not use the privacy curtain while obtaining a blood sample and administering the insulin injection. Although the resident expressed that it did not bother her, the LVN admitted to not providing privacy, assuming it was acceptable since the resident did not have a roommate. The Director of Nursing (DON) stated that it was expected for nursing staff to provide privacy by at least pulling the privacy curtain and closing the door during care. The lack of privacy during these procedures was identified as an invasion of privacy, with the DON emphasizing the importance of maintaining residents' dignity in their living environment. A policy and procedure regarding privacy and dignity was requested but not provided at the time of the report's exit.
Failure to Implement Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included specific interventions for the use of oxygen therapy. The resident, a female with diagnoses including dementia, heart failure, pneumonia, and shortness of breath, was admitted and readmitted to the facility. Her medical records indicated the need for oxygen therapy, with specific orders to check oxygen saturation every shift and to use oxygen at 2 liters per minute as needed. However, the comprehensive care plan did not specify the amount, duration, or frequency of oxygen use, despite changes in the resident's orders dating back to December. Observations revealed that the resident was using oxygen at 3 liters per minute, which was not documented in the care plan. Interviews with the MDS Coordinator and the DON confirmed that the care plan should have been updated to reflect the resident's specific needs for oxygen therapy. The facility's policy on comprehensive care planning emphasized the need for measurable objectives and timeframes to meet residents' needs, which was not adhered to in this case.
Failure to Utilize Fall Mat as Ordered
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, the facility did not utilize a fall mat for a resident as per the physician's orders. The resident, a female with severe cognitive impairment and dependent on staff for bed mobility and transfers, was observed without the fall mat in place while in bed, contrary to the care plan and physician's orders. During observations, the fall mat was found folded and leaning against the wall at the foot of the bed, rather than being placed on the floor beside the bed as required. Staff interviews revealed confusion about who was responsible for ensuring the fall mat was in place, with the CNA and Hospice Aide both indicating that the mat was not in use when they entered the room. The Director of Nursing acknowledged that the fall mat should be on the floor when the resident is in bed to prevent injury from falls, and that it was the responsibility of the CNA, nursing staff, and ultimately the DON to ensure compliance with this safety measure.
Improper Storage and Handling of Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as observed during multiple instances. The resident's oxygen nasal cannula was not properly stored or protected when not in use, which is inconsistent with professional standards of practice and the facility's policy. Observations revealed that the nasal cannula was left on the floor and in an open drawer, rather than being stored in a protective bag. The tubing was also not replaced as needed, despite being visibly contaminated and dated several days prior. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the improper handling and storage of the oxygen equipment. The ADON acknowledged that the tubing should have been replaced and stored correctly, while the DON emphasized the importance of keeping the tubing clean to prevent infections. The facility's policy on oxygen administration requires that tubing be changed when contaminated and stored properly, which was not adhered to in this case.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals, as evidenced by two specific incidents. In the first incident, a resident was found to have a jar of mentholated ointment on their nightstand, despite the facility's policy that residents are not allowed to self-medicate. The resident, who was moderately cognitively impaired and had a history of dementia and other health conditions, was observed with the ointment on multiple occasions. The Director of Nursing (DON) confirmed that no residents were permitted to have medications at their bedside due to the risk of inappropriate use or access by other residents, particularly those who wander. In the second incident, a medication cart on The Long Hall was found unlocked and unattended during a medication pass. The Licensed Vocational Nurse (LVN) acknowledged the oversight, noting that it posed a risk as any resident or unauthorized person could access the medications. The DON reiterated the expectation that medication carts should remain locked and secured to prevent unauthorized access. The facility's policy on medication storage emphasizes that medications should be stored safely and securely, accessible only to authorized personnel.
Incomplete Medical Records Due to Expired Guardianship
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the current status of the resident's guardianship paperwork. The resident, a male with severe cognitive impairment and multiple diagnoses including unspecified dementia and major depressive disorder, was admitted to the facility with a guardian as the only emergency contact and responsible party. The guardianship paperwork on file had expired, and no renewal was found in the medical record, which could affect the validity of consent for treatment. During the survey, the resident was observed to be frequently yelling and was not interviewable due to cognitive issues. The facility's administrator acknowledged the importance of keeping guardianship paperwork up to date and indicated reliance on the social services worker for this task. The social services worker confirmed it was her responsibility to maintain current guardianship paperwork and stated she would contact the guardian to obtain the updated document.
Ineffective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen, as evidenced by the presence of a live roach observed crawling on the wall near the oven, which was next to the steam table. This incident was witnessed during an observation and interview with the Dietary Supervisor, who promptly removed the roach and informed the Administrator to contact the pest control company. Despite recent pest control treatment, the presence of roaches indicates that the measures taken were insufficient. A review of the pest control log revealed that the pest control company had visited the facility on a previous date to address roaches and other pests. The report from this visit noted heavy German Cockroach activity in the kitchen and recommended an after-hours targeted service of kitchen equipment. However, there was no documentation indicating that this recommended service was carried out. The facility's policy for insect and rodent control, dated 2012, outlines procedures for maintaining an insect and vermin-free environment, but the observed deficiency suggests these procedures were not effectively implemented.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a resident environment free of pests and rodents, as evidenced by the presence of German cockroaches. Interviews with staff and residents revealed that cockroaches had been observed in various parts of the facility, including the kitchen, for about a year. Despite the presence of pests, the facility's grievance and pest control logs did not reflect any reports of cockroaches, indicating a lack of documentation and communication regarding the issue. The facility's policy on insect and rodent control, which requires maintaining an effective pest control program, was not effectively implemented. Interviews with staff, including CNAs, an LVN, and the DON, confirmed sightings of live roaches and previous incidents involving mice. The pest control service inspection report noted heavy German cockroach activity in the kitchen and recommended after-hours targeted service and structural repairs to prevent pest access. The ADM acknowledged that staff were expected to document pest sightings in the pest control log, but this was not consistently done, preventing timely intervention by the maintenance director.
Failure to Report Alleged Neglect in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, as required by regulations. This deficiency was identified in the case of a resident who had moderate cognitive impairment and required assistance with mobility. The resident was reportedly left on the floor by a nurse after a fall, and staff members did not report this incident to the administrator within the mandated timeframe. Interviews with staff members revealed that they were aware of the incident where the nurse left the resident on the floor, but they assumed it would be handled by the Director of Nursing (DON). The staff members did not report the incident directly to the administrator, as they believed the DON would take the necessary steps. The DON, however, did not report the incident to the administrator, as she believed the fall did not occur and therefore no neglect took place. The administrator stated that he expected all allegations of abuse, neglect, or exploitation to be reported to him directly. However, the staff had been trained to report such incidents to the DON, which led to a breakdown in communication and reporting. The facility's policy required immediate verbal reporting of suspected abuse or neglect to the Abuse Preventionist or designee, but this protocol was not followed in this case.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents who are unable to perform activities of daily living received the necessary services to maintain grooming and personal hygiene. This deficiency was identified for three residents who were scheduled to receive showers on the evening shift of Monday, Wednesday, and Friday. However, due to staffing issues, these showers were not consistently provided. Specifically, on a Monday shift, only one CNA was available, which resulted in the showers not being completed for the residents. Resident #1, who has a history of cerebral infarction, hemiplegia, and requires extensive assistance with bathing, reported having to repeatedly ask staff for a shower. Despite eventually receiving a shower, the resident expressed frustration over the uncertainty of receiving necessary care. Resident #4, who requires supervision or touching assistance with bathing due to cognitive and physical impairments, did not receive a shower for the entire month of January 2025, as documented in the POC task records. Similarly, Resident #5, who has dementia and requires setup or cleanup assistance, also did not receive a shower for the same period. Interviews with staff revealed that the lack of adequate staffing on the 2-10 PM shift contributed to the failure to provide showers. A CNA working that shift confirmed the inability to complete resident baths, and an LVN acknowledged awareness of the issue, noting that it had been ongoing since December 2024. The facility's administrator was informed of the situation and was in the process of addressing staffing shortages. The facility's policy on bathing emphasizes the importance of regular showers for maintaining hygiene and comfort, yet this standard was not met due to the staffing challenges.
Privacy and Confidentiality Breach by LVNs
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as observed in two separate incidents involving Licensed Vocational Nurses (LVNs). In the first incident, LVN J was observed entering two residents' rooms without knocking, which was confirmed during an interview with LVN J, who acknowledged the oversight and expressed an intention to improve. This action violated the residents' right to personal privacy as outlined in the facility's policy. In the second incident, LVN Z left a computer screen open in a hallway, displaying a resident's personal information while people passed by. During an interview, LVN Z admitted to forgetting to turn off the monitor due to being preoccupied with checking residents' lunch trays. This oversight was a breach of the facility's policy on safeguarding resident confidentiality and personal privacy, which mandates that access to personal and medical records be limited to authorized personnel only.
Failure to Address Resident's Hand Contracture in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a left-hand contracture. The resident, who had a history of cerebral infarction, epilepsy, and hemiplegia, did not have interventions in place to maintain or improve mobility in the affected hand. Observations revealed that the resident's care plan lacked specific measures to address the contracture, such as the use of a device to prevent fingernails from digging into the skin. Interviews with staff, including a CNA and a PT, confirmed that the resident's left hand was contracted and that there were no restorative aides or devices available to assist with the condition. The PT mentioned that the resident did not have the finances for therapy, and the facility occasionally paid for therapy services. However, the resident had not received a splint or device for the left-hand contracture, and there was no restorative program in place due to the facility's financial constraints and the impact of COVID-19. The MDS coordinator acknowledged that the resident's care plan did not include restorative services, and the facility's policy on comprehensive care planning was not effectively implemented. The resident's financial situation and lack of insurance coverage were cited as reasons for the absence of therapy and restorative interventions. Despite having funds in a trust, the resident's care plan did not reflect necessary interventions to address the contracture, leading to a deficiency in meeting the resident's medical and physical needs.
Failure to Provide Appropriate Care for Resident's Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited mobility, specifically regarding the management of a left-hand contracture. The resident, who had a history of cerebral infarction, epilepsy, and hemiplegia affecting the left side, was observed to have a left-hand contracture without any devices to maintain or improve mobility. Interviews with the resident and staff revealed that no interventions were in place to prevent the fingernails from digging into the skin, and there was no therapy or restorative program addressing the contracture. The resident's care plan did not include interventions for the left-hand contracture, despite the resident's condition being documented in various records. The facility's physical therapist confirmed that the resident had not received a splint or device for the contracture and that the facility lacked restorative aides. Financial constraints were cited as a reason for the lack of therapy, with the facility occasionally covering therapy costs due to the resident's limited insurance coverage. Interviews with staff, including CNAs and the MDS coordinator, indicated a lack of awareness and action regarding the resident's contracture. The facility had previously had a restorative program, but it was discontinued, and no current policies or interventions were in place to address the resident's needs. The absence of a comprehensive care plan for the contracture and the lack of restorative services contributed to the deficiency in care for the resident.
Failure to Develop Comprehensive Care Plan for Resident with Vascular Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with multiple medical conditions, including peripheral vascular disease and multiple wounds. The resident, an 84-year-old female, was admitted with diagnoses such as sepsis, type 2 diabetes with neuropathy, and peripheral vascular disease, particularly affecting her right foot. Despite these conditions, the baseline care plan only addressed fall prevention, wound care for lacerations and skin tears, and diabetes management, without specific interventions for the resident's peripheral vascular disease or wound care. The resident's medical records indicated severe peripheral artery disease and other complications, including a lower extremity ulcer with cellulitis and MRSA. The resident received treatment for arterial wounds as ordered by the physician, but the comprehensive care plan did not reflect these interventions. Interviews with staff, including the MDS nurse and the former DON, revealed that the comprehensive care plan was not completed within the required timeframe, and the necessary interventions for the resident's condition were not documented. The absence of a comprehensive care plan was acknowledged by the facility's staff, including the administrator and the MDS nurse, who admitted that the plan was not developed as required. The failure to document and communicate the necessary interventions for the resident's peripheral vascular disease and wound care through a comprehensive care plan could have impacted the quality of care provided to the resident, as it did not capture the physician's orders or the resident's specific needs.
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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