Cedar Hollow Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman, Texas.
- Location
- 5011 North Us Hwy 75, Sherman, Texas 75090
- CMS Provider Number
- 676488
- Inspections on file
- 37
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 5 (2 serious)
Citation history
Health deficiencies cited at Cedar Hollow Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including DM, hyperlipidemia, depression, cerebral infarction, and a recent fracture, was ordered several scheduled medications at bedtime, including Tramadol, Atorvastatin, Farxiga, Remeron, Eliquis, and a protein supplement. A CMA reported making three attempts to administer the evening medications, during which the resident refused, spat out, and then regurgitated the crushed, thick medication mixture, ultimately receiving only part of the doses while the remainder was discarded. The MAR nevertheless showed all medications as given, and there was no documentation of vomiting, refusal, assessment, or MD notification in the clinical record. The DON stated she only learned of the incident after a family complaint, and the facility could not provide a medication administration policy that addressed this situation, resulting in missed doses and failure to follow pharmaceutical service requirements.
A resident with dementia, osteoporosis, and a prior femur fracture, who was care planned for Hoyer lift transfers due to muscle weakness, was transferred by a CNA without the required mechanical lift. During the transfer, the resident's legs gave out, resulting in a fall and a new femur fracture that required hospitalization and surgery. The care plan directive for mechanical lift use was not followed at the time of the incident.
A resident with dementia, osteoporosis, and a healing femur fracture was transferred from bed to wheelchair by a CNA without using the required Hoyer lift, as specified in the care plan. During the transfer, the resident's legs gave out, resulting in a fall and a new femur fracture that required hospitalization and surgery. Staff interviews and records confirmed the care plan was not followed at the time of the incident.
A resident with respiratory failure who required nebulizer treatments had their nebulizer mask and tubing stored in a drawer with other personal items, rather than in a plastic bag as required by facility policy. Nursing staff and the DON confirmed the mask should have been bagged to prevent infection, but this was not done, resulting in improper storage of respiratory equipment.
A resident who was not authorized to self-administer medications was found with multiple over-the-counter drugs stored at her bedside, contrary to facility policy and regulatory requirements. Staff interviews confirmed that medications should not have been left in the room and that family members sometimes brought in such items.
The facility did not promptly address or communicate responses to repeated grievances raised by the Resident Council regarding care and quality-of-life issues, such as call light wait times, staffing, and customer service. Despite grievances being submitted and some actions reportedly taken, residents were not informed of the outcomes, and written updates requested by the council were not provided, contrary to facility policy.
Two residents did not have comprehensive, person-centered care plans reflecting their current needs. One resident's use of chewing tobacco was not documented or addressed in the care plan, despite staff awareness. Another resident's right-hand contracture and OT services were not included in her care plan, and staff were unaware of the contracture. These omissions were identified through observation, interviews, and record review, and staff acknowledged the care plans were not updated to reflect the residents' needs.
Staff failed to provide timely and proper perineal care for a male resident after an incontinent episode, did not deliver prompt incontinence care to a female resident with a UTI, and did not maintain a foley catheter drainage bag below the bladder during a transfer for another male resident. These actions included not changing wipes between strokes, using soiled gloves, delays in responding to call lights, and improper handling of catheter equipment, all contrary to facility policy and staff training.
Surveyors found that medications, including controlled substances, antifungal powder, and eye drops, were not properly labeled or stored. Two residents had controlled medications with broken blister pack seals left in the medication cart, while antifungal powder and Systane eye drops were found at the bedside of several residents without physician orders. Additionally, a prescribed medication was left on a resident's bedside table after refusal, contrary to facility policy. Staff interviews confirmed that these practices did not follow required procedures for medication storage and administration.
Surveyors found that food items in the facility's kitchen were not consistently labeled or dated, with trays of liquids lacking identification and an expired block of cheese present in the refrigerator. Additionally, a dented can was found in dry storage. Dietary staff interviews revealed inconsistent labeling practices, and facility policy requiring proper labeling and timely use of food was not followed.
Staff failed to consistently follow infection prevention and control protocols, including proper use of PPE and hand hygiene, during incontinence care, wound care, and food service. Multiple residents were affected as CNAs and an LVN did not change gloves or perform hand hygiene between dirty and clean tasks, handled soiled linens improperly, and delivered food trays without sanitizing hands between residents.
A medication cart audit revealed that a resident received Tramadol HCL 50 mg tablets five times after the medication had expired. Staff interviews indicated that while medication counts were done at shift changes, there was no clear record of recent cart audits, and expired medication was not removed as required by facility policy.
A resident with severe cognitive impairment and multiple health conditions developed a bruise and a wound that were not documented or reported to the physician or responsible party. Staff were unaware of the injuries, and no incident report or required notifications were completed, in violation of facility policy.
Two residents who were dependent on staff for ADL care did not receive proper personal hygiene services, including regular fingernail cleaning and scheduled showers, as required by their care plans. One resident had dirty, overgrown fingernails, and another received only one shower in two weeks, despite being fully dependent on staff for bathing. Staff interviews and documentation confirmed that these deficiencies occurred due to lack of adherence to facility policies and care plans.
A resident admitted with a PICC line for IV therapy did not have the line dressing changed within the required 7-day interval as ordered by the physician and facility policy. The dressing remained unchanged since hospital discharge, and documentation falsely indicated the change had occurred. Nursing staff and administration confirmed the oversight, which resulted in the resident being at risk for infection due to the overdue dressing change.
Two residents with severe cognitive impairment and incontinence were not provided timely incontinence care, leading to prolonged periods without being checked or changed. Despite facility protocols requiring checks every two hours, staff interviews revealed challenges in adhering to this schedule due to meal service and staffing issues. Hospice aides and facility staff failed to detect and address incontinence in a timely manner, resulting in residents being found soaked or with bowel movements.
The facility failed to use gait belts during transfers for two residents, one with moderate cognitive impairment and another with severe cognitive impairment. Both residents required substantial assistance with toileting, and staff did not adhere to the facility's policy of using gait belts, increasing the risk of falls and injuries.
A resident was seriously injured when an unscheduled CNA entered the facility and stabbed him multiple times. The resident, who required substantial assistance due to various medical conditions, was attacked in his room, resulting in stab wounds to the neck, chest, and arm. The incident was discovered by an LVN who provided first aid until EMS arrived. The CNA fled but was later arrested. The facility's security measures failed to prevent the CNA's unauthorized access, leading to the resident's hospitalization.
Failure to Administer and Document Medications After Resident Vomiting Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for a cognitively intact resident with multiple complex medical conditions. The resident, an older female with diagnoses including a left tibia fracture, type 2 DM, paroxysmal atrial fibrillation, cerebral infarction, chronic kidney disease, hyperlipidemia, depression, edema, and other conditions, had multiple scheduled medications ordered, including Tramadol for pain, Atorvastatin for hyperlipidemia, Farxiga for DM, Remeron for depression, Eliquis for cerebral infarction, and Protein Oral Liquid for wound healing. The resident’s care plan and orders directed that medications be administered as ordered, with monitoring for side effects, effectiveness, and documentation of relevant symptoms such as nausea and vomiting. On the date in question, CMA A was responsible for administering the resident’s medications, including the bedtime doses of Tramadol, Atorvastatin, Farxiga, Remeron, Eliquis, and Protein Oral Liquid. The MAR reflected that all of these medications were documented as administered by CMA A. However, CMA A later reported that each time she administered medications to the resident that day, the resident regurgitated the medications. During the evening medication pass, CMA A stated she made three attempts to administer the medications: on the first attempt, the resident refused; on the second attempt, the resident spat the medications out; and on the third attempt, while a family member was present, the resident again regurgitated the medications. CMA A stated that on the last attempt she gave the resident half of the medications and, when the resident could not keep them down, she threw the remaining medications away, but she was unable to specify which medications were actually taken or discarded. Despite these events, the clinical record, including the MAR and nursing notes, contained no documentation of the resident’s vomiting, no assessment of the resident’s condition related to the regurgitation, and no evidence of physician notification or monitoring for adverse events. CMA A acknowledged awareness of the vomiting episodes and stated that protocol required reporting such events to the nurse and documenting when a resident refused or vomited medications, but there was no documentation to support that this occurred. The DON reported that she only became aware of the vomiting incident after a family complaint several days later. The resident’s family member described witnessing CMA A crush the medications into a thick, pasty mixture, administer approximately half by spoon, observe the resident regurgitate the medications, and then state that the remaining portion was thrown away because the resident was not going to keep it down. The facility was unable to provide a medication administration policy that addressed these practices, and the failures resulted in the resident missing at least one dose each of Tramadol, Atorvastatin, Farxiga, Remeron, Eliquis, and Protein Oral Liquid on that date. The survey findings specifically note that these failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life.
Failure to Implement Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, consistent with the resident's rights and needs as identified in the comprehensive assessment. The care plan specified that the resident, who had dementia, osteoporosis, and a history of left femur fracture, required the use of a Hoyer lift for all transfers due to muscle weakness and inability to bear weight. Despite this, a CNA attempted to transfer the resident without the mechanical lift, contrary to the care plan instructions. During the transfer, the resident's legs gave out, and the CNA lowered her to the floor. The resident was subsequently assessed by nursing staff and began complaining of pain in her left leg after being returned to bed. Emergency services were called due to the extent of her pain, and the resident was transferred to the hospital, where she was diagnosed with a left distal femur fracture requiring surgical intervention. Interviews and record reviews confirmed that the care plan intervention requiring a Hoyer lift for transfers was not followed at the time of the incident. Staff statements and documentation indicated that the resident's care plan was clear about the need for mechanical lift assistance, but this directive was not implemented, resulting in a fall and serious injury.
Failure to Follow Care Plan for Safe Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required a mechanical lift for transfers. The resident, an elderly female with dementia, osteoporosis, and a healing left femur fracture, was care planned to be transferred using a Hoyer lift due to muscle weakness and an alteration in musculoskeletal status. Despite this, the CNA attempted to transfer the resident from her bed to her wheelchair without the mechanical lift and without assistance, contrary to the documented interventions in the care plan. During the transfer, the resident's legs gave out, and the CNA assisted her to the floor. The resident was then placed back in bed, after which she began complaining of pain in her left leg. The nurse on duty assessed the resident, and due to the extent of pain upon movement and touch, emergency services were called. The resident was transferred to the hospital, where she was diagnosed with a left distal femur fracture that required surgical intervention. Interviews and record reviews confirmed that the care plan specified the use of a Hoyer lift for all transfers, and staff were aware of the resident's transfer status. The CNA involved did not follow the established protocol, resulting in a fall and injury. The incident was self-reported by the facility, and staff interviews indicated knowledge of the importance of following care plans for safe resident transfers.
Improper Storage of Nebulizer Mask for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with acute and chronic respiratory failure with hypoxia was not provided respiratory care consistent with professional standards and the facility's own policies. The resident, who was cognitively intact and receiving oxygen therapy, had a physician's order for Budesonide inhalation via nebulizer twice daily. During an observation, the resident's nebulizer mask and tubing were found stored in a drawer with other personal items and not placed in a bag as required. The resident was unaware that the mask should have been bagged. Interviews with nursing staff and the DON confirmed that the nebulizer mask should have been stored in a plastic bag when not in use to prevent infection, and that it was the nurse's responsibility to ensure proper storage. The facility's policy specifically required nebulizer equipment to be stored in a dated, resident-labeled plastic bag between uses. This failure to follow policy and professional standards resulted in the resident's respiratory equipment being improperly stored.
Unsecured Medication Storage in Resident Room
Penalty
Summary
Facility staff failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as required by state and federal regulations. During an observation, a cognitively intact female resident with dementia, osteoporosis, and a recent femur fracture was found with a plastic container of over-the-counter medications, including Voltaren cream, Pepto Bismol chewable tablets, saline nasal spray, Icy Hot pain relief cream, and Mentholatum ointment, on her bedside table. The resident stated the medications were kept there for her use, but her care plan did not indicate she was permitted to self-administer medications. Interviews with nursing staff, the DON, and the Executive Director confirmed that the resident was not authorized to self-administer medications and that medications should not be left in her room. Staff also noted that family members sometimes brought items, including medications, into the resident's room. The facility's medication storage policy requires nursing staff to maintain secure storage of all medications, which was not followed in this instance.
Failure to Respond to Resident Council Grievances and Communicate Outcomes
Penalty
Summary
The facility failed to act promptly upon grievances raised by the Resident Council regarding issues of resident care and life within the facility. Over the course of four consecutive monthly Resident Council meetings, concerns were repeatedly voiced by residents, including issues such as residents being left in bed and missing activities, concerns about staffing, nails not being cut, long wait times for call lights and medications, agency aides not being responsive, internet service problems, aides turning off call lights without returning, and customer service issues. Despite these concerns being documented in meeting minutes and submitted as grievances, there was no evidence that the facility addressed these concerns following the meetings. Additionally, the Resident Council members were not notified about any facility actions taken to address or resolve their concerns in subsequent meetings. Residents specifically requested written updates from each department regarding their previous concerns, but did not receive any such responses. The Activity Director confirmed that grievances were submitted to the appropriate departments and the Administrator, but was unaware if the Resident Council ever received a response. The Administrator stated that grievances were addressed and filed with the responsible departments, and that some actions were taken, but communication of these actions to the Resident Council as a whole did not occur, with only the Resident Council President being informed verbally. The Resident Council President confirmed that while some improvements were noticed, the same concerns persisted and the lack of a written response from the facility was a significant issue for the residents. The facility's grievance policy requires that all grievances and recommendations from resident or family groups be considered and responded to verbally, including a rationale for the response, and that the findings and corrective actions be communicated to the person filing the grievance. However, the facility did not follow this policy, resulting in residents not being informed of the outcomes of their concerns.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interviews, and record reviews. For one resident, who had a history of paraplegia, seizure disorder, and spina bifida, the care plan did not reflect his use of chewing tobacco, despite multiple staff members, including the DON and Executive Director, being aware of this behavior. The resident was observed using chewing tobacco at his bedside, and staff interviews confirmed ongoing awareness of this practice. However, the care plan and MDS documentation did not address tobacco use, and there was no policy or guidance in place regarding smokeless tobacco, nor any documentation of counseling or risk mitigation related to this behavior. For another resident, who had Alzheimer's disease, rheumatoid arthritis, osteoporosis, and significant physical debility, the care plan failed to address a contracture in her right hand or the occupational therapy (OT) services she received. The resident was observed with a contracture affecting two fingers of her right hand, and staff interviews revealed a lack of awareness and documentation regarding this condition. Although OT had previously worked with the resident and made recommendations, these were not incorporated into the care plan, and there was no documentation of ongoing interventions or resident preferences related to the contracture. The facility's policy requires that care plans be comprehensive, person-centered, and updated as residents' conditions change, including measurable objectives and timetables. In both cases, the care plans did not reflect the residents' current needs or the services provided, as identified in assessments and through staff and resident interviews. This lack of documentation and individualized planning was confirmed by the MDS Coordinator and other staff, who acknowledged the omissions and the need for care plan updates.
Deficient Incontinence and Catheter Care Leading to Increased UTI Risk
Penalty
Summary
Staff failed to provide timely and appropriate perineal care to a male resident who was occasionally incontinent of bladder and frequently incontinent of bowel. On one occasion, two CNAs did not check or change the resident from 6:00 a.m. to 10:25 a.m., despite the resident being saturated in urine and having soiled bed linens. During the care, the CNAs did not change the surface of the peri-wipes with each stroke, used soiled gloves to apply barrier cream, and disposed of dirty linens on the floor. Both CNAs acknowledged they were aware of proper procedures but did not follow them, citing workload and frustration as contributing factors. A female resident with a history of urinary tract infection, stroke, and Parkinson's disease was not provided timely incontinence care during the overnight shift. The resident and her family reported delays in response to call lights, resulting in the resident remaining in wet clothing and bedding for extended periods. Observations revealed the resident had significant redness in the perineal area, and staff interviews confirmed that she was found soaked multiple times during the night and in the morning. There was confusion among staff regarding room assignments, and some staff were instructed not to enter the resident's room, further contributing to lapses in care. Another male resident with a foley catheter and colostomy was not provided appropriate catheter care during a transfer with a mechanical lift. Staff placed the urinary drainage bag on the resident's lap and abdomen, elevating it above the level of the bladder, which caused urine to back up in the tubing. Both CNAs involved stated they were aware of the requirement to keep the drainage bag below the bladder but were unsure how to do so during a mechanical lift. The facility's policies and staff training documents confirmed the expectation to maintain the drainage bag below the bladder at all times.
Improper Labeling and Storage of Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of drugs and biologicals. During observations of medication carts, it was found that two residents' controlled medications (hydrocodone acetaminophen) had blister packs with broken seals, with the pills still inside and taped, rather than being discarded as required. The responsible RN stated that while narcotic counts were performed at shift change, the physical condition of the blister packs was not checked, and she was unaware of when or how the seals were broken. The DON confirmed that such pills should be discarded and that nurses are responsible for checking blister packs for broken seals and expiration dates during shift changes. Further deficiencies were observed regarding the storage and administration of antifungal powder and Systane eye drops. For two residents, antifungal powder was found stored at the bedside and applied by CNAs without a physician's order, and in one case, the powder was retrieved from a resident's chest of drawers. Interviews revealed that CNAs accessed antifungal powder from a cabinet behind the nurse's station and applied it as needed, without nursing assessment or orders. Additionally, Systane eye drops, which were not ordered by a physician, were found at the bedside of two residents, who reported bringing them from home and using them independently. Another deficiency involved a resident's prescribed Tums (calcium carbonate) being left on the bedside table after the resident declined to take it during medication administration. The assigned MA admitted to leaving the medication at the bedside, despite knowing this was not permitted. Staff interviews confirmed that medications, including over-the-counter products, should not be left at the bedside and must have a physician's order and record of administration. The facility's policy requires all drugs and biologicals to be stored securely and not left in resident rooms or at the bedside.
Failure to Properly Store, Label, and Monitor Food Items
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards for food storage, preparation, and service in its only kitchen. Specifically, food items in the refrigerators were not consistently labeled or dated, as evidenced by trays of various liquids in clear plastic cups that lacked identification or date markings. Additionally, an unopened block of sliced cheese was found to be past its manufacturer’s use-by date, and the Dietary Manager confirmed it was expired. In dry storage, a can of black beans was found with a dent on the bottom seal, and the Dietary Manager acknowledged it should be discarded due to the dent. Interviews with dietary staff revealed inconsistent practices regarding labeling and dating of food items. Dietary aides and cooks were responsible for labeling food and liquids in the refrigerators, as well as items in the freezer and dry goods area. The facility’s policy required all leftover and refrigerated foods to be covered, labeled, and dated, and to be used within specified timeframes or discarded. However, observations indicated these procedures were not consistently followed, resulting in expired and improperly labeled food being present in storage areas.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program for multiple residents, as evidenced by direct observations of staff not adhering to required infection control protocols. In several instances, certified nursing assistants (CNAs) and a licensed vocational nurse (LVN) did not perform hand hygiene or change gloves appropriately during incontinence and wound care. For example, two CNAs provided incontinence care to a resident on enhanced barrier precautions due to a venous access device without donning gowns, failed to perform hand hygiene before gloving, and handled soiled linens improperly by placing them on the floor. The same staff did not change gloves or perform hand hygiene between dirty and clean tasks, and one CNA re-entered the room and donned new gloves without hand hygiene after leaving the room. Another resident receiving incontinence care was attended by two CNAs who, despite initially following some PPE protocols, failed to change gloves and perform hand hygiene between dirty and clean care steps. One CNA applied antifungal powder and handled resident belongings with soiled gloves, and only washed hands after completing all care tasks. Similar lapses were observed with another CNA during incontinence care, who changed gloves multiple times without performing hand hygiene, citing irritation from hand sanitizer as a reason for non-compliance. During wound care, an LVN changed gloves between wound sites but did not perform hand hygiene before re-gloving. In the dining area, a CNA was observed delivering food trays and handling residents' food items with bare hands, without performing hand hygiene between each tray delivery. The CNA also touched her clothing and other surfaces between tasks, further increasing the risk of cross-contamination. Interviews with staff and administration confirmed awareness of the required protocols, but also revealed inconsistent understanding and application of hand hygiene expectations, particularly regarding the frequency of hand hygiene during food service and resident care activities. Facility policies reviewed indicated clear requirements for hand hygiene and PPE use, which were not consistently followed by staff.
Expired Medication Administered Due to Inadequate Cart Audits
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that expired medication was removed from a medication cart. During an observation and record review of a medication cart on Hall B, it was found that a card of Tramadol HCL 50 mg for a resident had an expiration date that had already passed. Despite this, the medication was administered to the resident five times after its expiration date, as confirmed by the medication log. Interviews with staff revealed that medication counts were performed at shift changes, but there was uncertainty about when the last audit of the cart had been conducted. The LVN acknowledged that administering expired medication could be ineffective, and the DON stated that expired medications should be discarded and that nurses were responsible for checking expiration dates during shift changes and before administration. The facility's policy also required immediate removal and disposal of outdated medications, but this procedure was not followed in this instance.
Failure to Notify Physician and Responsible Party of Resident Injury
Penalty
Summary
The facility failed to notify a resident's physician and responsible party after the resident sustained a bruise to her right hand and a dime-sized wound on her right underarm. The resident, who was severely cognitively impaired and required extensive assistance with activities of daily living, was observed to have these injuries during surveyor visits. There was no documentation in the nurse's notes or incident reports regarding the injuries, nor any evidence that the physician or family had been notified as required by facility policy. Multiple staff interviews revealed a lack of awareness and communication regarding the injuries. Certified Nursing Assistants (CNAs) who provided care to the resident could not specify when the injuries occurred, and some believed the injuries were related to blood draws or skin tears during care. Nursing staff, including the Assistant Director of Nursing (ADON) and Registered Nurses (RNs), were unaware of the injuries until informed by the surveyor. The treatment nurse and ADON confirmed that no incident report had been completed, and the responsible party had not been notified until the time of the survey. Facility policy required prompt notification of the physician and resident representative in the event of accidents, injuries, or changes in condition. Despite these requirements, the facility did not follow protocol for assessment, documentation, or notification regarding the resident's injuries. The lack of communication and documentation was confirmed by interviews with the Director of Nursing (DON) and Executive Director, who both stated they had not been informed of the injuries prior to the survey. The responsible party also confirmed she had not been notified until contacted by the surveyor.
Failure to Provide ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, a female with multiple sclerosis, dementia, and depression, was observed with dirty and overgrown fingernails. Her care plan indicated she required substantial to maximum assistance with ADLs, and nail care was to be performed by CNAs weekly or as needed. However, her fingernails were not cleaned or trimmed as required, and she was unable to communicate about their condition. Another resident, a female with a history of cerebrovascular accident and hemiplegia, was dependent on staff for bathing. Her care plan specified that she should receive showers three times a week and as needed. Documentation and observation revealed that she received only one shower in a 14-day period, and her skin was noted to be oily and flaky. The resident reported not having had a shower since her recent hospital stay, and staff interviews confirmed that scheduled showers were missed without proper documentation or follow-up. Facility policies required daily cleaning and regular trimming of fingernails, as well as scheduled showers to promote cleanliness and comfort. Staff interviews indicated that CNAs were responsible for providing these services and notifying charge nurses of any refusals or issues. However, the lack of adherence to these policies resulted in residents not receiving appropriate hygiene care as outlined in their care plans.
Failure to Timely Change PICC Line Dressing per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of cellulitis and recent sepsis was admitted with a PICC line in place for IV therapy. Physician orders and facility policy required the PICC line dressing to be changed every 7 days using sterile technique. Documentation indicated the dressing was due to be changed, but observation revealed the dressing was still dated from the hospital admission and had not been changed since the resident's arrival. The resident confirmed that the dressing had not been changed during her stay. Review of the medication administration record showed the dressing change was signed off as completed, but the nurse later admitted this was an error and the dressing had not actually been changed. Interviews with nursing staff and administration confirmed that the dressing change order was not initially entered upon admission and was only obtained several days later. Despite daily line flushes and checks, the overdue dressing change was not identified or addressed until it was brought to the attention of staff during the survey. The failure to change the PICC line dressing as ordered and per professional standards placed the resident at risk of infection.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, both of whom required extensive assistance due to severe cognitive impairment and limited mobility. Resident #2, who was always incontinent of bladder and bowel and received hospice services, was not checked for incontinence from 9:00 a.m. to 1:30 p.m. on the day of observation. Despite being in the common area and later taken to the dining room, staff did not check her for incontinence. It was only after lunch that the hospice CNA found her soaked in urine and provided the necessary care. Similarly, Resident #3, who also had severe cognitive impairment and was dependent on staff for toileting hygiene, was not checked for incontinence from 9:35 a.m. to 1:45 p.m. on the same day. Although hospice aides attended to her in the morning, they did not change her brief as they did not detect any wetness or odor. It was only later in the afternoon that facility staff provided incontinence care, discovering a moderate-sized bowel movement and slight skin redness. Interviews with facility staff, including CNAs and the DON, revealed that residents were supposed to be checked every two hours for incontinence, regardless of hospice care. However, due to meal service schedules and staffing challenges, this protocol was not consistently followed. The facility's policy on perineal care emphasized the importance of cleanliness and infection prevention, which was not adhered to in these cases.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to ensure the use of gait belts during resident transfers, which is a critical safety measure to prevent falls and injuries. On December 10, 2024, a CNA did not use a gait belt while transferring a resident from a wheelchair to the toilet. The resident, who was moderately cognitively impaired and had limited range of motion due to a stroke, required substantial assistance with toileting. The CNA assisted the resident by pulling up on the back of her pants instead of using a gait belt, which is against the facility's policy for safe resident transfers. Another incident involved a hospice aide who also failed to use a gait belt while assisting a severely cognitively impaired resident with incontinence care. The resident, who had Alzheimer's disease and was dependent on staff for toileting, was assisted to stand without a gait belt, leading to her knees buckling. The hospice aide acknowledged forgetting to use the gait belt, which is essential for stabilizing residents during transfers. Interviews with staff, including the ADON and DON, revealed a lack of consistent training and adherence to the facility's policy on the use of gait belts. The facility's policy mandates the use of gait belts for safe lifting and movement of residents to prevent injuries. The absence of documented training and the failure to use gait belts during transfers highlight a significant oversight in ensuring resident safety.
Resident Stabbed by Unscheduled CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA entered the resident's room and inflicted multiple stab wounds, resulting in serious injuries that required hospitalization. The resident, a 95-year-old male with a history of various medical conditions including a neck fracture, osteoporosis, depression, cerebrovascular disease, polyneuropathy, dysphagia, COPD, muscle wasting, and prostate cancer, was cognitively intact and required substantial assistance with personal hygiene and toileting. The incident occurred when the CNA, who was not scheduled to work, entered the facility using a door code and attacked the resident with a knife, causing stab wounds to the neck, chest, and arm. The attack was discovered by an LVN who responded to a CNA's alert about the presence of the unscheduled CNA in the resident's room. Upon entering the room, the LVN found the resident bleeding profusely and called for help, applying pressure to the wounds until EMS arrived. The CNA fled the scene but was later apprehended by law enforcement. The facility had video footage of the CNA entering and exiting the facility and the resident's room, which was turned over to the police. Interviews with staff and residents revealed that the CNA had previously entered the facility earlier in the night, looked at the staffing book, and left, only to return later and commit the attack. Staff initially believed the CNA was attempting to steal time by clocking out without being scheduled. The facility's failure to prevent the CNA from accessing the building and the resident's room led to the serious injury of the resident, highlighting a significant lapse in security and monitoring procedures.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
