Cibolo Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Boerne, Texas.
- Location
- 1440 River Rd, Boerne, Texas 78006
- CMS Provider Number
- 676240
- Inspections on file
- 27
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Cibolo Creek during CMS and state inspections, most recent first.
A resident experienced a significant change in mental status, becoming unresponsive and twitching, but the facility failed to notify the physician or family. The resident, who was cognitively intact and had chronic pain syndrome, was found lethargic by an LVN who did not take appropriate action. Other staff intervened later, but the delay in care placed the resident at risk.
A resident with chronic pain syndrome was found unresponsive and twitching, but the night shift nurse failed to assess or notify the physician, leading to a delay in care. The nurse did not check on the resident for several hours and relied on aides to search the room, finding a box of pills. The situation was only addressed when the morning shift nurse arrived, assessed the resident, and called 911 for emergency care.
A resident with a history of self-administering medications without notifying staff was found unresponsive after consuming a marijuana-laced brownie and having unauthorized medications at her bedside. Despite previous incidents, the facility's care plan did not address the resident's behaviors, and staff failed to provide adequate supervision and timely medical intervention, leading to an Immediate Jeopardy situation.
The facility failed to secure medications for two residents, leaving prescription shampoo, ointment, and eye drops unattended in their rooms. One resident had not been assessed for self-administration, while the other, although assessed, did not store medications in a locked box as required. Staff acknowledged the need for secure storage, but the facility's policies did not adequately address this, leading to the deficiency.
A facility failed to develop a comprehensive care plan for a resident who self-medicated with narcotics brought from outside. Despite being cognitively intact and having chronic pain, the resident's care plan lacked interventions for managing the behavior of bringing in medications. Staff interviews revealed the oversight, and the facility's policy on timely care plan development was not followed.
A resident with chronic pain syndrome was found unresponsive, but the facility failed to document the change in condition, assessments, or interventions, including the activation of EMS. Despite the resident's significant change in condition, there were no records of assessments or notifications, violating the facility's documentation policy.
A resident with chronic pain and mental health diagnoses experienced a significant change in condition, becoming unresponsive and exhibiting altered mental status. The nurse on duty failed to notify the physician and family or initiate timely emergency intervention, despite being aware of the resident's condition for several hours. The issue was only addressed when the oncoming nurse recognized the emergency and took appropriate action.
A resident with a history of chronic pain and recent orthopedic injuries was found unresponsive and twitching by an LVN, who failed to promptly assess, intervene, or notify medical personnel or family. The LVN did not conduct regular checks or initiate emergency protocols, resulting in delayed care until the next shift, when another LVN intervened and the resident was transferred to the hospital for altered mental status and hypoxemia.
A resident with a history of bringing unauthorized medications, including narcotics, into the facility was not adequately supervised, despite staff awareness of her behaviors and a late-night visitor. Staff failed to monitor the resident overnight, did not intervene after suspicious activity, and delayed emergency response when the resident was found unresponsive with unmarked pills at bedside. The resident was later hospitalized for altered mental status and hypoxemia after consuming a marijuana-laced brownie and possessing multiple medications.
Two residents were found with unsecured prescription and over-the-counter medications in their rooms, including prescription shampoo, ointments, and eye drops. One resident had not been assessed for self-administration and had no physician orders for the medications found, while the other, though approved for self-administration, did not keep medications locked as required. Staff interviews revealed inconsistent understanding and implementation of medication security policies, and facility policies lacked clear guidance on medication storage.
A resident with a history of chronic pain and multiple diagnoses brought in medications from outside sources and self-administered them without staff knowledge. Although these behaviors were documented by staff, the care plan was not updated to address the resident's actions related to polypharmacy or unauthorized medication use, contrary to facility policy and comprehensive assessment findings.
A resident with multiple medical conditions was found minimally responsive, and staff failed to document a complete assessment, SBAR communication, and timely interventions in the medical record. The lack of documentation included the resident's change in condition, discovery of pills at bedside, and the activation of EMS and hospital transfer, resulting in an incomplete record of care.
The facility failed to ensure call lights were within reach for three residents, all with severe cognitive impairments and requiring substantial assistance. Observations revealed call lights on the floor or out of reach, preventing residents from calling for help. Staff interviews confirmed the importance of accessible call lights for safety and fall prevention.
The facility failed to comply with food safety standards, as an employee was observed preparing food without a beard guard, contrary to policy. Additionally, improperly stored food items were found in the walk-in refrigerator and freezer, with containers unsealed and food exposed to potential contamination. The Dietary Manager confirmed these practices were against facility policy and FDA guidelines.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents. A Medication Aide did not sanitize a blood pressure cuff between residents, and two CNAs did not change gloves or sanitize hands after touching potentially contaminated surfaces while providing catheter care to a resident on Enhanced Barrier Precautions. These actions were contrary to the facility's infection control policies, despite staff having received training.
A resident with severe cognitive impairment and multiple medical conditions did not receive adequate privacy during wound care, as the ADON failed to fully close the privacy curtain, leaving the resident exposed. This was confirmed by the ADON and DON, despite staff having received training on resident rights.
A resident with multiple diagnoses, including type 2 diabetes, was inaccurately documented as receiving insulin in their MDS assessment. The resident was actually receiving Trulicity, a non-insulin medication, as per physician orders. The MDS nurse confirmed the error, acknowledging that Trulicity is not insulin and should not have been coded as such.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. This deficiency was identified for a resident who was found sleepier than usual on one day and unresponsive with a significant alteration in mental status the following morning. Despite these changes, the facility did not notify the resident's physician or family, which led to a delay in care. The resident, who had a history of chronic pain syndrome and was cognitively intact, was found by a nurse to be lethargic and unable to fully arouse. The nurse, LVN A, did not notify the physician or the family about the resident's condition and instead reported the situation to the oncoming shift. The resident was later found unresponsive and twitching, with a significant alteration in mental status, and was eventually treated for altered mental status at the hospital. Interviews with staff revealed that LVN A was aware of the resident's condition but failed to take appropriate action, such as notifying the physician or calling emergency services. Other staff members, including LVN B and nurse aides, expressed concern about the resident's condition and took steps to address the situation, but only after a significant delay. The facility's failure to act promptly placed the resident at risk for serious harm.
Failure to Provide Timely Care for Unresponsive Resident
Penalty
Summary
The facility failed to provide timely and appropriate care to a resident who was found unresponsive and twitching. On the night of the incident, the resident, who had a history of chronic pain syndrome and was cognitively intact, was not properly monitored by the night shift nurse, LVN A. Despite being informed by aides that the resident was lethargic and unresponsive, LVN A did not perform a thorough assessment or notify the physician or family. Instead, she waited for the next shift to arrive, resulting in a delay in care. LVN A's inaction continued throughout the night as she failed to check on the resident between 11:00 p.m. and 5:00 a.m., despite the facility's policy to check on residents every two hours. When she finally entered the resident's room at 5:30 a.m., she found the resident unresponsive but did not take immediate action. Instead, she relied on the aides to search the room and found a small box of pills, which she did not report or act upon. LVN A's failure to assess the resident's condition and notify the appropriate parties led to a significant delay in the resident receiving necessary medical attention. The situation was only addressed when LVN B arrived for the morning shift and immediately assessed the resident, recognizing the severity of the situation. LVN B called 911 and ensured the resident received emergency medical care. The delay in care and lack of appropriate response from LVN A was identified as a deficiency in the facility's care practices, highlighting a failure to adhere to professional standards and the resident's care plan.
Inadequate Supervision and Medication Mismanagement
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with a history of bringing medications, including narcotics, into the facility without notifying staff. The resident consumed a marijuana-laced brownie and was found with Ambien and trazadone in an unmarked container at her bedside. On the night of the incident, staff failed to check on the resident between 11:00 p.m. and 5:00 a.m., despite an unknown visitor being seen in her room. The resident was later found unresponsive and twitching, leading to an Immediate Jeopardy situation. The resident had a history of chronic pain and was under the care of a pain specialist. She had been self-administering medications, including morphine, without notifying the facility staff. Despite previous incidents where the resident was found with unauthorized medications, the facility's care plan did not address the resident's behaviors of polypharmacy or having medications in her room without staff knowledge. The facility's staff, including a nurse and nurse aides, failed to respond appropriately to the resident's change in condition, delaying necessary medical intervention. Interviews with staff revealed a lack of communication and appropriate action in response to the resident's condition. The nurse on duty did not notify the physician or call 911 when the resident was found unresponsive, and there was confusion among the aides about their responsibilities. The facility's administrator acknowledged the failure to provide adequate supervision and the presence of unauthorized medications in the resident's room, which contributed to the resident's altered mental status and subsequent hospitalization.
Failure to Secure Medications for Residents
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, resulting in unsecured medications being left in their rooms. For Resident #2, clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin ointment were found unsecured on the dresser in the resident's room. The resident, who was observed in bed and did not respond to questions about the medications, had not been assessed for self-administration of medication, and there were no physician orders for these medications. LVN B confirmed that the shampoo was a prescription and stated that the resident could not keep these medications in the room. For Resident #3, two bottles of Simbrinza ophthalmic suspension and five medication cups with an unknown ointment were left unsecured on the over-bed table while the resident was not present. Although Resident #3 had been assessed as capable of self-administering medications, the medications were supposed to be kept in a lockbox, which was found unlocked with the key in the lock. CNA D and LVN P both acknowledged that medications should be secured, especially since some residents might confuse them with candy. Despite this, the medications were left unattended in the room. The facility's policies on medication administration and self-administration did not adequately address the storage of medications, contributing to the oversight. The lack of secure storage for medications poses a risk of inaccurate or inappropriate administration, particularly in a setting where residents may wander and potentially access unsecured medications.
Failure to Address Self-Medication Behavior in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included addressing behaviors related to self-medicating with medications brought from outside the facility. The resident, who was cognitively intact and had a history of chronic pain, was found to have been self-administering morphine and other narcotics obtained from an outside pharmacy without informing the facility staff. Despite being followed by a pain specialist, the resident's care plan did not include interventions to manage the behavior of bringing in medications from home or other sources. Interviews with facility staff revealed that the care plan did not address the resident's behavior of bringing in medications, and no interventions were put in place to manage this issue. The MDS Coordinator acknowledged that the behavior should have been included in the care plan to ensure all staff were aware and could manage the resident's care appropriately. The Regional RN also noted that the behavior should have been documented in the care plan to ensure comprehensive care. The facility's policy required that comprehensive care plans be developed within seven days of the MDS assessment, but this was not adhered to in this case.
Failure to Document Resident's Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to a deficiency in documentation. The resident, who was cognitively intact with a history of chronic pain syndrome, was found unresponsive by a nurse (LVN A) on the morning of 11/19/2024. Despite the resident's significant change in condition, there were no documented assessments, notifications, or interventions recorded in the medical records, such as an SBAR assessment or the activation of emergency services. Interviews revealed that LVN A was aware of the resident's lethargy the previous night but did not document any assessments or notify the physician. When LVN B arrived for the morning shift, he found the resident in a concerning state and instructed LVN A to call 911. However, LVN A had not documented any of these events or the subsequent transfer to the hospital. The facility's policy required timely and accurate documentation of all assessments and changes in condition, which was not adhered to in this case. The lack of documentation could result in an incomplete view of the resident's care and services. The facility's policy emphasized the importance of documenting the entire chain of events, including assessments, vitals, and notifications, to ensure continuity of care. The failure to document these critical events and interventions represents a significant lapse in maintaining professional standards for medical records.
Failure to Notify Physician and Family of Significant Change in Resident Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician and family following a significant change in the resident's condition. The resident, who had a history of chronic pain syndrome, depression, anxiety disorder, and was cognitively intact, was found to be sleepier than usual on one evening and then unresponsive with altered mental status the following morning. Despite these acute changes, the nurse on duty did not notify the physician or the resident's family, nor did she initiate emergency medical services in a timely manner. Multiple staff interviews and record reviews revealed that the nurse was aware of the resident's unresponsiveness and abnormal behavior for several hours but did not take appropriate action. Nurse aides reported the resident was not waking up, was twitching, and had a bag of pills at her bedside, but the nurse did not assess vital signs promptly or notify medical personnel. The nurse admitted to being tired and waiting for the next shift to take over, and she did not follow established protocols for change of condition notifications. The delay in care was further corroborated by statements from other staff, who expressed concern over the nurse's lack of response and failure to act according to her training. The resident was eventually sent to the hospital by the oncoming nurse, who immediately recognized the severity of the situation, notified the physician and family, and called EMS. Hospital records confirmed the resident was treated for altered mental status and hypoxemia, and facility documentation showed that the required notifications and interventions were not made in a timely manner.
Failure to Respond to Resident's Acute Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of chronic pain syndrome, depression, anxiety disorder, and recent orthopedic injuries was found unresponsive and twitching in the early morning hours by an LVN. The resident, who was normally alert and oriented, was discovered to have a significant change in mental status, including lethargy, inability to fully arouse, and incomprehensible speech. Despite these acute symptoms, the LVN did not immediately assess or intervene appropriately, nor did she notify the physician, call 911, or inform the resident's family. The LVN also failed to conduct regular checks on the resident between 11:00 p.m. and 5:00 a.m., citing the resident's preference not to be disturbed, and instead relied on aides who were not qualified to provide clinical assessment or intervention. Multiple staff statements and interviews confirmed that the LVN was made aware of the resident's unresponsiveness by aides but did not take timely action. The LVN delayed obtaining vital signs and did not perform a thorough assessment or initiate emergency protocols. When the oncoming LVN arrived for the next shift, he immediately recognized the severity of the resident's condition, performed an assessment, obtained vital signs, and ensured that 911 was called. The resident was subsequently transferred to the hospital, where she was treated for altered mental status and hypoxemia, and received Narcan for suspected opioid overdose, with some improvement noted. Throughout the incident, documentation and interviews revealed that the LVN failed to follow professional standards of practice, the resident's care plan, and facility policy regarding timely assessment and intervention for a change in condition. There was no evidence that the physician or family were notified in a timely manner, and the LVN did not document appropriate actions or interventions. The inaction and lack of appropriate response to the resident's acute change in condition constituted a failure to provide care and treatment in accordance with orders, resident preferences, and established protocols.
Failure to Supervise Resident with History of Unauthorized Medication Use
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent accident hazards for a resident with a history of bringing in multiple medications, including narcotics, without staff knowledge. The resident, who was cognitively intact and had diagnoses including chronic pain syndrome, depression, and anxiety, was known to self-administer medications obtained from outside providers and pharmacies. Despite previous incidents where staff discovered unapproved medications in the resident's room and provided education, the care plan did not address the resident's behaviors related to polypharmacy or unsupervised medication possession. On the night in question, staff observed an unknown visitor entering and leaving the resident's room with a package, but did not intervene or monitor the situation further. The resident was not checked on between 11:00 p.m. and 5:00 a.m., despite staff awareness of the visitor and the resident's history. At 5:30 a.m., the resident was found unresponsive and twitching, with a container of mixed, unmarked pills at her bedside. Staff delayed notifying the physician and calling emergency services, and there was confusion among staff regarding who was responsible for monitoring the resident and responding to her change in condition. Interviews and record reviews revealed that staff failed to follow up on reports of suspicious activity, did not conduct timely assessments, and did not ensure the resident's safety despite clear risk factors. The resident was ultimately found to have consumed a marijuana-laced brownie and had opioids and other medications in her system, resulting in hospitalization for altered mental status and hypoxemia. The facility's lack of supervision and failure to implement effective interventions placed the resident at risk for serious harm.
Failure to Secure Resident Medications and Ensure Proper Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that medications were properly secured for two residents. For one resident, clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin ointment were found unsecured on the resident's dresser while the resident was in bed and unattended by staff. The resident did not respond to questions about the medications, and it was unclear if he was cognitively intact. There were no physician orders for these medications, and the resident had not been assessed for self-administration of medication. A nurse confirmed that these medications should not have been kept in the resident's room and removed them after the observation. For another resident, two bottles of prescription Simbrinza ophthalmic suspension and five medication cups containing an unknown white ointment were observed on the over-bed table while the resident was not present in the room. Although this resident had been assessed as cognitively intact and approved for self-administration of certain medications, the care plan specified that medications should be kept in a lockbox. During the observation, the lockbox was present but unlocked, and the key was left in the lock. Staff interviews revealed confusion about which residents were permitted to self-administer medications and how medications should be stored. The nurse acknowledged that medications should be locked up when the resident was not in the room, but left the medications unsecured after the observation. Facility policies reviewed did not adequately address the storage of medications or provide clear guidance for self-administration. The policy on self-administration referenced the need for residents to store medications safely and securely, but this was not consistently implemented. Staff interviews indicated a lack of awareness and inconsistent practices regarding medication security, contributing to the deficiencies observed.
Failure to Address Self-Medication Behaviors in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited behaviors of bringing in medications from home, from other providers, and from visitors, and self-medicating without informing staff. Despite documentation in provider and nursing progress notes that the resident had obtained and self-administered narcotic pain medications from outside sources, these behaviors were not addressed in the resident's care plan. The care plan only included interventions for chronic pain management as per orders, without any mention of the resident's actions related to polypharmacy or unauthorized medication use. Interviews with facility staff, including the MDS Coordinator and Regional RN, confirmed that the care plan did not reflect the resident's behaviors, and that this omission was not recognized until after multiple incidents had occurred. The facility's own policy required that comprehensive care plans address all factors identified by the interdisciplinary team or in accordance with resident preferences, but the care plan was not updated to include interventions for the resident's medication-related behaviors, despite staff awareness and documentation of these incidents.
Failure to Document Change of Condition and Interventions in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced a significant change in condition. The resident, who had a history of chronic pain syndrome, depression, anxiety disorder, and recent orthopedic injuries, was found by staff to be lethargic and minimally responsive in the early morning hours. Despite these findings, there was no documentation in the medical record of a thorough assessment, SBAR (Situation, Background, Assessment, Recommendation) communication, or timely notification and activation of emergency services. The nurse on duty noted the resident's unresponsiveness and the discovery of unidentified pills in the room but did not document further assessments or interventions in the medical record. Interviews revealed that the nurse on the previous shift was informed by aides of the resident's change in condition but did not notify the physician or transfer the resident to the hospital. The oncoming nurse, upon learning of the situation, immediately assessed the resident, found her to be very lethargic, and instructed the previous nurse to call 911. However, neither nurse documented the full chain of events, assessments, or notifications in the resident's medical record as required by facility policy and professional standards. Facility policy requires that all assessments, observations, and services provided be documented in a timely, factual, and complete manner. In this case, the lack of documentation regarding the resident's change in condition, the discovery of medication at bedside, and the subsequent transfer to the hospital resulted in an incomplete medical record. This failure was confirmed through interviews with staff and review of the resident's records, which lacked the necessary details to provide an accurate and comprehensive account of the care provided during the incident.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents, which could prevent them from calling for help when needed. Resident #19, who has severe cognitive impairment and requires substantial assistance for mobility and is at high risk for falls, was observed with her call light on the floor under her bed. During an interview, a medical assistant confirmed that the call light should be within reach and placed it back on the bed. Resident #21, also with severe cognitive impairment and requiring substantial assistance, was observed with her call light on the floor next to her bed. A CNA acknowledged that the call light should have been within reach and placed it under the resident's hand. Later, the call light was again found on the floor, and a medical assistant reiterated the importance of having the call light accessible for safety. Resident #49, with severe cognitive impairment and requiring maximal assistance, was observed with her call light hanging behind her and later on the floor. The resident stated she could not reach it, and a CNA confirmed the importance of having the call light within reach. The ADON also noted the call light was inaccessible and placed it across the resident. The DON emphasized that call lights are part of fall prevention measures and should always be within reach.
Food Safety Violations in Kitchen and Storage Areas
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. An employee, identified as [NAME] I, was seen preparing food without wearing a moustache or beard guard, despite having facial hair. This was against the facility's policy, which mandates the use of hair restraints to prevent hair from contacting food. The Dietary Manager confirmed that it was the policy for kitchen staff to use such restraints, but [NAME] I stated he had never been instructed to wear them and was unaware of their availability. This lack of compliance with the facility's policy and the U.S. FDA Food Code could potentially expose food to contamination. Additionally, the facility's walk-in refrigerator and freezer were found to contain improperly stored food items. In the refrigerator, a cardboard container of lunchmeat was wet and deteriorating, and a container of butter was uncovered, with loose pieces of butter exposed. In the freezer, three unsealed cardboard containers held tater tots, vegetable medley, and cinnamon roll pinwheels, all in unsealed plastic bags, leaving the food exposed to air. The Dietary Manager acknowledged that these items should have been stored in sealed containers to prevent contamination and freezer burn. These practices were not in line with the facility's policy or the U.S. FDA Food Code, which requires food to be stored in a manner that protects it from contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving improper care practices. In the first incident, a Medication Aide did not sanitize a blood pressure cuff between its use on two residents. This oversight was confirmed by the Medication Aide, who acknowledged forgetting to use a disinfecting wipe to prevent cross-contamination, despite having received infection control training within the year. The Director of Nursing (DON) also confirmed that the blood pressure cuff should have been sanitized between uses, in accordance with the facility's policy on cleaning and disinfection of resident-care equipment. In the second incident, two CNAs providing catheter care to a resident on Enhanced Barrier Precautions failed to change their gloves or sanitize their hands after touching the privacy curtain and the environment outside the resident's room. The CNAs admitted to not sanitizing their hands before donning gloves and gowns and acknowledged that they should have changed gloves and sanitized their hands after touching potentially contaminated surfaces. The DON confirmed that the environment outside the resident's room was considered contaminated and that proper hand hygiene should have been practiced. Both incidents highlight lapses in adherence to the facility's infection control policies, which require multiple-resident use equipment to be disinfected after each use and staff to perform hand hygiene when indicated. Despite the facility providing infection control training multiple times a year and conducting annual skills checks, these deficiencies were observed, indicating a need for improved compliance with established protocols.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during wound care, as observed by surveyors. The Assistant Director of Nursing (ADON) did not completely close the privacy curtain while providing wound care to a resident, leaving the resident exposed and visible from the room's door. This lapse in privacy was further compromised when a hospice services nurse entered the room and could see the resident receiving care. The resident involved had a history of severe cognitive impairment, osteomyelitis, osteoporosis, and a stage 4 pressure ulcer, requiring extensive assistance with activities of daily living. Interviews with the ADON and the Director of Nursing (DON) confirmed that the privacy curtain was not fully closed during the care, which was against the facility's policy on maintaining resident dignity. Both the ADON and DON acknowledged that staff had received training on resident rights within the year, and the DON stated that privacy must be provided during nursing care. The facility's policy emphasized the importance of maintaining resident privacy, which was not adhered to in this instance.
Inaccurate Assessment of Resident's Medication
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically for a resident who was incorrectly documented as receiving an insulin injection. The resident, who had diagnoses including dementia, hemiplegia, Alpers disease, and type 2 diabetes mellitus, was actually receiving Trulicity, a non-insulin medication, as per physician orders. The medication administration record confirmed that the resident received Trulicity as ordered, but the significant change Minimum Data Set (MDS) inaccurately recorded the resident as having received insulin. During an interview, the MDS nurse confirmed the error, acknowledging that Trulicity is not an insulin and should not have been coded as such. The nurse had access to the Resident Assessment Instrument (RAI) for reference but still made the coding error. This inaccuracy in the resident's assessment could potentially place residents at risk for inadequate care and services due to the incorrect documentation of their medical treatment.
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.
