Coral Rehabilitation And Nursing Of Austin
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 6909 Burnet Ln, Austin, Texas 78757
- CMS Provider Number
- 455862
- Inspections on file
- 58
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 47 (10 serious)
Citation history
Health deficiencies cited at Coral Rehabilitation And Nursing Of Austin during CMS and state inspections, most recent first.
Surveyors found that care plans were not revised after significant incidents for two residents. One resident with multiple chronic conditions and moderately impaired cognition experienced a witnessed fall during a supervised smoke break, but this event was not added to the existing fall care plan. Another resident with communication and cognitive deficits, who had documented physical and verbal behaviors, was involved in a verbal/physical altercation requiring staff intervention, yet the care plan was not updated to reflect this aggression. The DON confirmed that these care plans were not revised after the incidents, despite facility policy requiring care plans to be reviewed and revised when new problems or goals are identified.
A resident with severe cognitive impairment and a history of strokes eloped from the facility after staff failed to monitor an exit door during an EMS response. The door's alarm system was not functioning, and staff were unaware of the malfunction. The resident was missing for several days before being found by law enforcement, during which time she was exposed to cold weather and missed her medications. The facility did not follow its elopement prevention policies, and the responsible party was not notified immediately.
A resident with severe cognitive impairment eloped from the facility and was not located for several days. Although staff notified law enforcement, the administrator, and family, the resident's court-appointed guardian was not immediately informed as required by policy. Interviews and records showed confusion among staff about notification responsibilities, resulting in a significant delay before the guardian was contacted.
A resident with chronic obstructive pulmonary disease and other conditions was using a CPAP machine as documented in care plans, progress notes, and hospital discharge summaries, but there was no corresponding physician order in the medical record. Nursing staff confirmed the resident's use of the CPAP machine, and the device was observed at the bedside, but the required physician order was not present as per facility policy.
A resident with multiple mobility and cognitive diagnoses experienced an unwitnessed fall resulting in injury, but the nursing staff did not notify the physician or family as required by facility policy. The resident was later found unresponsive and died after hospital transfer. Documentation of notification and neurological checks was incomplete, and interviews confirmed that required notifications were not made.
A resident with mobility and cognitive needs suffered an unwitnessed fall with a head injury, after which nursing staff failed to complete required neuro checks, notify the physician and family, and follow post-fall protocols. Incomplete documentation and lack of communication led to the resident being found unresponsive the next morning and passing away, with staff interviews revealing gaps in training and protocol adherence.
A resident with mobility and cognitive challenges experienced an unwitnessed fall resulting in head injury, but nursing staff failed to complete required neuro checks, post-fall assessments, and timely notifications to family and physician. The nurse involved lacked knowledge of fall protocols and EMR documentation, and the incident was not properly communicated or documented, leading to incomplete monitoring and a fatal outcome.
A resident with severe cognitive impairment and multiple comorbidities was found with a significant bruise and later diagnosed with an acute femur fracture of unknown origin. Despite staff recognizing the injury as unexplained and facility policy requiring prompt investigation, no investigation was initiated or completed to determine the cause of the injury.
A cognitively impaired resident with multiple risk factors for falls and requiring two-person assistance was not properly monitored or assisted during transfers, resulting in an unwitnessed injury and acute femoral fracture. Staff failed to follow fall protocols, did not complete required assessments, and inconsistently used the care plan or EMR to determine transfer needs, leading to a deficiency in accident prevention and supervision.
A resident with severe cognitive impairment and multiple comorbidities was found with a bruise and later diagnosed with an acute femur fracture of unknown origin. Despite staff recognizing the injury as suspicious and knowing the requirement to report such incidents, the event was not reported to the SSA within the mandated timeframe. Interviews confirmed that staff were aware of the policy but did not follow it, and there was no recent staff training on reporting injuries of unknown origin.
A resident with a tracheostomy did not have physician orders for trach care or suctioning, and nursing staff did not perform regular care, instead allowing the resident to manage his own trach without supervision or competency validation. The resident reused disposable cannulas and was later hospitalized with pneumonia. Another resident received trach care that did not follow infection control protocols, and multiple nurses reported inadequate training and lack of competency checks. These failures were identified as Immediate Jeopardy due to the risk of infection and respiratory complications.
A resident with chronic pain and complex medical needs was left without Hydrocodone due to the facility's failure to reorder the medication in time, resulting in severe, unrelieved pain and repeated requests for hospital transfer. Documentation discrepancies between the MAR and narcotic count sheet, as well as lack of follow-up pain assessments after PRN administration, were also identified. Nursing staff and providers were not notified promptly about the medication shortage, and facility policies for pain management and documentation were not followed.
A resident with a tracheostomy did not receive care according to professional standards, as observed when a nurse failed to perform hand hygiene, used non-sterile equipment, and did not follow required procedures for suctioning and oxygenation. Multiple nurses reported inadequate training and lack of competency validation for trach care, and the facility could not provide documentation of staff competencies. These failures led to an Immediate Jeopardy situation due to the inability of staff to safely care for residents with tracheostomies.
The facility did not provide two residents and their representatives with written notification of facility-initiated discharges, including reasons for the move, appeal rights, or Ombudsman contact information. Instead, families were informed by phone on the day of discharge or after the fact, with no written notice or options for alternative placements, and the required notifications to the Ombudsman were not made.
Two residents with pressure ulcers did not receive physician-ordered wound care on multiple days, and the facility failed to maintain complete and accurate medical records documenting these treatments. Staff interviews revealed confusion about responsibility for wound care in the absence of the wound nurse, leading to missed treatments and incomplete documentation.
A nurse failed to perform proper hand hygiene and did not use sterile technique while providing tracheostomy care and suctioning for a resident with complex medical needs, including respiratory failure and a tracheostomy. The nurse did not sanitize hands before and after glove changes, used non-sterile equipment, and did not follow facility policies for infection prevention, as confirmed by staff interviews and policy review.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
The facility did not ensure that a resident with a colostomy had physician orders for its management, nor did it have orders specifying the dialysis schedule for two residents receiving regular hemodialysis. Staff interviews confirmed that these orders were expected but not present, which could result in missed care.
Several residents with open wounds and indwelling catheters did not have required PPE signage or supplies at their doors, and staff—including an ADON—were observed providing high-contact care without wearing gowns or following proper hand hygiene. Staff interviews revealed a lack of understanding about Enhanced Barrier Precautions, and the facility could not provide current hand hygiene or EBP policies when requested.
A resident with neurogenic bladder and an order for an indwelling foley catheter experienced a delay of over eight hours in catheter reinsertion after it was found to have come out. Despite the resident's repeated requests and staff awareness, the RN postponed the procedure, causing the resident discomfort and distress. The facility was unable to provide a catheter care policy when requested.
A resident with a history of stroke, dementia, and chronic pain experienced a significant decline, including staying in bed, inability to self-feed, and leg pain, over several days. Staff observed these changes but did not promptly notify the NP or responsible party, nor document the decline, resulting in delayed medical intervention. The resident was later hospitalized with aspiration pneumonia, UTI, and a femur fracture, and the facility was cited for failing to follow notification protocols.
A resident with a history of stroke, dementia, and chronic pain experienced a significant decline, including lethargy, inability to feed himself, and leg pain, which staff observed but did not promptly report or document. The lack of timely recognition and escalation led to delayed medical intervention, and the resident was later hospitalized with aspiration pneumonia, UTI, and a femur fracture. The facility did not follow its policy for notifying the physician and responsible party of significant changes in condition.
The facility did not maintain required indoor temperatures, resulting in several residents experiencing excessive heat in their rooms for extended periods. Despite multiple complaints and requests for fans or air conditioning, not all residents received relief, and temperature monitoring and documentation were inconsistent. Residents with conditions such as COPD, diabetes, and heart failure were affected, and staff interviews confirmed delays in addressing the air conditioning failures.
A resident with bipolar disorder and a history of aggression did not receive timely psychiatric evaluation or behavioral health interventions despite repeated physician orders and escalating behaviors, resulting in an altercation where another resident was injured. Staff and documentation confirmed ongoing behavioral issues and delays in psychiatric care, with inadequate monitoring and follow-up for both the resident exhibiting aggression and the resident who was harmed.
Two residents were involved in an incident where one pushed another's walker, resulting in a fall and a significant skin tear. Although the event was documented and reported internally to the DON and NP, it was not reported to the State Survey Agency as required by facility policy, due to the administrator's belief that there was no malicious intent. Both residents had complex medical and behavioral histories, and the failure to report the incident constituted a deficiency in abuse reporting protocols.
A resident with multiple medical and psychiatric diagnoses missed several doses of prescribed medications while out on pass, and staff failed to notify the physician or NP as required. Interviews and record review showed inconsistent practices and lack of documentation regarding provider notification, despite facility policy mandating prompt communication of missed medications.
A resident with multiple chronic conditions missed several doses of prescribed medications while out on pass, and staff failed to consistently notify the NP or physician or document these missed doses as required by facility policy. This resulted in a breakdown of pharmaceutical services and a deficiency in medication administration procedures.
Three residents did not receive timely dental care, including exams, denture placement, and cleanings, despite physician orders and care plan indications. Staff interviews revealed confusion about referral responsibilities, and the social worker had only recently arranged a new dental contract, with no dental visits yet scheduled. Facility policy required social services to assist with dental appointments, but documentation and follow-through were lacking.
A resident with multiple medical and psychiatric diagnoses experienced several falls that were documented in incident reports, but these events were not reflected in the resident's care plan. Staff interviews confirmed that falls should have been included in the care plan and that it is the responsibility of various team members to ensure updates. The facility's policy requires care plans to be comprehensive and revised as conditions change, but this was not followed, resulting in a deficiency.
Two residents experienced unsafe conditions due to inadequate wheelchair maintenance. One resident's wheelchair, which was from the 1960s, had a loose lock, posing a risk during transfers. Another resident's wheelchair brakes were not functioning, leading to a potential fall risk. Despite work orders and staff awareness, repairs were not completed timely, violating facility policies on maintenance and resident safety.
The facility failed to maintain resident dignity and privacy in two incidents. A CNA was observed using his phone during peri care for a resident with dementia, leaving her exposed. Another resident with a catheter was seen without a privacy bag, contrary to facility policy. Both incidents highlight lapses in respecting resident rights.
A resident receiving enteral nutrition through a gastrostomy tube was left lying flat, contrary to her care plan and facility policy, which required her head of bed to be elevated at least 30 degrees to prevent aspiration. The oversight was discovered by the resident's family member, who found her struggling to breathe with foam around her mouth. The family member intervened by elevating the bed, which alleviated the resident's breathing difficulties. Interviews with staff revealed a lack of communication and awareness regarding the incident.
The facility failed to develop baseline care plans within 48 hours for several newly admitted residents, who had various medical conditions. This deficiency was due to a backlog in care plans caused by recent management changes and staffing shortages, leading to potential miscommunication and inadequate care.
The facility failed to develop comprehensive care plans for three residents, despite their medical needs and cognitive status. Interviews with staff revealed a backlog in care plans due to management changes and staffing issues, leading to potential miscommunication and inadequate care. The facility's policy requires a baseline care plan within 48 hours and a comprehensive plan within seven days, which were not met.
A resident was left exposed during a change when a CNA failed to close the door and pull the privacy curtain, despite being trained on resident rights. The resident, who required substantial assistance, was cognitively intact and had multiple health conditions. Interviews with the CNA, DON, and ADM confirmed the lapse in privacy, which is against the facility's dignity policy.
A resident with multiple health issues was found lying in bed with soiled sheets due to spilled coffee. Despite being dependent on staff for bed mobility, the sheets were not changed promptly, as required by facility policy. Interviews with staff revealed a lack of adherence to procedures for changing soiled bedding, potentially risking the resident's skin integrity and comfort.
A resident experienced a significant weight loss of 25.38% over six months due to the facility's failure to maintain acceptable nutritional status. Despite having diabetes and feeding difficulties, the resident's care plan did not address potential weight loss, and there was a lack of timely intervention. Communication and monitoring breakdowns among staff contributed to the oversight, as the RD relied on information from the DM and did not verify weight loss data independently.
A resident with a history of stroke and diabetes developed a skin tear that was not properly assessed or treated according to the care plan, leading to an infection. The facility missed several wound care treatments and failed to conduct weekly skin assessments, resulting in the need for antibiotics. Staff interviews revealed communication and documentation issues regarding the resident's wound care.
A resident was discharged from the facility without receiving a written notice of discharge, and the Ombudsman was not informed. The resident, who had a BIMS score indicating cognitive intactness, left the facility without oxygen and refused to sign an AMA form. Despite this, the facility discharged the resident without following proper procedures, leading to distress and confusion. Interviews with staff revealed a lack of adherence to discharge protocols, and the facility's discharge guidelines were not followed.
A resident with multiple medical conditions and moderate cognitive impairment was discharged without proper documentation or preparation, violating the facility's discharge policy. The resident was left at home without family present, and there was no documented communication about discharge plans or home health services. Facility staff admitted to not following the discharge policy, risking the resident's safety and care.
A facility failed to implement its abuse prevention policies when a resident's rape allegation was not reported to authorities or investigated properly. The resident, with a history of mental health issues, claimed abuse, but the facility did not notify the police or conduct a thorough investigation, placing residents at risk.
A resident with a history of making false allegations reported being raped multiple times, but the facility failed to investigate or report these claims as required by policy. The Administrator did not document the investigation or inform the resident's representative, and relevant staff and authorities were not notified. This led to an Immediate Jeopardy situation due to the risk of undetected abuse.
Three residents experienced unsafe and inconvenient room conditions due to the placement of air conditioning units and cords obstructing closet access. A resident with Paralytic syndrome struggled to move a portable unit blocking her closet, while another resident had to unplug an air conditioner cord to access her closet, causing the room to warm. A third resident, at high risk for falls, faced a trip hazard from a cord draped across his closet door. Staff interviews confirmed the unsafe setup.
A facility failed to provide necessary ADL assistance for three residents, leading to deficiencies in nutrition and hygiene. A resident, who is blind, was left without meal assistance, causing frustration and neglect. Two other residents did not receive regular showers as per their care plans, impacting their personal hygiene. The facility's policies on meal assistance and hygiene were not effectively implemented, resulting in unmet needs and potential emotional distress.
The facility failed to ensure that residents' call lights were within reach, affecting four residents reviewed for rights. A resident with moderately impaired cognition and multiple medical conditions had his call light out of reach, preventing him from calling for help. Another resident, severely cognitively impaired and dependent on a wheelchair, also had her call light consistently out of reach. A third resident, with severe cognitive impairment and mobility dependence, was unable to reach his call light, and a fourth resident, with intact cognition but dependent on staff for personal care, had her call light on the floor while calling for help.
A resident with a history of mental health issues made multiple allegations of rape, which the facility failed to report to the State Agency within the required timeframe. Despite the resident's history of false allegations, the facility's policy mandates immediate reporting of all abuse allegations. Interviews revealed inconsistencies in the handling of the allegations, with the Administrator initially deciding not to report based on a conversation with the resident.
A resident's dignity was compromised when their urinary bedside drainage bag was left uncovered and visible from the hallway on two occasions. Despite the resident's satisfaction with care, the facility's policy required such bags to be covered for privacy, which was not followed, as confirmed by the DON and ADM.
Two residents in the facility refused their prescribed medications, but the facility failed to notify the physician or document these refusals. One resident, with dementia and schizophrenia, refused Mirtazapine and Risperidone, while another, with heart failure, refused Coreg. Interviews revealed that staff did not follow the protocol of notifying physicians and documenting refusals, contrary to the facility's medication administration policy.
A resident with severe dementia was inappropriately restrained in a Geri chair with a tray, which was not ordered by a physician or included in the care plan. The tray was used to prevent the resident from getting up, despite the facility's restraint-free policy. Staff and the resident's authorized representative had conflicting views on the tray's use, and there was a lack of proper documentation and communication regarding its necessity.
The facility failed to create comprehensive care plans for two residents. One resident, with a history of diabetes and heart conditions, refused prescribed medication, but his care plan did not address his right to refuse or his preference for self-administering supplements. Another resident, diagnosed with malnutrition, had a care plan focused on weight reduction instead of weight gain. Staff interviews revealed a lack of communication and coordination in updating care plans, contrary to facility policy.
Failure to Update Care Plans After Falls and Behavioral Incidents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure comprehensive care plans were reviewed and revised by an interdisciplinary team after each assessment and after acute incidents. For one resident with Type 2 diabetes, Crohn’s disease, asthma, dementia, major depressive disorder, and hypertension, the quarterly MDS dated 2/26/26 showed moderately impaired cognition and a need for supervision when walking up to 50 feet. The resident’s care plan documented a prior fall on 11/25/25 but contained no additional falls. However, progress notes and the facility’s incident log showed the resident sustained a witnessed fall on 1/22/26 during a supervised smoke break when another resident pushed her while reaching for a cigarette butt, and this fall was not added to or reflected in the care plan. A second resident, admitted with aphasia, memory deficit, cognitive social or emotional deficit, and cognitive communication deficit, had a comprehensive MDS dated 2/27/26 indicating intact cognition and documented physical and verbal behaviors toward others. The resident’s care plan identified a potential to demonstrate physical behaviors related to anger and poor impulse control, but there were no updates following an incident on 2/13/26. Progress notes and the incident log documented that staff had to intervene and separate this resident from another resident due to verbal/physical aggression on that date, yet the care plan was not revised to reflect this event. During interview, the DON acknowledged that the care plans for both residents had not been updated after these incidents and stated that the MDS nurse was responsible for updating care plans after acute incidents, and that care plans are expected to be reviewed and revised when new problems or goals are identified per facility policy.
Failure to Prevent Resident Elopement Due to Unmonitored Exit and Non-Functioning Door Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of strokes, and impaired safety awareness eloped from the facility. The resident was able to exit through a door in Unit 3 vicinity hall 100, which was not properly monitored or secured during an EMS response for another resident's medical emergency. The door's 15-second delay alarm system was not functioning correctly, and staff were unaware of the malfunction. The resident was last seen in her room by staff and was later found missing during routine rounds. The facility's records indicated that the resident was considered low risk for elopement, and there was no prior evidence of exit-seeking behavior, but she had a history of confusion and required redirection when wandering into previous rooms. Staff interviews revealed that during the time of the emergency involving another resident, the exit door used by EMS was not monitored, and staff attention was diverted. Multiple staff members, including the DON, LVNs, and CNAs, stated they were not aware that the exit door alarm was not working. Additionally, it was observed that residents with high cognitive scores had access to the keypad code for the exit doors, and there was no list of which residents knew the codes. The facility's logbook for door checks was incomplete, and not all exit doors were being checked as required by policy. The resident was missing for several days, during which time she was exposed to cold weather and missed her medications, before being found by law enforcement on a bus and taken to the hospital. The facility failed to follow its own elopement prevention and response policies, which required all exit doors to have functioning alarms and to be checked each shift, as well as monitoring of doors during EMS entry and exit. The responsible party (guardian) was not notified immediately of the resident's elopement, and there was a delay in communication. The deficiency was identified as Immediate Jeopardy due to the failure to provide adequate supervision and maintain a safe environment, resulting in the resident's elopement and exposure to potential harm.
Removal Plan
- Resident #8 was readmitted to a room across from the nurse's station for better monitoring and placed on one-to-one supervision to assure safety and monitor for elopement tendencies.
- Implement a check procedure with nursing to document Resident #8's presence.
- Activities and meal attendance for Resident #8 will be completed with an escort.
- All exit doors were checked by Maintenance to confirm alarms were operational and documented.
- Any EMS arrival requires a dedicated staff member posted at the door to maintain supervision during the entire EMS presence in the building.
- A full resident headcount was completed by the DON to ensure no other residents were missing or unaccounted for.
- All on-duty staff were re-educated on elopement prevention policy, door-monitoring requirements during emergencies, and that exit codes will not be shared with residents or visitors.
- Random competency quizzes will be completed.
- Exit door audits will be completed.
- Review of elopement risk assessments for all residents, including Resident #8.
- Full staff retraining on elopement procedures, supervision, and emergency response for all active personnel, with PRN or leave staff retrained prior to return.
- Maintenance audit of all door alarms will be completed.
- Administrator/DON will audit 100% of EMS entry/exit logs, door monitoring logs, and elopement assessments.
- Mock elopement drills will be completed.
- All audits and drill results will be reviewed in Standards of Care meetings, with immediate corrective action for any deviations.
Failure to Immediately Notify Guardian After Resident Elopement
Penalty
Summary
The facility failed to immediately notify the resident's legal representative, a court-appointed guardian, after the resident eloped from the facility. The resident, an elderly female with severe cognitive impairment due to multiple strokes and other significant medical conditions, was discovered missing during evening rounds. Staff initiated a search, notified law enforcement, the administrator, the DON, and family members, but did not promptly contact the resident's guardian as required by facility policy and federal regulations. Record reviews and interviews revealed that the resident's guardianship had been established due to her cognitive deficits, and the guardian was listed as the responsible party. Despite this, there was confusion among staff regarding who was responsible for notifying the guardian, with some assuming that management would handle the notification. Documentation and interviews indicated that the guardian was not notified until several hours after the resident was found missing, with conflicting accounts of the exact timing of notification. The facility's policy required immediate notification of the legal representative within one hour of recognizing a significant change in the resident's condition, such as elopement. The delay in notifying the guardian was confirmed by both facility staff and the guardianship agency. The resident was eventually found several days later by a bus driver and transported to the hospital, where she was admitted for further assessment. The hospital case manager also noted that the guardian had not been notified in a timely manner about the elopement. The deficiency centers on the facility's failure to promptly inform the resident's legal representative of a significant event affecting the resident, as required by policy and regulation.
Missing Physician Order for CPAP Machine
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was using a continuous positive airway pressure (CPAP) machine. Record reviews showed that while the resident's care plan, progress notes, and hospital discharge summary all referenced the use of a CPAP machine at night, there was no corresponding physician order for this treatment in the monthly physician orders for the relevant period. The resident's face sheet and Minimum Data Set (MDS) assessments also documented the use of the CPAP machine, and direct observation confirmed the presence of the device at the bedside. Interviews with nursing staff confirmed the resident's use of the CPAP machine, but staff were unaware of why the physician order was missing from the records. The Director of Nursing (DON) acknowledged that the omission may have occurred during the resident's discharge and subsequent re-admission, resulting in the physician order not being reactivated. The facility's policy requires that all drug and biological orders be recorded on the physician's order sheet in the resident's chart, but this was not done for the CPAP machine. The deficiency was identified through observation, interview, and record review, which collectively demonstrated that the facility did not ensure the resident's medical record was complete and accurately documented regarding the use of the CPAP machine.
Failure to Notify Physician and Family After Resident Fall Resulting in Death
Penalty
Summary
The facility failed to immediately notify a resident's physician and family member following an unwitnessed fall that resulted in injury and ultimately the resident's death. The resident, a male with diagnoses including muscle weakness, unsteadiness on feet, cognitive communication deficit, and muscle wasting, was assessed as being at risk for falls and required assistance with mobility. After experiencing an unwitnessed fall, the resident was found with redness on the back of his head and neck, but there was no documented evidence that the physician or family were notified of the incident. Nursing staff involved in the incident did not recall or document notifying the physician or the resident's family member after the fall. The nurse who responded to the fall assessed the resident but did not inquire if the resident had hit his head, nor did she notify the physician or family. Subsequent staff were not informed of the fall, and the resident was later found unresponsive and subsequently passed away after being transported to the hospital. The family was only notified when the resident was being sent to the hospital, and observed injuries at that time. Interviews with facility leadership and staff confirmed that the facility's policy required immediate notification of the physician and family after such incidents, but this was not followed. Documentation related to neurological checks and notifications was incomplete or missing. The physician stated he was not notified of the fall and expected to be informed of such events due to the risk of head trauma. The failure to notify the appropriate parties was identified as an Immediate Jeopardy situation by surveyors.
Failure to Protect Resident from Neglect After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to protect a resident's right to be free from neglect following an unwitnessed fall with a head injury. The resident, who had a history of muscle weakness, unsteadiness, and required assistance for mobility, experienced an unwitnessed fall in the evening. The nurse on duty assessed the resident and noted redness on the back of the head/neck area but did not complete or document ongoing neurological checks as required by facility policy. Additionally, there was no documentation of family or physician notification regarding the fall, and the facility's fall protocol and the resident's person-centered care plan were not followed. The medical record review revealed that neurological monitoring was only initiated for a short period and was incomplete, with the remainder of required checks not performed or documented. The nurse did not complete an incident report, and the post-fall evaluation, including assessments for delayed complications and changes in the resident's condition, was not conducted. The resident was found unresponsive the following morning and subsequently passed away. Interviews with staff confirmed a lack of communication and understanding of the facility's fall protocol, as well as insufficient training and knowledge regarding required post-fall assessments and documentation procedures. Further interviews with facility leadership and staff indicated that the nurse responsible for the initial assessment lacked adequate training on the facility's electronic medical record system and was unaware of the full scope of required post-fall procedures. The failure to follow established protocols, conduct ongoing monitoring, and communicate with the physician and family constituted neglect, as defined by facility policy and federal regulations. The deficiency was identified as Immediate Jeopardy due to the systemic failures in assessment, documentation, and communication following the resident's fall.
Failure to Ensure Nursing Staff Competency in Post-Fall Assessment and Notification
Penalty
Summary
Nursing staff at the facility failed to demonstrate the necessary competencies and skills to provide safe and appropriate care for a resident who experienced an unwitnessed fall. The resident, who had a history of muscle weakness, unsteadiness, and mobility issues, was found to have fallen and sustained redness to the back of his head and neck. Despite these findings, there was no documented evidence that neurological checks were properly conducted, nor that the resident’s family or physician were notified of the incident. The nurse involved did not complete the required post-fall assessments or incident report, and only provided an oral report to the DON. The nurse also lacked knowledge of the facility’s fall protocol, procedures, and the use of the EMR system, having received only minimal training before being assigned as charge nurse. Further review revealed that the last documented fall risk or post-fall evaluation for the resident was not completed for the most recent fall, and there was no follow-up for delayed complications related to the incident. The neurological monitoring initiated was incomplete, and subsequent checks were not performed as required. Other staff, including the RN on the following shift, were not informed of the fall and therefore did not continue necessary monitoring. Interviews with facility leadership confirmed that the fall protocol was not followed, care plan interventions were not implemented, and required documentation was missing. The facility’s policies required immediate and ongoing assessment, documentation, and notification following a fall, none of which were adequately carried out in this case. The resident was later found unresponsive and subsequently passed away after being transported to the hospital. Interviews with family members indicated they were not notified of the fall until after the resident was sent to the hospital. The physician also confirmed he was not informed of the fall. Facility leadership acknowledged that the expected protocols and procedures were not followed, and that the nurse involved did not possess the necessary competencies to perform required assessments or documentation. The failure to ensure staff competency and adherence to protocols placed residents at risk for significant harm.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated for one resident who experienced an injury of unknown origin. Staff observed the resident with discoloration on the buttocks, which was later confirmed to be associated with an acute, mildly displaced comminuted right proximal femoral fracture. Despite the presence of a significant injury and the facility's policy requiring prompt and thorough investigation of injuries of unknown origin, there was no documentation or evidence that an investigation was initiated or completed to determine the cause of the injury. Multiple staff members, including CNAs, RNs, the ADON, and the DON, acknowledged that the injury was of unknown origin and recognized the importance of investigating such incidents. The DON stated that she was informed of the injury and instructed staff to notify the physician and obtain an x-ray, but did not initiate or conduct an investigation. The ADM, who was responsible for investigating injuries of unknown origin, reported not being notified of the incident until informed by surveyors and confirmed that no investigation had been conducted. The facility's own policy, revised in December 2024, required that all reports of resident abuse, neglect, and injuries of unknown source be promptly and thoroughly investigated by management. Despite this, interviews and record reviews confirmed that the required investigation did not occur, and there was no evidence to show that the facility attempted to determine how the resident sustained the injury.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision for a cognitively impaired resident with a high risk for falls. The resident, who had severe cognitive impairment, bilateral hip osteoarthritis, osteoporosis, schizoaffective disorder, vascular dementia, muscle weakness, lack of coordination, and right eye blindness, required substantial to maximal assistance with transfers and was care planned for two-person assistance. There was no documentation indicating the use of a mechanical lift for transfers, despite this being required. On the day prior to the resident's hospital transfer, staff observed the resident had pain and dark discoloration on the buttocks during repositioning for perineal care. The resident reported having fallen, but could not provide details. Staff did not complete a skin assessment as required, and there was no documentation of an accident or incident prior to the discovery of the injury. The resident was later found to have an acute, displaced femoral fracture and was sent to the hospital for surgery. Multiple staff interviews revealed inconsistent knowledge and practices regarding the resident's transfer status, with some staff relying on verbal reports or outdated lists rather than the care plan or electronic medical record (EMR). Further interviews indicated that staff, including CNAs and nurses, were not consistently following the facility's fall protocol when a cognitively impaired resident reported a fall or presented with a new skin issue. The facility's policies required notification of the physician and responsible party, completion of assessments, and documentation of incidents, but these steps were not followed. The resident's roommate reported that staff often used only one-person assistance for transfers, and there was uncertainty among staff about the proper use of mechanical lifts. There was also a lack of in-service training related to fall protocol, transfers, and accident/incident management during the relevant period.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. Specifically, staff observed a resident with discoloration to the buttocks area, which was later confirmed as an acute femur fracture. Despite multiple staff members, including the ADON, DON, and CNA, recognizing the injury as one of unknown origin and acknowledging the requirement to report such incidents to the State Survey Agency (SSA), the injury was not reported as required. The resident involved had significant medical conditions, including bilateral primary osteoarthritis of the hip, age-related osteoporosis, schizoaffective disorder, vascular dementia, muscle weakness, lack of coordination, and severe cognitive impairment. The resident was at risk for falls and complications related to his diagnoses. Staff first noticed the discoloration and pain during routine care and subsequently ordered a stat x-ray, which revealed a right proximal femoral fracture. The resident was then transferred to the hospital for further evaluation and management. Throughout the process, staff interviews confirmed that the source of the injury was unknown and met the criteria for an injury of unknown origin. Despite facility policy and regulatory requirements mandating immediate reporting of such injuries, the DON, ADON, and other staff did not notify the SSA within the required timeframe. Interviews revealed that staff were aware of the importance of reporting injuries of unknown origin but failed to do so. The facility's in-service records also showed no recent training related to reporting injuries of unknown origin. The administrator stated she was not informed of the injury and only learned of it during the surveyor's interview.
Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care, including tracheostomy care and suctioning, for residents who required such interventions. One resident, who was admitted with a tracheostomy and a history of acute respiratory failure, did not have physician orders in place for trach care or suctioning since admission. Nursing staff did not perform regular tracheostomy care, citing discomfort and lack of training, and instead allowed the resident to perform his own trach care without supervision or documented competency. The resident was observed reusing disposable cannulas and cleaning them in non-sterile conditions, and his responsible party reported having to bring supplies from home. The resident was later hospitalized and diagnosed with pneumonia after experiencing respiratory distress and low oxygen saturation. Another resident with a tracheostomy and severe cognitive impairment also did not receive trach care and suctioning according to professional standards. Observations revealed that a nurse performed trach care without following infection control protocols, such as proper hand hygiene, use of sterile equipment, and appropriate suctioning technique. The nurse also reported not receiving adequate training or periodic competency evaluations for trach care, and had difficulty locating necessary supplies. Multiple staff interviews confirmed gaps in training, lack of skill checks, and uncertainty about who was responsible for trach care education and oversight. Record reviews showed that the facility's policies required physician orders for trach care, adherence to sterile technique, and regular staff training and competency checks. However, these requirements were not met, as evidenced by the absence of orders, improper care practices, and lack of documentation of staff competencies. The failures were identified as placing residents at risk for infection, respiratory distress, and other complications, and resulted in the identification of an Immediate Jeopardy situation by surveyors.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident with chronic pain and multiple complex medical conditions, including acute respiratory failure, tracheostomy status, dysphagia, chronic pain, and end-stage renal disease. The resident had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for pain, but the medication was not reordered in a timely manner, resulting in the resident running out of the medication and experiencing excruciating pain for two days. During this period, the resident repeatedly requested pain relief and ultimately requested to be sent to the emergency room due to unrelieved pain. The resident's responsible party reported that the resident was crying and in severe distress due to lack of effective pain control. Documentation failures were also identified, as the resident's medication administration record (MAR) did not match the narcotic count sheet for PRN Hydrocodone, raising concerns about accurate medication administration and record-keeping. Additionally, the facility did not consistently assess or document the effectiveness of PRN Hydrocodone after administration, as required by physician orders and facility policy. Interviews with nursing staff revealed that documentation was sometimes missed due to being busy, and that pain assessments following PRN administration were not consistently performed or recorded. The nurse practitioner and director of nursing both stated that they were not notified in a timely manner about the resident's medication running low, and that the order for PRN Hydrocodone was not appropriate for the resident's needs in the facility setting. The facility's policies required timely reordering of medications, accurate documentation, and follow-up assessment of pain management interventions, but these were not followed. These failures led to the identification of Immediate Jeopardy by surveyors, as the resident was left without effective pain management and required transfer to the hospital for pain control.
Failure to Ensure Competent Tracheostomy Care by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skills to provide safe and effective care for a resident with a tracheostomy. Direct observation revealed that a nurse performed tracheostomy care and suctioning without adhering to professional standards of practice, including failure to perform hand hygiene, improper use of gloves, use of non-sterile equipment, and not following required procedures for oxygenation and suctioning. The nurse did not clean the resident’s trach stoma or change saturated dressings, and did not check or adjust oxygen prior to or during the procedure. The resident was observed with excessive secretions, soiled dressings, and was visibly distressed during the care. Interviews with multiple nursing staff indicated a lack of adequate training and competency validation in tracheostomy care. Several nurses reported not receiving hands-on training, periodic evaluations, or instruction on the use of trach care equipment. One nurse stated she had only practiced on mannequins and would require supervision to perform the procedure on a resident. Another nurse reported not being familiar with the resident or the necessary equipment, and both nurses expressed the need for reeducation on trach care. The responsible director of nursing was unable to provide documentation of staff competency evaluations when requested. The facility’s own policies required sterile technique, hand hygiene, and specific steps for tracheostomy care and suctioning, which were not followed during the observed incident. The lack of staff training, competency checks, and adherence to policy resulted in an Immediate Jeopardy situation, as staff were not equipped to safely care for residents with tracheostomies. The deficiency was identified through direct observation, staff interviews, and review of facility records and policies.
Removal Plan
- The facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies will be safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.
- Residents #2 and #3 were identified as potentially affected and will be discharged accordingly. They have been assessed by Consultant RN and found to be safe, unaffected by deficiencies and in no distress. They will be discharged upon formulation of discharge plan. Resident #2 will be discharged to SNF and Resident #3 will be discharged to hospital pending SNF placement due to need for dialysis.
- A Special Bulletin inservice with sign-in sheet. RN consultant to review. The Facility does not maintain a policy for residents to provide their own treatments outside of self-administration of medication; if a resident refuses or is non-compliant with ordered nursing procedures or treatments it will be documented in progress notes, physician notified, and care plan will be updated. All clinical staff and admissions team members have been notified by mass message that we will no longer accept residents or referrals for tracheostomy dependent residents.
- The facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies have been safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.
- IJ and POR reviewed during adhoc QAPI with medical director, administrator, outside consultant and DON; POR and POC will be reviewed during monthly QAPI and revised as needed, to sustain improvement. An adhoc QAPI was conducted via teleconference to update education plan and review of revisions. An adhoc QAPI was conducted including RT to discuss further areas of revision to POR and engagement of RT, duties and oversight responsibilities. A QAPI will be held to notify and discuss plan and new clinical capabilities with medical director.
Failure to Provide Required Written Discharge Notices and Appeal Rights
Penalty
Summary
The facility failed to provide written notification to two residents and their representatives regarding facility-initiated discharges, including the reasons for the move, the right to appeal, and the required contact information for the State Long-Term Care Ombudsman. In both cases, the residents and their families were not given written notice in a language and manner they understood, nor was the notice provided at least 30 days in advance as required. Additionally, the facility did not send a copy of the discharge notice to the Ombudsman for either resident. One resident, a male with a history of tracheostomy, cerebral infarction, and respiratory failure, was discharged to another skilled nursing facility. The resident's family reported receiving only a phone call from the social worker on the day of discharge, with no written notice or options for alternative placements. The family was not informed of the actual discharge date or the final destination, and there was confusion regarding which facility the resident was transferred to. Documentation in the electronic medical record did not include a discharge notice, and the family learned of the discharge after it had already occurred. Another resident, a female with hemiplegia, hemiparesis, cognitive communication deficit, and acute respiratory failure, was sent to an acute care hospital and subsequently not allowed to return to the facility. The family was informed by phone that the resident would not be readmitted due to staffing limitations, but did not receive written notice, information about the discharge location, or the resident's appeal rights. The facility's own policies required consultation with the resident or representative, provision of discharge details, and notification of the Ombudsman, none of which were followed in these cases.
Failure to Administer and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for two residents who were being treated for pressure ulcers. For both individuals, physician orders for wound care were not followed on multiple consecutive days, as documented in the Treatment Administration Records (TARs). Specifically, wound care treatments ordered by the physician were not administered on four separate days for each resident, and these omissions were not documented or explained in the medical records. One resident, a male with diagnoses including acute congestive heart failure, obesity, asthma, and edema, was assessed as being at risk for pressure ulcers and had specific wound care orders in place. Despite these orders, the TARs showed that the prescribed wound care was not provided on several days. Similarly, a female resident with chronic obstructive pulmonary disease, muscle weakness, end-stage renal disease, hypertension, and a pressure ulcer also did not receive the ordered wound care on the same dates. Observations confirmed that, at the time of survey, there was no infection or worsening of wounds, but the required treatments had not been administered as ordered. Interviews with facility staff revealed confusion and lack of communication regarding responsibility for wound care, particularly in the absence of the wound nurse (WN). Nurses on duty sometimes assumed the WN would provide the care, resulting in missed treatments. The Assistant Director of Nursing (ADON) and other staff acknowledged the importance of adhering to physician orders and confirmed that the omissions occurred. Facility policies required documentation of all wound care provided, but the records did not reflect that the treatments were given as ordered.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a nurse failed to adhere to infection prevention and control protocols during tracheostomy care and suctioning for a resident with significant medical needs. The nurse did not perform hand hygiene before and after glove changes, and did not follow sterile technique while suctioning. Specifically, the nurse donned gloves without hand hygiene, used soiled gloves to access personal items, and repeatedly failed to sanitize hands between glove changes. The nurse also used non-sterile equipment and did not properly clean or change necessary items during the procedure. The resident involved was a male with a history of tracheostomy, acute and chronic respiratory failure with hypoxia, gastrostomy, congestive heart failure, cerebral infarction, and dysphagia. He required ongoing oxygen therapy, suctioning, and tracheostomy care, and was assessed as having severe cognitive impairment. Physician orders and care plans specified the need for regular trach care, suctioning, and monitoring for signs of infection, with clear instructions for maintaining sterility and hand hygiene. Facility policies reviewed by surveyors outlined the requirement for hand hygiene before and after resident contact, between glove changes, and after removing gloves, as well as the use of sterile technique for invasive procedures. During interviews, the nurse acknowledged awareness of hand hygiene protocols but cited lack of sanitizer in the room as a reason for non-compliance. The Director of Nursing confirmed expectations for staff to follow infection control policies, including proper hand hygiene and sterile technique during trach care.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Obtain and Document Orders for Colostomy and Dialysis Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive care plan, and residents' preferences for three residents. One resident with a history of spina bifida, epilepsy, muscle weakness, and paraplegia was admitted with a colostomy, but there were no physician orders in place for managing or maintaining the colostomy since admission. The resident's care plan addressed bowel incontinence and skin integrity but did not include specific interventions for colostomy care, and the physician orders lacked any direction for colostomy management. Additionally, two residents with chronic kidney disease and other comorbidities required regular dialysis treatments. Although their care plans and assessments indicated the need for dialysis, there were no physician orders specifying the days on which dialysis was to be provided, despite both residents attending dialysis sessions on a set schedule. Interviews with facility staff, including the DON, RN, and ADON, confirmed that orders for colostomy care and dialysis schedules were expected but missing, and that the absence of such orders could result in missed care.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for several residents requiring Enhanced Barrier Precautions (EBP). Surveyors observed that signage indicating the need for personal protective equipment (PPE) was missing from the doors of four residents who had conditions such as open wounds, indwelling catheters, and pressure ulcers. Additionally, PPE bins were not present at these residents' doors, and staff were not consistently informed or aware of which residents required EBP. Staff interviews revealed a lack of understanding regarding EBP, with some CNAs stating they had never been instructed to wear gowns for high-contact care or catheter care for these residents. Direct observations showed that staff, including the ADON, did not wear appropriate PPE such as gowns while performing high-contact care activities like wound care, dressing, and bathing for residents with open wounds or indwelling catheters. In one instance, the ADON performed wound care on a resident's left heel without changing gloves or performing hand hygiene after removing a soiled dressing, thereby contaminating the wound. The ADON also did not wear a gown during this procedure, and similar lapses were observed during care for other residents requiring EBP. Review of the facility's policies indicated that PPE should be used as needed during wound care, and that infection control policies were intended to prevent and manage transmission of diseases. However, the facility was unable to provide current hand hygiene and EBP policies when requested. Interviews with staff and management confirmed that there had been no recent in-service training on EBP, and that responsibilities for ensuring PPE availability and signage were unclear or not consistently followed. These failures were observed for residents with significant medical needs, including chronic wounds, indwelling catheters, and other conditions requiring strict infection control measures.
Delayed Catheter Reinsertion and Inadequate Bladder Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to promptly reinsert a foley catheter for a female resident with multiple sclerosis, neuromuscular dysfunction of the bladder, paralytic syndrome, and overactive bladder. The resident's care plan and physician orders indicated the need for an indwelling catheter due to neurogenic bladder, with instructions to maintain and change the catheter as needed. On the morning in question, the resident's catheter was found to have come out, and the certified nursing assistant (CNA) notified the RN. Despite the resident expressing discomfort and a preference for the catheter to be reinserted, the RN delayed replacement for over eight hours, only reinserting the catheter in the afternoon after being prompted by the Director of Nursing (DON). Throughout the day, the resident was unable to sense when she was voiding, which caused her distress. Interviews with staff confirmed that the RN was aware of the situation but chose to postpone the procedure, and the nurse practitioner (NP) stated that such a delay could lead to urinary retention and a distended bladder. The facility was unable to provide a catheter care policy when requested. The failure to provide timely catheter care and adhere to physician orders constituted a deficiency in ensuring appropriate treatment and services to prevent urinary tract infections for the resident.
Failure to Notify Physician and Responsible Party of Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's physician and responsible party of a significant change in the resident's condition. The resident, an older male with a history of stroke, dementia, chronic pain, and nicotine dependence, experienced a notable decline over several days. Staff observed that he was no longer getting out of bed, was unable to feed himself, and complained of leg pain during personal care. Despite these changes, there was no timely documentation or notification to the nurse practitioner or responsible party regarding his altered status. Multiple staff interviews revealed that the resident's decline was apparent for several days, with increased lethargy, decreased participation in meals, and a cessation of his usual smoking routine. Some staff members noted the changes but did not consistently communicate them to the nursing team or document them in the medical record. The resident's responsible party was not informed of these changes and only became aware of the situation after visiting and finding the resident unresponsive and in bed, which was a significant deviation from his baseline behavior. The lack of prompt notification and documentation led to a delay in medical intervention. The resident was eventually transferred to the hospital, where he was diagnosed with possible aspiration pneumonia, a urinary tract infection, and a left femur fracture. The facility's policy required immediate notification of significant changes in a resident's condition to the physician and responsible party, but this protocol was not followed in this case, resulting in the identification of an Immediate Jeopardy situation.
Failure to Recognize and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident reviewed for quality of care. The resident, an older male with a history of stroke, dementia, chronic pain, and nicotine dependence, experienced a significant change in condition that was not promptly recognized, addressed, or documented by staff. Over several days, the resident became increasingly lethargic, stopped getting out of bed, was unable to feed himself, and complained of leg pain during personal care. Despite these changes, there was no timely follow-up or documentation regarding his post-fall status, pain, lethargy, or decreased functional abilities. Multiple staff interviews revealed that the resident's decline was observed by CNAs and nurses, including his staying in bed, not eating independently, and not smoking as usual. Some staff noted the changes but did not consistently notify the nurse or document the observations. Nurses who were aware of the changes did not escalate the concerns or notify the nurse practitioner (NP) or physician in a timely manner. The resident's responsible party was also not informed of the changes until after a care plan meeting, at which point the resident was found to be difficult to arouse and not at his baseline. The resident was eventually assessed as febrile, hypertensive, and unresponsive, leading to his transfer to the hospital, where he was diagnosed with possible aspiration pneumonia, a urinary tract infection, and a left femur fracture. The facility's policy required prompt notification of significant changes in a resident's condition to the physician and responsible party, but this protocol was not followed. The failure to recognize and act upon the resident's change in condition resulted in the identification of Immediate Jeopardy by surveyors.
Failure to Maintain Safe and Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for seven residents by not keeping temperatures within the required range of 71 to 81 degrees Fahrenheit on two halls. Multiple residents reported that the air conditioning had not been working for at least two weeks, with some stating it had been out for up to three months. Observations confirmed that room and hallway temperatures repeatedly exceeded 81 degrees, with thermostat readings as high as 83 degrees. Several residents were provided with window air conditioning units or fans, but not all rooms had these, and some residents continued to experience discomfort due to heat. Maintenance logs and staff interviews indicated that complaints about room temperatures and requests for fans or air conditioning units had been made over several weeks, but not all were addressed promptly. Residents affected by the heat had various medical conditions, including chronic obstructive pulmonary disease (COPD), diabetes mellitus, heart failure, vascular dementia, and other serious health issues. Some care plans specifically included interventions to avoid exposure to extreme heat or cold, and to encourage adequate hydration. Despite these documented needs, residents reported feeling excessively hot, sweating, and in some cases, needing to move to cooler areas of the facility. Observations showed that not all residents had access to fans or functioning air conditioning, and some staff acknowledged that complaints had been made but not always acted upon. Interviews with facility staff and maintenance personnel revealed a lack of consistent monitoring and documentation of room temperatures, especially during periods when the central air conditioning was not functioning. The maintenance supervisor and administrator provided conflicting accounts regarding the duration and extent of the air conditioning failure. Maintenance logs showed delayed responses to requests for cooling equipment, and the facility's emergency preparedness plan, which included procedures for heat alerts and relocating residents, was not fully implemented. The air conditioning repair company confirmed that repairs could have been completed sooner if requested, but delays in obtaining quotes and authorizations contributed to the prolonged period of inadequate temperature control.
Failure to Provide Timely Behavioral Health Services and Protect Residents from Harm
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder and a history of aggressive behaviors received timely and necessary behavioral health care and services. Despite physician orders for psychiatric evaluation and management issued on two separate occasions, there was a significant delay in the resident being seen by psychiatric services. The resident exhibited escalating behaviors, including yelling, threatening, and physical aggression towards staff and other residents, which were documented in progress notes. The care plan included interventions for managing mood and behaviors, but these were not effectively implemented, and the resident did not receive psychological therapy as indicated in the MDS assessment. The resident's aggressive behaviors culminated in an incident where she scratched another resident with her fingernails during an outburst, resulting in injuries to the other resident's thigh. Documentation showed that the resident had a pattern of verbal and physical aggression, including threats with utensils and physical altercations. Staff interviews confirmed that the resident had ongoing behavioral issues since admission, and there was a lack of timely psychiatric intervention despite multiple referrals and physician orders. The delay was attributed to issues with the psychiatric service provider, including staff turnover and insurance problems, but there was no evidence of follow-up or alternative arrangements to ensure the resident's behavioral health needs were met. The other resident involved in the altercation had moderate cognitive impairment and required substantial assistance with activities of daily living. He sustained injuries as a result of the incident and expressed dissatisfaction with his care following the altercation. The facility's failure to implement behavioral health interventions and protect residents from harm was further evidenced by the lack of documentation of behavioral monitoring and the absence of timely psychiatric evaluation, despite clear indications and orders for such services.
Removal Plan
- Resident #1 was assessed and noted to be stable.
- An audit of Resident #1's current list of medications was performed by the Administrator to ensure all current medications were delivered and available in the facility.
- Resident #1 will be seen by Psych services for follow up and intervention (personal safety).
- Resident #1's care plan was updated with current psych diagnosis and interventions as well as specific behaviors and interventions.
- One on one monitoring has been placed for Resident #1 when near other residents until stable per psych NP recommendation or transfer out of the facility.
- Resident #2 was assessed after the event involving Resident #1, revealing no signs of distress or emotional agitation.
- Training of staff and audits of all residents identified as in need of behavioral health services as well as abuse and neglect were initiated by the Administrator.
- A spreadsheet was created with the identification of the services and if services were needed.
- The facility is verifying comprehension on staff training by following up after education based on a random selection.
- Staff will not be allowed to work their shifts until this Inservice and training has been completed.
- The Administrator will be responsible for the direct Inservice of her staff.
- All residents who have diagnoses or demonstrated signs of behavioral health concerns have the potential to be impacted by this deficient practice.
- The Administrator is directing the review of all residents with Behavioral Health diagnoses to identify unmet behavioral or psychiatric needs.
- All open psychiatric referrals were verified and re-submitted or scheduled.
- Review of all residents with Behavioral Health Diagnosis was started and completed by DON, ADON, Administrator.
- Creation of spreadsheet identifying unmet behavioral or psychiatric needs. Any other residents identified will be referred to psych as well. Responsible: DON, Admin, Social Worker.
- A review of their medications will be completed as well. The Psychiatrist will assist with any referrals or review of concerns that were identified with this audit.
- A review is scheduled for the Psychiatrist and Attending Physician on the medications as it relates to any current behaviors or events since the last Dose Reduction Review.
- The Regional Director of Operations has educated the Administrator, DON and ADON on behavioral care and services for the residents for the facility and comprehension will be verified at this same time.
- The administrator has created an audit tool to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders on behavioral health matters.
- Audits will be conducted by the DON daily for two weeks, weekly for two weeks and monthly for two months.
- A spreadsheet was created for the audit to be conducted and documented.
- Any negative findings will be reported to the administrator for immediate correction.
- The Medical Director was notified of the deficiency (F740) and an Ad-Hoc QAPI meeting was held to discuss the findings.
- All findings will be reported to the QAPI team for QAPI.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, or misappropriation were reported immediately to the State Survey Agency, as required. Specifically, an incident occurred in which one resident grabbed another resident's walker and pushed it, causing the second resident to fall and sustain a large skin tear on his forearm. This event was documented in progress notes and reported internally to the Director of Nursing (DON) and Nurse Practitioner (NP), but was not reported to the State Survey Agency within the required timeframe. Resident records show that the injured resident had a history of thrombocytopenia, muscle weakness, recurrent falls, chronic kidney disease, and alcoholic cirrhosis, and required a walker for mobility. The resident's care plan included interventions to prevent falls, and wound care orders were in place following the incident. The resident who caused the fall had diagnoses including encephalopathy, cognitive communication deficit, Alzheimer's disease, and unspecified dementia, with documented behavioral issues and a care plan addressing potential for verbal and physical aggression. Interviews with staff revealed that the incident was reported internally but not externally, as the administrator did not believe the event constituted abuse due to a perceived lack of malicious intent. Facility policy required immediate reporting of all suspected or substantiated incidents of abuse, including resident-to-resident abuse, to the appropriate state agencies, but this protocol was not followed in this case.
Failure to Notify Physician of Missed Medications Due to Resident Absence
Penalty
Summary
The facility failed to immediately notify a resident's physician or nurse practitioner when multiple doses of prescribed medications were missed due to the resident being out on pass. The resident, who had diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, was noted to have missed several doses of critical medications such as aspirin, divalproex, doxepin, haloperidol, folic acid, multivitamin, and metoprolol over several days when she was away from the facility. Medication Administration Records (MAR) indicated these missed doses, but there was no documentation that the physician or nurse practitioner was notified upon the resident's return. Interviews with nursing staff revealed inconsistent practices regarding notification of missed medications. Some staff stated that they would notify the nurse practitioner or physician depending on the number of missed doses, while others indicated that the expectation was to always notify and document such events in the progress notes. However, review of the resident's progress notes confirmed that no such notifications or documentation occurred for the missed medications during the relevant period. The nurse practitioner also confirmed that he was not informed about the missed doses and emphasized the importance of being notified to provide appropriate recommendations. Further review showed that the facility's policy required prompt notification of the physician for changes in a resident's condition or status, including refusal or missed medications. Despite this, there was no evidence of staff training on this requirement during the period in question, and staff interviews indicated a lack of clarity and consistency in following the policy. The deficiency was identified through record review and staff interviews, which confirmed the failure to notify the physician or nurse practitioner as required.
Failure to Ensure Proper Administration and Notification for Missed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for a resident. The resident, a woman with multiple diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, had physician orders for several medications including aspirin, doxepin, divalproex, haloperidol, folic acid, multivitamin, and metoprolol. Review of the medication administration record (MAR) showed that multiple doses of these medications were missed on several days, with the MAR indicating the resident was 'away from the facility' during those times. The resident frequently went out on pass, sometimes overnight, and staff interviews revealed that when a resident was out during medication times, the MAR was marked accordingly. However, there was inconsistency in notifying the nurse practitioner (NP) or physician about missed medications, and documentation of such notifications was lacking. Staff interviews indicated that while some nurses believed they should notify the NP or physician and document it in the progress notes, this was not consistently done. The NP confirmed that he was not informed about the resident missing several days of medications and emphasized the importance of such notifications for clinical decision-making. Facility policy required prompt notification of the physician for changes in a resident's condition or status, including refusal or missed medications, and documentation of such notifications. Despite this, the review found no evidence that the NP or MD was contacted when the resident returned after missing medications, nor was there documentation in the progress notes. The failure to follow established procedures for medication administration and notification led to the deficiency.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly assist residents in obtaining routine dental services, resulting in unmet dental needs for three residents. For one resident, physician orders indicated a referral to the dentist for a dental exam due to complaints of tooth and gum pain, but there was no documentation of a dental exam or follow-up in the progress notes, and the resident reported not having seen a dentist in over five years despite ongoing dental issues. Another resident had a physician order for denture placement and expressed a desire for new dentures, but there was no evidence that the referral was made within three days or that the resident was seen by a dentist, even though the resident reported discomfort from a broken tooth and requested denture adjustment. A third resident expressed the need for a dental cleaning and had not seen a dentist in over a year, despite a care plan indicating poor dental condition and a request for dentures. There was no documentation of a dental referral or appointment for this resident, and the last recorded dental visit was over a year prior, during which a new cavity was noted. Interviews with staff revealed confusion regarding responsibility for making dental referrals, with some believing it was the nurse's responsibility and others indicating it was the social worker's role. The social worker, who had started six months prior, was unclear about the previous dental provider and had only recently secured a new dental contract, but as of the time of the survey, no dental visits had occurred under the new arrangement. Facility leadership, including the DON and administrator, confirmed that social services was responsible for dental appointments and acknowledged delays in securing a dental contract and arranging dental visits. The facility's policy required routine and emergency dental services to be available in accordance with residents' assessments and care plans, with social services responsible for assisting with appointments. However, the lack of timely referrals and absence of dental services for the residents reviewed demonstrated a failure to meet these requirements.
Failure to Update Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan did not reflect the resident's history of falls, despite documented incidents on three separate occasions. The resident, an older woman with multiple diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, was noted to have no cognitive impairment and was independent with transfers. However, her care plan did not include any mention of falls, even though incident reports documented both witnessed and unwitnessed falls without injury. Interviews with facility staff, including LVNs, the MDS RN, the DON, and the ADM, confirmed that falls should have been included in the resident's care plan and that it is the responsibility of various staff members to update the care plan with such information. The facility's policy requires that care plans be individualized, comprehensive, and revised as the resident's condition changes, incorporating measurable objectives and timetables. Despite these requirements and the staff's understanding of the process, the care plan was not updated to reflect the resident's falls, resulting in a deficiency.
Failure to Maintain Safe Wheelchair Conditions for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the inadequate maintenance of their wheelchairs. Resident #1, a male with a history of osteomyelitis and an above-the-knee amputation, reported that his wheelchair, which was from the 1960s, could not lock properly. Despite informing the social worker and therapy staff about the issue, no maintenance work order was recorded for his wheelchair. Interviews with the physical therapy assistant and occupational therapist confirmed that the wheelchair had a loose lock and was not safe for Resident #1, who was an amputee and required a stable wheelchair for safe transfers. Resident #2, a male with cerebral infarction, visual impairments, and a history of falls, also experienced issues with his wheelchair brakes. Although a work order was documented in the maintenance logbook, it was mistakenly marked as completed without the necessary repairs being made. During an observation, Resident #2 demonstrated that his wheelchair's left wheel did not lock, posing a risk of falling when he attempted to stand. The maintenance director acknowledged the error and expressed concern for Resident #2's safety, emphasizing that wheelchair repairs should be prioritized as emergencies. The facility's policies on maintenance and resident rights were not adhered to, as evidenced by the failure to address the residents' grievances and ensure their safety. The maintenance department's oversight in marking incomplete work orders as done and the lack of timely repairs for critical equipment like wheelchairs contributed to an unsafe environment for the residents. Interviews with staff, including the maintenance director and CNA, highlighted the communication breakdown and procedural lapses that led to the deficiencies.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by two specific incidents involving two residents. In the first incident, a certified nursing assistant (CNA) was observed using his phone during peri care for a female resident with a history of dysphagia, cerebral infarction, vascular dementia, and muscle weakness. The resident's family member provided video footage showing the CNA on his phone while the resident's lower body was exposed, which lasted for two minutes before the CNA resumed care. This incident was reported to the Director of Nursing (DON), who confirmed the CNA was texting during the care process. In the second incident, a male resident with paraplegia and a suprapubic catheter was observed moving through the facility without a privacy bag covering his catheter bag. Although the resident stated he was not bothered by the lack of a privacy bag, the facility's policy requires catheter bags to be covered to prevent potential embarrassment. The lack of a privacy bag was noted by a Licensed Vocational Nurse (LVN) only after it was pointed out, indicating a lapse in adherence to the facility's resident rights policy, which mandates treating all residents with kindness, respect, and dignity.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a gastrostomy tube had her head of bed (HOB) elevated at least 30 degrees, as required to prevent complications such as aspiration. On the evening of February 17, 2025, a licensed vocational nurse (LVN) connected the resident's feeding tube but did not elevate the HOB, leaving the resident lying flat. This oversight was captured on video footage provided by the resident's family member, who later found the resident struggling to breathe with foam around her mouth. The resident, a female with a history of dysphagia, cerebral infarction, vascular dementia, and muscle weakness, was on a continuous feeding regimen of Nepro at 50 ml/hr for 22 hours a day. Her care plan specified the need for HOB elevation during and after feeding. Despite this, the LVN left the resident's room without adjusting the bed, and the family member had to intervene by elevating the bed and clearing the foam from the resident's mouth, which alleviated her breathing difficulties. Interviews with facility staff, including the Director of Nursing (DON) and the LVN involved, revealed a lack of awareness and communication regarding the incident. The DON acknowledged the risk of aspiration if the HOB is not elevated and stated that all staff are responsible for ensuring proper positioning during tube feeding. The facility's policy and external guidelines both emphasize the importance of maintaining HOB elevation to prevent aspiration, yet this protocol was not followed, leading to the resident's distressing experience.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for four residents within 48 hours of their admission, as required. This deficiency was identified through interviews and record reviews, which revealed that Residents #3, #4, #5, and #6 did not have baseline care plans completed. These residents had various medical conditions, including respiratory failure, end-stage renal disease, diabetes, pressure ulcers, cognitive communication deficits, and more. The absence of baseline care plans could lead to a lack of continuity of care and miscommunication among staff, potentially affecting the residents' immediate care needs. Interviews with facility staff, including the social worker, Director of Nursing (DON), and Administrator, highlighted that the facility was behind on care plans due to recent changes in management and staffing shortages. The social worker, who had been at the facility for only three weeks, acknowledged the backlog of care plans and the importance of having them completed to ensure proper resident care. The DON and Administrator also confirmed the delay in care plan completion and the potential for miscommunication among staff without them. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not adhered to for the residents in question.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which is a requirement to meet their medical, nursing, and psychosocial needs. The residents involved were admitted with various medical conditions, including respiratory failure, end-stage renal disease, diabetes, and cognitive communication deficits. Despite being cognitively intact, as indicated by their BIMS scores, these residents did not have completed care plans, which are essential for ensuring their needs and preferences are met. Interviews with facility staff, including the social worker, Director of Nursing (DON), and Administrator, revealed that the facility was behind on care plans due to recent changes in management and staffing shortages. The social worker, who had been at the facility for only three weeks, acknowledged the backlog of care plans and the potential for staff confusion in providing proper care without them. The DON and Administrator confirmed the facility's policy of completing a baseline care plan within 48 hours and a comprehensive care plan within seven days, but admitted that these were not being met, leading to potential miscommunication and inadequate care for the residents.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident during personal care. Specifically, a Certified Nursing Assistant (CNA) was observed changing a resident without closing the door or pulling the privacy curtain, leaving the resident exposed. The resident, a cognitively intact female with multiple health conditions including dementia and epilepsy, required substantial assistance with activities of daily living. Despite the CNA's training on resident rights, the privacy measures were not adequately implemented during the care process. Interviews with the CNA, Director of Nursing (DON), and Administrator (ADM) confirmed that staff were trained to ensure privacy during personal care activities. The DON and ADM acknowledged that failing to provide privacy could impact the resident's dignity. The CNA believed she had closed the door, but it did not remain shut, leading to the exposure. The facility's policy on dignity and privacy, dated August 2009, mandates the protection of resident privacy during personal care, which was not adhered to in this instance.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The resident, a cognitively intact female with multiple diagnoses including respiratory failure, muscle weakness, and post-polio syndrome, was observed lying in bed with sheets soiled by a brown substance, later identified as spilled coffee. Despite the resident's dependency on staff for bed mobility and the presence of soiled sheets, the staff did not change the bedding promptly. Interviews with the CNA and DON revealed that the facility's policy required changing soiled bedding immediately to prevent skin breakdown and discomfort. However, the CNA did not change the sheets because the resident was not ready to get up, and the DON acknowledged that the sheets should have been changed. The ADM also confirmed that bedding should be changed as needed and expressed that the situation should have been handled by the nursing staff. The facility's failure to change the soiled sheets could have led to potential risks for the resident, such as skin breakdown and discomfort.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure a resident maintained acceptable parameters of nutritional status, resulting in a significant weight loss of 25.38% over six months. The resident, a male with diabetes, reduced mobility, muscle weakness, and feeding difficulties, experienced a decline in weight from 226.5 pounds to 169.0 pounds between May and November 2024. Despite the resident's quarterly MDS assessment indicating no weight loss and a care plan that did not address potential weight loss, the resident's weight records showed a clear decline. The resident's nutrition assessments by the RD were inconsistent with the recorded weights, and there was a lack of timely intervention to address the weight loss. Interviews with facility staff revealed a breakdown in communication and monitoring processes. The RD, who worked remotely, relied on information from the DM and did not independently verify weight loss data. The DM acknowledged the resident's deterioration and the late implementation of a supplement order in October. The NP and CNO expressed concerns about the lack of timely interventions and communication regarding the resident's weight loss. The facility's policy required monitoring and reporting of significant weight changes, but these procedures were not effectively followed, leading to the resident's unplanned weight loss.
Failure to Provide Timely Wound Care and Skin Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the resident's care plan for a resident with a skin tear. The resident, a 47-year-old male with a history of cerebral infarction, type II diabetes, and muscle wasting, developed a skin tear on his left lower extremity. The facility did not conduct a complete skin assessment when the skin tear was first noted, and several wound care treatments were missed, leading to an infection that required antibiotic treatment. The resident's care plan included interventions for diabetes management, such as checking the body for skin breaks and treating them promptly. However, the facility did not adhere to this plan, as evidenced by missed treatments on specific dates. The resident's wound care orders were not consistently followed, and the necessary skin assessments were not conducted weekly as required by the facility's policy. Interviews with staff revealed a lack of communication and documentation regarding the resident's wound care needs. The facility's failure to perform timely skin assessments and adhere to wound care protocols resulted in the resident developing an infection. The resident's nurse practitioner was not informed of the wound until it had already worsened, and antibiotics were only started after the infection was identified. The facility's policies on skin assessments and wound care were not followed, contributing to the resident's compromised skin integrity and subsequent infection.
Failure to Provide Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident and their representative before discharging the resident. The resident, who had a BIMS score indicating cognitive intactness, was admitted with diagnoses including respiratory failure, type 2 diabetes, and hypertension. The resident left the facility without oxygen and refused to sign an Against Medical Advice (AMA) form. Despite this, the facility discharged the resident without providing the required notice or involving the Ombudsman. Interviews with facility staff revealed a lack of clarity and adherence to discharge procedures. The social worker acknowledged the necessity of a discharge notice and admitted that the resident should have been allowed to return since they did not sign an AMA. The RN confirmed that the resident was told they no longer lived at the facility and was not provided with discharge papers, leading to the resident's distress. The Chief Nursing Officer (CNO) and Administrator also confirmed that the resident was not given a discharge notice, and the facility's usual practice of documenting AMA refusals was not followed. The Nurse Practitioner (NP) was informed of the resident's desire to leave but did not approve a pass due to the resident's medical needs. The NP was not informed of the resident's return or subsequent discharge. The facility's discharge guidelines require notifying the resident in writing of the discharge and its reasons, which was not done in this case, leading to a deficiency in the facility's compliance with discharge procedures.
Inadequate Discharge Planning and Documentation
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident's discharge, which compromised the safety and orderliness of the transfer. The resident, an elderly female with multiple medical conditions including metabolic encephalopathy, sequelae of cerebral infarction, chronic pulmonary embolism, congestive heart failure, type 2 diabetes, and age-related physical debility, was discharged without a documented discharge plan. The resident had a moderate cognitive impairment and required substantial assistance with toileting hygiene, as indicated by her MDS assessment. The discharge process was inadequately managed, as evidenced by the lack of documentation regarding the resident's preparation for discharge. The facility's discharge policy, which mandates a post-discharge plan to be reviewed with the resident or their family at least 24 hours before discharge, was not followed. The resident was discharged to her family member's home without the family member being present, and there was no documentation of communication with the family or the resident about the discharge plans, including the involvement of home health services. Interviews with facility staff, including the Administrator and Social Worker, revealed a lack of awareness and adherence to the facility's discharge policy. The Administrator acknowledged the absence of documentation and communication, which could lead to delayed care or unsafe discharge. The Social Worker admitted to not having seen the discharge policy and failing to document the discharge process. The facility's failure to document and follow its discharge policy placed the resident at risk of not receiving necessary care and services upon discharge.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse for one resident reviewed for abuse and neglect policies. The facility did not report an allegation of rape made by a resident to the State of Texas and the facility administrator. The facility also failed to immediately notify the police of the alleged allegations and take action to protect the resident from possible physical and emotional abuse. This failure resulted in the identification of an Immediate Jeopardy (IJ) situation. The resident involved was a male with a history of paraplegia, traumatic brain injury, and several mental health conditions, including delusional disorder and bipolar disorder. Despite having a history of making false allegations, the resident's claims of being raped were not thoroughly investigated or reported as required by the facility's policies. The facility's administrator did not follow the protocol to report the allegations to the appropriate authorities or take measures to ensure the resident's safety. The administrator failed to document the incident in the resident's progress notes, inform the police, or discuss the possibility of a SANE exam with the resident or his representative. Additionally, the administrator did not interview the resident's attending physician, staff members, or other relevant individuals to investigate the allegations. This lack of action placed residents at risk of undetected abuse and compromised their feelings of safety and well-being.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of rape made by a resident, identified as Resident #11, who had a history of making false allegations. Despite the resident's cognitive assessment indicating intact cognition, the facility did not provide evidence of investigations into multiple allegations of rape. The resident had a complex medical history, including paraplegia, traumatic brain injury, and several mental health disorders, which may have contributed to his claims. However, the facility's care plan noted a history of false allegations, and interventions included reorientation and reassurance. Interviews and record reviews revealed that the facility did not follow its policy for investigating and reporting abuse allegations. The Administrator did not report the allegations to the appropriate authorities, nor did he document the investigation process or inform the resident's representative. The facility also failed to conduct interviews with relevant staff, the resident's physician, or other residents who might have been involved. This lack of action placed residents at risk of undetected abuse and psychosocial harm. The facility's policy required immediate reporting and thorough investigation of abuse allegations, but these procedures were not followed. The Administrator's failure to report the allegations promptly and conduct a comprehensive investigation led to the identification of an Immediate Jeopardy situation. The facility's records did not show any self-reports of the allegations until after the surveyors' intervention, highlighting a significant deficiency in the facility's handling of abuse allegations.
Unsafe Room Conditions Due to Air Conditioner Placement
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents, leading to potential risks for falls and discomfort due to overheating. Resident #13, a female with a diagnosis of Paralytic syndrome and Multiple sclerosis, required substantial assistance with daily activities and used a wheelchair for mobility. Her room had a portable air conditioning unit placed in front of her closet door, obstructing access to her clothing. This placement forced her to move the unit, which was difficult due to her right-sided paralysis, making it inconvenient to access her clothes. Resident #17, a female with End stage renal disease, Heart Failure, and Type 2 diabetes, also required moderate assistance with daily activities and used a wheelchair. Her room had an electrical cord running from the air conditioner across her closet door, obstructing access. She and the staff had to unplug the cord to access the closet, causing the room to become warm when the air conditioner was disconnected. This setup was inconvenient and potentially unsafe. Resident #63, a male with chronic kidney disease, Type 1 diabetes, and Hypertension, was at high risk for falls and required assistance with ambulation. His room had an air conditioner cord draped across the closet door, obstructing access and creating a trip hazard. He had to unplug the cord to access his closet, occasionally forgetting to plug it back in, leading to a warm room. Interviews with staff, including an LVN and the Maintenance Director, confirmed the unsafe setup of the air conditioning units and acknowledged the potential risks posed by the cords obstructing closet access.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in nutrition, grooming, and personal hygiene. Resident #79, who is blind and has multiple health conditions including schizoaffective disorder and idiopathic aseptic necrosis, was not provided with the required assistance during meals as outlined in his care plan. Despite needing total assistance to eat, staff left him alone with his meal tray, resulting in frustration and a sense of neglect. Observations revealed that Resident #79 was left to eat with his hands and without proper setup, leading to incidents where he struggled to locate his food and even fell while attempting to manage his meal tray. Residents #66 and #68 were not provided with regular showers as per their care plans. Resident #66, who has congestive heart failure and diabetes, received only three showers over a 29-day period, despite needing supervision or assistance. Resident #68, who has severe cognitive impairment and requires assistance with bathing, did not receive any showers during a similar timeframe. This lack of personal hygiene care was confirmed by interviews with Resident #66 and a family member of Resident #68, who noted the resident's unclean condition. The facility's policies on meal assistance and the red napkin program, intended to identify residents needing feeding assistance, were not effectively implemented. The Director of Nursing acknowledged that Resident #79 should not have been left alone with his meal tray and expressed concern over the lack of assistance provided. The failure to adhere to care plans and facility policies resulted in unmet needs for these residents, potentially impacting their dignity and emotional well-being.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach, which is a critical aspect of accommodating residents' needs and preferences. This deficiency was observed in four out of five residents reviewed for resident rights. Specifically, Resident #81, who had a moderately impaired cognition and was dependent on staff for various activities, was found with his call light out of reach on multiple occasions. Despite being in a vulnerable state due to his medical conditions, including diabetes and end-stage renal disease, his call light was either hanging on the bed or on the floor, making it impossible for him to call for assistance. Similarly, Resident #44, who was severely cognitively impaired and dependent on a wheelchair, had her call light consistently out of reach. Observations revealed that her call light was placed on the floor at various locations around her bed, preventing her from being able to signal for help. This resident's inability to communicate effectively further exacerbated the risk of her needs not being met in a timely manner. Resident #15, who was also severely cognitively impaired and dependent on staff for mobility and personal care, had his call light wrapped around the bed rail and out of reach. Despite his attempts to reach it, he was unable to do so, leaving him without a means to request assistance. Additionally, Resident #7, who had intact cognition but was dependent on staff for toileting and personal hygiene, was found with her call light on the floor, out of reach, while she was calling for help. This situation was compounded by a staff member's inappropriate response to her request for assistance, further highlighting the facility's failure to accommodate residents' needs adequately.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse involving a resident, identified as Resident #11, to the State Agency within the required two-hour timeframe. Resident #11, a male with a history of mental health conditions including delusional disorder and bipolar disorder, made multiple allegations of rape occurring in his room. Despite these allegations being reported to various staff members and documented in psychiatric assessments, the facility did not immediately report these allegations to the appropriate authorities. Resident #11's care plan noted a history of making false allegations, which may have influenced the facility's response. However, the facility's policy mandates that all allegations of abuse, regardless of the resident's history, must be reported immediately. The facility's delay in reporting these allegations was evident as the first report to the State Agency was not made until days after the initial allegations were made, and only after external investigators were involved. Interviews with facility staff, including the Administrator and the PMHNP, revealed inconsistencies in the handling of the allegations. The Administrator initially decided not to report the allegations based on his conversation with Resident #11, who reportedly denied being raped and expressed a desire for different positioning. However, subsequent interviews with Resident #11 indicated that he continued to assert that he was being raped, contradicting the Administrator's account. This discrepancy highlights a failure in the facility's internal communication and adherence to reporting protocols.
Failure to Maintain Resident Dignity by Not Covering Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering the urinary bedside drainage bag (BSDB) with a privacy bag, as observed on two separate occasions. The resident, a male with multiple medical conditions including diabetes, a fractured right humerus, anemia, and end-stage renal disease, was dependent on staff for personal care and had an indwelling catheter. Observations on two consecutive days revealed that the resident's BSDB was uncovered and visible from the hallway, compromising the resident's dignity as staff and other residents passed by. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the facility's policy required catheter BSDBs to be covered for privacy when visible to others. Despite the resident expressing satisfaction with the care received and having no concerns, the uncovered BSDB was acknowledged by the DON and ADM as a potential dignity issue. The facility's policy on resident rights emphasized treating all residents with respect and dignity, which was not adhered to in this instance.
Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to notify the physician when there was a need to alter treatment for two residents who were refusing their medications. Resident #57, a male with diagnoses including unspecified dementia, schizophrenia, and depression, refused his prescribed medications Mirtazapine and Risperidone for the majority of July and all of August. Despite this, there was no documentation indicating that the physician or responsible party was notified of these refusals. Resident #57 reported experiencing headaches from the medications and was unaware if his doctor had been informed. Similarly, Resident #61, a male with diagnoses including type 2 diabetes mellitus, aortic valve stenosis, and congestive heart failure, refused his prescribed medication Coreg for most of July and all of August. Like Resident #57, there was no documentation of physician notification regarding these refusals. Resident #61 expressed a preference for natural supplements over medication. Interviews with facility staff, including an LVN, the DON, and the ADM, revealed that there was an expectation for nurses to notify physicians of medication refusals and document these occurrences in the progress notes. However, this protocol was not followed, leading to a lack of appropriate medical treatment for the residents. The facility's policy on administering medications, dated December 2012, indicated that medications should be administered safely, timely, and as prescribed, which was not adhered to in these cases.
Inappropriate Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a Geri chair with a feeding tray attached across the resident's lap. This restraint was not ordered by a physician, nor was it included in the resident's care plan. The resident, who had severe cognitive impairment and a history of falls, was observed multiple times with the tray attached, restricting his movement and causing him distress. Staff interviews revealed conflicting accounts of whether the resident could remove the tray, but it was clear that the tray was used to prevent the resident from getting up, which constitutes a restraint. The resident's medical history included severe dementia with agitation, dysphagia, and repeated falls. Despite these conditions, there was no documented assessment or order for the use of the Geri chair and tray as a restraint. Observations showed the resident attempting to remove the tray unsuccessfully, indicating that it was indeed a restraint. The facility's policy stated that restraints should only be used to treat medical symptoms and not for staff convenience, yet the tray was used to keep the resident from getting up and walking, which was against the facility's restraint-free policy. Interviews with staff and the resident's authorized representative (AR) revealed a lack of communication and understanding regarding the use of the tray. The AR requested the tray to prevent falls, but this was not communicated or documented properly within the facility. The Director of Nursing (DON) and the Administrator were unaware of the tray's use, and there was no consent or physician's order for it. The hospice nurse confirmed that the tray was not necessary and should not have been used as a restraint. This lack of proper documentation, assessment, and communication led to the inappropriate use of a physical restraint on the resident.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident #61, who had a history of Type 2 diabetes mellitus, Aortic Valve Stenosis, and Congestive Heart Failure. Despite being cognitively intact with a BIMS score of 15, Resident #61 refused his prescribed cardiac medication, Coreg, for most of July and all of August. The care plan did not address his right to refuse medication or his preference to self-administer vitamin supplements, which he expressed during an interview. Additionally, the facility did not accurately care plan for Resident #68, who was diagnosed with unspecified protein-calorie malnutrition. Despite this diagnosis, the care plan focused on a diet for weight reduction rather than weight gain, which was inappropriate given the resident's condition. Resident #68 was severely cognitively impaired with a BIMS score of 6 and had no significant weight loss or gain, yet the care plan did not align with his nutritional needs. Interviews with facility staff, including the MDS coordinator, DON, and ADM, revealed that the interdisciplinary team was responsible for updating care plans. However, there was a lack of communication and coordination in addressing medication refusals and self-administration preferences. The facility's policy required care plans to be comprehensive and person-centered, incorporating residents' rights and expressed wishes, but these were not adequately reflected in the care plans for Residents #61 and #68.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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