Cypress Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Marcos, Texas.
- Location
- 1351 Sadler, San Marcos, Texas 78666
- CMS Provider Number
- 676226
- Inspections on file
- 39
- Latest survey
- December 6, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Cypress Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident's confidential medical information was left visible on a tablet attached to a medication cart when an LVN left the device unattended during a med pass. Staff interviews confirmed awareness of HIPAA and privacy requirements, and facility policy restricts access to authorized personnel only. The incident resulted in a breach of privacy due to failure to lock or minimize the screen.
Two residents receiving hospice care, both with intact cognition, reported that a CNA failed to communicate respectfully when removing food trays and responding to call lights, leading to feelings of being devalued and emotional distress. Staff interviews confirmed the residents' complaints, and facility policy required immediate reporting and investigation of such incidents.
A resident with type 2 diabetes and moderate cognitive impairment repeatedly refused both insulin and oral diabetes medications over several weeks. Staff did not notify the provider of these refusals or document education provided to the resident, despite facility policy and staff expectations requiring such actions.
Surveyors identified multiple deficiencies in food safety and infection control, including improper hand hygiene by dietary staff, failure to check produce quality, lack of training and record-keeping for dishwasher sanitation, and improper storage and labeling of refrigerated foods. The facility also did not maintain required documentation for dietary in-services and staff training.
Surveyors observed persistent foul odors of urine and feces on two halls, with staff and a family member confirming the issue and attributing it in part to old carpeting. Despite some residents not noticing the odors, the facility did not meet its policy to maintain a clean and odor-free environment.
Staff failed to consistently treat residents with dignity and respect by not assisting a resident with feeding in an attentive manner and by entering the rooms of three residents without knocking, despite facility policy and staff training requiring respect for privacy and proper use of personal cell phones during care.
The facility did not ensure a private space for resident council meetings, resulting in repeated interruptions by staff and family members despite residents' requests for privacy. Interviews confirmed that meetings were routinely held in dining areas where privacy was not maintained, and staff acknowledged the lack of effective measures to provide a confidential environment as required by facility policy.
Three residents with significant medical and cognitive needs had personal care and treatment instructions posted in their rooms, including reminders for barrier cream application and positioning to prevent pressure sores. The signage, intended for staff, was visible in the residents' living spaces and made the residents feel uncomfortable and that their privacy was not respected. Staff interviews confirmed the use of these signs for care reminders, despite facility policies on resident privacy and dignity.
Staff failed to supervise a resident during medication administration, leaving pills unattended at the bedside without a self-administration evaluation or care plan. Expired medications and supplies were found on two medication carts and in the medication storage room, despite staff being responsible for regular checks. Residents affected had complex medical conditions and required careful medication management, but facility policies for safe administration and storage were not followed.
Surveyors found that medication carts and storage areas were left unlocked and unattended, contained loose and unlabeled prescription medications, and included opened glucose control solution without proper dating. Staff interviews confirmed that these actions were not in line with facility policy, which requires all drugs and biologicals to be stored securely, labeled correctly, and maintained in their original packaging.
Surveyors found that the facility failed to provide meals that met residents' nutritional needs and preferences, with food often served at improper temperatures, lacking flavor, and not following current menus. Multiple residents expressed dissatisfaction, frequently refusing meals or choosing alternatives due to poor quality. Staff did not consistently document meal refusals or substitutions as required by policy, and food storage practices were not properly followed.
The facility did not consistently prepare or serve food in a way that maintained flavor, appearance, or safe temperatures, with observations of early meal preparation, improperly stored and rotting produce, and meals lacking taste and proper temperature. Multiple residents reported dissatisfaction with the food, describing it as cold, flavorless, and unappetizing, and staff interviews confirmed awareness of these issues and lapses in documentation and food quality checks.
A resident with physical disabilities and diabetes did not receive required fingernail care, despite being unable to perform personal hygiene independently. Staff observations and interviews revealed the resident's nails were long and untrimmed, and there was confusion among CNAs and nurses about responsibility and procedures for nail care, especially for diabetic residents. The facility's policy required nurses to provide and document nail care, but this was not consistently followed, resulting in the resident not receiving adequate grooming.
The facility did not ensure pureed foods were prepared with appropriate liquids, as a cook used water instead of following established recipes, and residents reported dissatisfaction with meal quality, flavor, and variety. Staff interviews revealed lapses in training documentation and adherence to dietary policies, contributing to inadequate food service and unmet resident needs.
The facility failed to maintain a clean and homelike environment in four resident rooms, with observations of food particles, debris, and soiled briefs left in the rooms. Staff interviews revealed short-staffing issues, and the DON acknowledged the uncleanliness did not meet expectations, emphasizing the importance of cleanliness for infection control.
A resident with severe cognitive impairment received a COVID-19 vaccine without her representative's consent. The facility's outdated charting system led a nurse to mistakenly believe the resident could consent, despite her representative having previously declined the vaccine. Staff interviews highlighted the resident's inability to understand the vaccine, contradicting the DON's belief in her decision-making capacity.
The facility failed to store medications securely, with two residents found having medications at their bedside without proper orders. One resident had Chloraseptic lozenges and medicated vapor rub, while another had anti-fungal powder and wound dressing cream. Staff interviews revealed a lack of awareness and adherence to policies requiring orders for all medications, including over-the-counter ones, and secure storage. Facility policies emphasized the need for secure storage and administration according to orders, but these were not followed, leading to the deficiency.
The facility failed to ensure proper medication management for two residents, leading to deficiencies. A resident with Parkinson's disease had unauthorized Chloraseptic lozenges and vapor rub at her bedside, while another resident with diabetes had anti-fungal powder and wound dressing without a physician's order. Staff interviews revealed a lack of adherence to policies requiring orders for all medications, including over-the-counter ones, and proper storage to prevent unauthorized access.
A resident was subjected to physical and emotional abuse by a CNA who forcefully dragged her to the shower room and sprayed her with water while she was fully clothed. Despite the resident's distress and refusal to shower, the CNA continued the abusive behavior, claiming to act on instructions from the DON. The DON failed to take immediate action to protect the resident, allowing the CNA to continue working and taunting the resident. This failure resulted in an Immediate Jeopardy situation, highlighting the facility's inadequate response to abuse prevention and investigation.
A resident with a history of mental health issues was subjected to physical and emotional abuse by a CNA, who forcefully showered her against her will. Despite being notified, the DON failed to take immediate action, allowing the CNA to continue working with the resident, leading to further emotional distress. The facility's policies on abuse prevention were not followed, resulting in an Immediate Jeopardy situation.
A resident with a history of mental health disorders was forcefully dragged to the shower and sprayed with water by a CNA, despite her protests. The DON was informed but failed to act, allowing the CNA to continue working with the resident. Witnesses reported the abuse, but the facility did not report it to the Administrator in a timely manner, resulting in Immediate Jeopardy.
A cognitively intact resident was forcefully dragged to the shower room by a CNA, sprayed with water while fully clothed, and laughed at, causing distress and hair loss. Despite being informed, the DON failed to investigate or report the incident, allowing the CNA to continue working on the same hall, further traumatizing the resident. The facility's inaction led to an Immediate Jeopardy situation.
Resident Information Left Visible on Unattended Medication Cart Tablet
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records by leaving a tablet on the medication cart open and displaying resident information during a medication pass. Observation revealed that the LVN left the tablet unattended and visible for approximately three minutes while in a resident's room, during which time anyone passing by could have viewed the confidential information. The LVN acknowledged that leaving the laptop open with resident information visible was a violation of HIPAA and facility policy. Interviews with other nursing staff, including RNs and the ADON, confirmed that staff were aware of the requirement to lock or minimize screens when leaving computers unattended and recognized that failing to do so constituted a breach of privacy and HIPAA regulations. Review of the facility's Electronic Medical Records policy indicated that only authorized personnel with appropriate credentials should access electronic records, and access should be limited to necessary data. The policy also stated that user codes are confidential and secured by the Administrator and DON. Despite staff training on HIPAA and resident rights, the incident demonstrated a lapse in following established procedures to protect resident information, resulting in a deficiency related to the security and confidentiality of medical records.
Failure to Ensure Respectful Communication and Dignified Care
Penalty
Summary
The facility failed to treat two residents with respect and dignity, and did not provide care in a manner that promoted or enhanced their quality of life. Both residents were on hospice care and had intact cognition, as indicated by their BIMS scores of 15. Their care plans included goals to remain comfortable and free from distress, with interventions to monitor and document for side effects and effectiveness of medications. Despite these plans, both residents reported negative interactions with a CNA, specifically regarding the removal of food trays and the manner in which call lights were answered. One resident reported that the CNA acted as if she was in charge, was not patient, and removed coffee cups and a milk carton from her table without asking. The resident stated she had reported the CNA's rude behavior to a nurse several times. The second resident described the CNA as unwilling to help, recounting an incident where the CNA responded to a request for pain medication with impatience and a dismissive tone. This resident expressed feeling sad as a result of the CNA's behavior and stated she no longer wanted the CNA to care for her. Both residents communicated their concerns to nursing staff, and one also spoke with the social worker during an interview. Interviews with staff revealed that the CNA in question had worked at the facility on an as-needed basis and claimed to always ask residents before removing items. The CNA also stated she was aware of abuse, neglect, and exploitation (ANE) policies. Other staff, including nurses and the DON, confirmed they had received ANE training and understood the requirement to report suspected abuse or neglect. The administrator reported that she had not previously received complaints about the CNA, but upon learning of the allegations, she suspended the CNA and initiated an investigation. Facility policy required immediate reporting and investigation of any suspected abuse or neglect.
Failure to Notify Provider of Repeated Diabetes Medication Refusals
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant need to alter treatment, specifically regarding repeated refusals of prescribed diabetes medications. The resident, an older male with diagnoses including type 2 diabetes, hypertensive heart disease, cerebral infarction, and moderate cognitive impairment, refused his prescribed insulin injections three times daily and his oral diabetes medication on multiple occasions over a period of nearly three weeks. Despite these refusals, there was no documentation that the provider was notified, nor was there evidence that the resident received education about the importance of medication compliance during this time. Record reviews showed that the resident's blood sugar levels fluctuated, with readings ranging from 110 mg/dL to 307 mg/dL, but the provider was only to be notified if levels exceeded 399 mg/dL. Interviews with nursing staff confirmed that the protocol required provider notification and documentation in the resident's chart when medications were refused, as well as education for the resident. However, staff interviews and documentation review revealed that these steps were not consistently followed, and the provider was not informed of the ongoing refusals until the day of the survey interview. Facility policies required that refusals and the reasons for them be documented, and that the provider be notified after two or more consecutive refusals. Despite these policies, the resident's repeated refusals were not communicated to the provider in a timely manner, and there was no documentation of education provided to the resident regarding the consequences of refusing diabetes medications.
Deficiencies in Food Safety, Hand Hygiene, and Dietary Staff Training
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed multiple lapses in food safety practices, including improper hand hygiene by dietary staff while preparing foods and when entering and exiting the kitchen. Specifically, one staff member was observed returning from a personal phone call and resuming food preparation without washing or sanitizing hands, while another staff member handled ice and water for residents without performing hand hygiene. Additionally, the facility did not check produce for quality prior to delivery, as evidenced by a large, unlabeled, and uncovered box of lettuce with black, rotting leaves found in the walk-in refrigerator. Further deficiencies were noted in the facility's dishwasher sanitation practices. Staff members responsible for dishwashing had not received adequate training on using the dishwasher or on monitoring and recording sanitation checks. There were no records or logs maintained for dishwasher sanitation, and staff were under the impression that only the hot water temperature needed to be checked, not the sanitation levels. The facility also failed to keep refrigerated foods tightly wrapped or packaged, and did not label and date all refrigerator and freezer items as required. The facility lacked proper documentation and training for dietary staff. There was no outline of dietary in-services or sign-in attendance sheets for food service employees, despite policies requiring yearly in-services on proper food handling and mandatory attendance records. Interviews with staff and the dietician confirmed gaps in training, monitoring, and adherence to established policies for infection control, hand hygiene, and food safety procedures.
Failure to Maintain Sanitary and Odor-Free Environment on Two Halls
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on two of five halls observed. Specifically, persistent foul odors were noted on the 400 and 500 halls, with surveyors detecting the smell of urine and feces during multiple observations over two consecutive days. The 400 hall was repeatedly noted to have a strong urine odor, while the 500 hall was reported to smell like feces. These conditions were directly observed by surveyors at various times of day. Interviews with staff and family members corroborated the presence of foul odors, with one CNA attributing the persistent smell on the 500 hall to old carpeting. A family member also reported noticing the odor over several days and expressed concern about the cleanliness of the area. However, several residents interviewed stated they did not notice any foul odors in the halls or their rooms. Review of the facility's policy indicated an expectation to maintain a clean environment and minimize odors, which was not met in these instances.
Failure to Ensure Resident Dignity and Privacy During Care and Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, and that care was provided in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, one resident who was totally dependent on staff for eating, with severe cognitive impairment and dysphagia, was observed being fed by a CNA who interrupted the feeding to use her personal cell phone for three minutes. This action occurred in the assisted dining room, where the resident required full assistance with feeding, and the CNA's attention was diverted from the resident during the meal. Additionally, staff members, including an LVN and another staff member, were observed entering the rooms of three residents without knocking. These residents had varying degrees of cognitive impairment and multiple medical diagnoses, including dementia, heart failure, and mobility issues. Observations confirmed that staff entered rooms and even opened bathroom doors without first knocking or waiting for a response, despite facility policy and staff training requiring them to do so to respect residents' privacy and dignity. Interviews with residents, staff, and facility leadership confirmed that the expectation was for staff to knock before entering resident rooms, except in emergencies. Some residents expressed a preference for staff to knock, while others were indifferent. Staff interviews revealed awareness of the policy, but lapses were attributed to being in a hurry or complacency. The facility's policies on resident rights and cell phone use were reviewed, indicating that staff should not use personal phones while providing direct care, especially during feeding, and that residents have the right to privacy and dignity.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide residents with a private space for resident council meetings, as required by their own policy and resident rights regulations. Observations showed that during the resident council meeting, staff and family members repeatedly entered the meeting space, which was held in the assisted dining room. Despite residents informing staff that a meeting was in progress and requesting privacy, staff continued to enter the room. Interviews with residents confirmed that these interruptions were a regular occurrence, and that requests for privacy were not respected. The administrator and other staff acknowledged that the meetings were always held in the dining room and that this was the first time the meeting was moved to the small dining room, which still did not provide adequate privacy due to ongoing interruptions. Interviews with the administrator, assistant director, and DON revealed that all were trained on resident rights and understood the requirement for a private meeting space for resident council. However, they were either unaware of the residents' requests for more privacy or did not take effective action to ensure a private environment. The facility's policy stated that a private space would be provided for resident council meetings, but this was not implemented in practice, as evidenced by the repeated intrusions during the meeting and staff statements that there was nothing the facility could do to prevent these interruptions.
Failure to Protect Resident Privacy Due to Display of Personal Care Signage
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of personal and medical information for three residents by displaying personal care and medical treatment signage in their rooms. Observations revealed that signage with specific care instructions, such as reminders to apply barrier cream and position cushions, was hung on the walls behind the residents' beds. These signs were visible in the rooms and contained information about the residents' care needs, which was intended for staff but was also visible to others entering the room. Interviews with the affected residents indicated that they were uncomfortable with the signage. One resident expressed that the signs made her feel uncomfortable and that she had previously discussed her concerns with staff, who told her the signs were necessary for care. Another resident stated she would prefer the signage not be present and felt staff should know her care needs without such reminders. A third resident reported feeling unimportant and unwelcome due to the signage, and although she had raised the issue with staff, she was told it was necessary for staff communication. Staff interviews confirmed that the signage was used to remind staff, especially those not regularly assigned to the facility, of specific care needs. While some staff acknowledged that the signage could negatively affect residents' sense of dignity and privacy, they also stated that they had not received formal complaints. Facility policies reviewed indicated that residents have the right to privacy, dignity, and self-determination, and that staff are to be educated on these rights. Despite this, the practice of posting personal care instructions in resident rooms was observed and reported by both residents and staff.
Failure to Ensure Safe Medication Administration and Removal of Expired Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by multiple deficiencies in medication administration and storage. One resident was observed with a cup containing nine unidentified pills left at the bedside without staff supervision, and the responsible nurse admitted to leaving the room to retrieve batteries, leaving the medication unattended. The resident did not have a self-administration evaluation or care plan in place, and the facility's policy required staff to ensure residents took their medication completely before leaving their side. Additionally, expired medications and supplies were found on two medication carts and in the medication storage room. Items such as insulin pens, suppositories, lubricating jelly, melatonin, dressing change trays, glucose control solution, intravenous solution, inhalation solution, hypodermic needles, zinc, and peri-stoma wipes were all found to be expired. Some medications were also labeled for individuals who were no longer residents at the time of the survey. Staff interviews confirmed that nurses, the ADON, the DON, and the pharmacist were all responsible for checking for expired medications and supplies, but these checks were not effectively carried out. The residents involved had significant medical histories, including diabetes mellitus type II, cerebral infarction, hypertension, atrial fibrillation, pain, dysphagia, apraxia, chronic kidney disease, dysarthria, vascular dementia, hyperlipidemia, anxiety, transient ischemic attack, and hypertensive heart failure. Care plans and medication orders were in place for these residents, but the facility failed to ensure medications were administered and stored according to policy, including removing expired items and supervising medication administration.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of medications and biologicals. On one occasion, a medication cart on the 500 hall was observed unlocked and unattended while the responsible LVN was at the other end of the hall. Additionally, both the 400-hall and 500-hall medication carts contained loose pills not secured in their original packaging, and the 500-hall cart had a bottle of glucose control solution that was opened but not labeled with the date it was first used, despite manufacturer instructions to discard after three months of opening. Further observations in the medication storage room revealed a large bag containing 100 individually wrapped ondansetron tablets without any prescription or resident label. The 500-hall medication cart also contained two unopened, unlabeled packages of Budesonide, a prescription medication, and an unlabeled blue pill. Interviews with nursing staff, the ADON, DON, and ADM confirmed that all prescription medications are required to have proper labeling, and that medication carts and storage areas should be kept locked and free of loose or unlabeled medications. Staff acknowledged that failure to follow these procedures could result in residents missing doses or receiving medications not intended for them. Facility policy review indicated that drugs and biologicals must be stored in their original packaging, labeled correctly, and kept in locked compartments when not in use. Only the issuing pharmacy is authorized to transfer medications between containers, and nursing staff are responsible for maintaining clean and secure medication storage areas. The observed failures to adhere to these policies were confirmed through staff interviews and direct observation.
Failure to Provide Nutritious, Palatable Meals and Document Substitutions
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to provide meals that meet residents' nutritional needs and preferences, as required by national guidelines and facility policy. Observations revealed that the kitchen stored unlabeled and uncovered produce, including rotting lettuce, and used old menus that were not current. During meal service, food was found to be served at suboptimal temperatures and described as flavorless and unappetizing by both surveyors and residents. Additionally, a cook was observed pureeing food with water instead of more nutritious liquids, and not following a specific recipe. Interviews with residents consistently indicated dissatisfaction with the meals, citing issues such as lack of flavor, repetitive menu items, poor food quality, and unappetizing alternatives. Several residents reported regularly refusing meals or choosing alternatives like cereal due to the poor quality of the main offerings. Staff interviews confirmed awareness of these complaints, and the Dietary Manager (DM) acknowledged that substitutions were offered but not documented, as required by facility policy. The DM also admitted to not inspecting food quality at delivery and not labeling returned items, and was unaware of some staff meal preparation practices that could affect food quality. Record reviews showed that facility dietary policies require proper labeling, dating, and storage of food, prompt and efficient meal service to maintain appropriate temperatures, and documentation of resident acceptance or refusal of meal substitutions. However, these policies were not consistently followed, as evidenced by the lack of documentation for meal refusals and substitutions, improper food storage, and failure to ensure meals were appetizing and at the correct temperature. No information was provided regarding corrective actions or follow-up after these deficiencies were identified.
Deficient Food Preparation and Service Practices
Penalty
Summary
The facility failed to ensure that food and drink were prepared and served in a manner that conserved nutritive value, flavor, and appearance. Observations revealed that food was being prepared more than two hours before meal service, and test trays for both regular and puree diets were served at suboptimal temperatures and lacked flavor. The kitchen was also found to have unlabeled, uncovered, and rotting produce, as well as outdated menus posted in the dining room. Additionally, a cook was observed pureeing cornbread muffin with water instead of following a specific recipe or using recommended ingredients, which was contrary to facility protocol. Multiple residents reported dissatisfaction with the meals, describing the food as flavorless, cold, tough, and unappetizing. Several residents stated they often declined the main meals and alternatives due to poor quality, lack of variety, and unappealing presentation. Some residents preferred to eat cereal or food brought by family members rather than consume the facility's offerings. Staff interviews confirmed awareness of resident complaints regarding food temperature, taste, and lack of variety, and the Dietary Manager acknowledged not inspecting food quality at delivery, not labeling returned items, and not documenting meal substitutions. Record reviews indicated that facility dietary policies required proper labeling, dating, and storage of food, prompt and efficient meal service to maintain appropriate temperatures, and documentation of meal refusals and substitutions. However, these policies were not consistently followed, as evidenced by the presence of improperly stored food, lack of documentation, and failure to ensure meals were appetizing and served at safe temperatures.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with significant physical impairments, including hemiplegia, hemiparesis, Parkinson's disease, and diabetes mellitus, did not receive necessary fingernail care. The resident was unable to open her left hand due to contracture and required assistance with activities of daily living, including personal hygiene. Despite being scheduled for nail care by a licensed nurse twice a week, observations on multiple occasions revealed that the resident's left thumb nail was long and had rough edges. The resident expressed a desire for her nails to be trimmed and denied refusing nail care. Interviews with staff revealed confusion and lack of clarity regarding responsibility and procedures for nail care, especially for diabetic residents. CNAs reported that they could not trim the resident's nails due to her diabetes and contracture, and stated they would report concerns to the nurse. Licensed nurses, including LVNs and RNs, acknowledged the importance of nail care but were either unaware of the resident's need, unsure of the schedule, or did not know where to document the care provided. The DON and ADON confirmed that nail care for diabetic residents should be performed by nurses and expected it to be done promptly when needed, but there was inconsistency in staff knowledge and execution of these expectations. The facility's policy required routine cleaning, inspection, and trimming of nails by nurses for diabetic residents, with documentation in the care system. However, the care plan for the resident did not address nail care, and there was no physician order for it. Multiple staff members, including the administrator, were unaware of the specific requirements for diabetic residents' fingernail care and the frequency of checks. This lack of coordination and adherence to policy resulted in the resident not receiving necessary nail care, as evidenced by repeated observations of long, untrimmed nails and staff interviews confirming the deficiency.
Failure to Prepare Pureed Foods Appropriately and Provide Palatable Meals
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual resident needs, specifically in the preparation of pureed foods. Observation revealed that a cook used water as the liquid to puree a cornbread muffin, rather than following a specific recipe or using appropriate liquids such as milk, butter, gravy, or broth as outlined by facility protocol. The cook was not adhering to established recipes, and the dietary manager (DM) confirmed that water should not be used for pureeing due to its lack of nutritional value. The DM also stated that he was unaware of the cook's actions and that all necessary supplies for proper pureeing were available. Multiple residents expressed dissatisfaction with the meals provided, citing issues such as lack of flavor, repetitive menu items, poor food quality, and unappetizing alternatives. Several residents reported not eating the facility meals due to these concerns, with some preferring to eat cereal or food brought by family members. Residents also noted that food was sometimes cold, tough, or poorly prepared, and that alternatives offered were not appealing or well-cooked. Interviews with staff revealed gaps in documentation and training practices. The DM stated that he receives training from the dietician and is responsible for training dietary staff, but in-service logs were not maintained or provided to the surveyor. The DM also acknowledged not inspecting food quality at delivery and not labeling returned items as required by policy. Facility dietary policies reviewed included requirements for proper food storage, prompt meal service, and documentation of food refusals and substitutions, but these were not consistently followed.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four of six resident rooms reviewed. Observations revealed that the floors and bedside tables in these rooms were caked with food particles and debris, and bags of soiled briefs were left in the rooms. Specific observations included sticky brown substances on the floors, dirt and debris on fall mats, brown streaks on the floors, and a dried blood-like substance on the ground. Additionally, a tied trash bag filled with soiled briefs and wipes was found on the floor of one room. Interviews with staff revealed that the facility was short-staffed on the day of the observations, with no housekeeper assigned to the hallway containing two of the affected rooms. The housekeeper interviewed stated that their responsibilities included sweeping, mopping, cleaning the sink and toilet, and taking out the trash. The Director of Nursing (DON) acknowledged that the uncleanliness did not meet her expectations and emphasized that maintaining clean resident rooms is crucial for infection control. The facility's Homelike Environment Policy mandates maintaining a clean environment in accordance with residents' rights.
Failure to Obtain Consent from Resident's Representative for COVID-19 Vaccine
Penalty
Summary
The facility failed to extend the right to make decisions on behalf of a resident to their representative, resulting in the administration of a COVID-19 vaccine without the representative's consent. The resident, an elderly female with severe cognitive impairment, was admitted with diagnoses including unspecified dementia and major depressive disorder. Her representative had previously declined the COVID-19 vaccine on her behalf. However, a nurse documented receiving verbal consent from the resident herself, despite her cognitive limitations. Interviews revealed that the nurse administered the vaccine based on outdated information in the facility's charting system, which incorrectly listed the resident as her own representative. The Director of Nursing believed the resident was capable of making the decision at the time, although interviews with other staff indicated otherwise. Attempts to contact the resident's representative were unsuccessful before the survey concluded. The facility's policy stated that the resident representative has the right to exercise the resident's rights as delegated.
Deficiency in Medication Storage and Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, making them inaccessible to unauthorized staff, visitors, and residents. This deficiency was observed in two residents who had medications stored at their bedside without proper orders. Resident #1, a woman with Parkinson's disease and moderate cognitive impairment, was found with Chloraseptic lozenges and medicated vapor rub in her room. There were no physician orders for these medications or for self-administration, and the resident's care plan indicated that medications should be administered as ordered. Similarly, Resident #2, who had Type 1 diabetes mellitus and other health conditions, was found with clinical anti-fungal powder and Triad Hydrophilic wound dressing at her bedside. There were no orders for self-administration or for the wound dressing, although there was an order for the anti-fungal powder to be applied by staff. Interviews with staff, including LVNs, CNAs, the NP, and the DON, revealed a lack of awareness of any residents having medications at bedside without orders. The staff confirmed that all medications, including over-the-counter ones, required an order and should not be stored in residents' rooms unless approved. The facility's policies and in-service training emphasized that medications should be administered according to established schedules and stored securely. The ADM and DON expressed concerns about the potential risks of having medications accessible in residents' rooms, highlighting the need for orders and secure storage. Despite these policies, the facility did not ensure compliance, leading to the observed deficiencies in medication storage and administration.
Deficiency in Medication Management and Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication management. Resident #1, an elderly woman with Parkinson's disease and moderate cognitive impairment, was found to have Chloraseptic throat lozenges and medicated vapor rub at her bedside without a physician's order. The resident and her family member confirmed that these medications were kept in her room for occasional use, but there was no documentation or order for self-administration of these over-the-counter medications. Similarly, Resident #2, who has Type 1 diabetes mellitus and other health conditions, had clinical anti-fungal powder and Triad Hydrophilic wound dressing at her bedside. The resident stated that the anti-fungal powder was used by staff after her showers, but there was no physician's order for these medications. Interviews with staff, including LVNs, CNAs, the NP, and the DON, revealed a lack of awareness and adherence to the facility's policy that all medications, including over-the-counter ones, require a physician's order and should not be stored in residents' rooms unless approved. The facility's policies on medication administration, storage, and orders were not followed, as evidenced by the presence of unauthorized medications in residents' rooms. Staff interviews indicated that medications should be secured and only administered with a proper order, yet there was a disconnect between policy and practice. The ADM acknowledged the potential risks associated with unsecured medications and emphasized the need for orders and proper storage to prevent unauthorized access and ensure resident safety.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by a CNA. The incident involved the CNA forcefully dragging the resident to the shower room, spraying her with water while she was fully clothed, and laughing at her distress. The resident, who was cognitively intact, had refused to shower, but the CNA claimed to be acting on instructions from the DON to ensure the resident was showered. Despite the resident's screams and cries, the CNA continued the abusive behavior, which included combing the resident's hair aggressively, causing hair loss. The DON was notified of the incident but failed to take immediate action to protect the resident from further abuse. The CNA continued to work at the facility and on the same hall as the resident, where she continued to taunt and emotionally abuse the resident. Other CNAs witnessed the incident but did not intervene to stop the abuse. The DON did not report the incident to the ADM or take steps to remove the CNA from the resident's care, allowing the abusive behavior to continue. The facility's failure to address the abuse promptly and effectively resulted in the identification of an Immediate Jeopardy situation. The lack of immediate action placed the resident at risk of further abuse and emotional distress. The facility's policies on abuse prevention and investigation were not followed, leading to a delay in addressing the situation and ensuring the resident's safety.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse for one resident. The incident involved a Certified Nursing Assistant (CNA) who forcefully dragged a resident to the shower room and sprayed her with water while she was still clothed, despite her protests. This act of physical and emotional abuse was witnessed by other CNAs who did not intervene. The Director of Nursing (DON) was notified but failed to take immediate action to protect the resident, allowing the abusive CNA to continue working with the resident and subjecting her to further emotional abuse. The resident involved was a cognitively intact female with a history of major depressive disorder, anxiety disorder, and unspecified psychosis. She was admitted to the facility with a care plan that required assistance with activities of daily living (ADLs), including showering. Despite her refusal to shower, the CNA, under the pretext of instructions from the DON, forcibly showered the resident, causing her significant distress and humiliation. The resident reported feeling helpless and humiliated, and the incident left her fearful and traumatized. The facility's failure to act promptly and appropriately in response to the abuse allegations resulted in the identification of an Immediate Jeopardy (IJ) situation. The DON's lack of documentation and delayed response to the incident further exacerbated the situation, as the abusive CNA continued to work in the facility and interact with the resident. The facility's policies on abuse prevention and investigation were not followed, leading to a significant risk of harm to the resident and a breach of her rights and dignity.
Failure to Report and Address Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect were reported to the facility Administrator immediately, but no later than two hours, for one resident reviewed for abuse and neglect. The incident involved a Certified Nursing Assistant (CNA) who forcefully dragged a resident to the shower room, sprayed her with water while she was still clothed, and continued to emotionally abuse her. Despite the resident's screams and cries, the Director of Nursing (DON) was notified but failed to take any action to protect the resident from further abuse, allowing the CNA to continue working at the facility and with the resident. The resident involved was a cognitively intact female with a history of major depressive disorder, anxiety disorder, and unspecified psychosis. She required assistance with activities of daily living (ADLs) but was able to ambulate without a wheelchair or walker. The incident occurred when the resident refused to shower, and the CNA, following alleged instructions from the DON, forcibly took her to the shower room. The resident was humiliated and traumatized by the experience, which included being sprayed with water and having her hair combed aggressively, resulting in hair loss. Witnesses to the incident, including other CNAs, reported the abuse to the DON, who did not document the incident or report it to the Administrator. The DON claimed to have been unaware of the incident until weeks later and did not take immediate action to remove the CNA from the resident's care. The facility's failure to report and address the abuse promptly resulted in the identification of an Immediate Jeopardy situation, placing residents at risk of further abuse and harm.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was cognitively intact and required assistance with activities of daily living. The incident involved a CNA who forcefully dragged the resident to the shower room, sprayed her with water while she was fully clothed, and laughed at her distress. Despite the resident's screams and resistance, the CNA continued the abusive behavior, which included combing the resident's hair aggressively, resulting in hair loss. The incident was witnessed by other CNAs who reported it to the Director of Nursing (DON), but no immediate action was taken to investigate or protect the resident. The DON was informed of the incident by multiple staff members, including an occupational therapist who received a text message detailing the abuse. However, the DON failed to document the investigation properly and did not report the incident to the Administrator or the appropriate authorities in a timely manner. The alleged perpetrator continued to work on the same hall as the resident, further traumatizing her. The DON's inaction and lack of documentation led to the identification of an Immediate Jeopardy situation, as the facility did not ensure the safety and protection of the resident. Interviews with staff and the resident revealed that the DON was aware of the incident but did not take appropriate steps to address the abuse or prevent further harm. The resident expressed feelings of humiliation and fear, and staff members reported that the DON appeared unconcerned about the resident's safety. The facility's failure to follow its abuse prevention and investigation policy placed residents at risk of further abuse and psychosocial harm.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
