Deerbrook Skilled Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Humble, Texas.
- Location
- 9250 Humble-westfield Rd, Humble, Texas 77338
- CMS Provider Number
- 676263
- Inspections on file
- 38
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Deerbrook Skilled Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and aggressive behaviors was transferred to a medical center without prior acceptance or adequate communication regarding the resident's needs. The receiving facility was unaware of the reason for the transfer, resulting in the resident being returned to the original facility within hours. Staff interviews confirmed that the transfer did not follow policy, which requires acceptance and notification before transferring a resident.
A resident with Parkinson's disease, diabetes, and moderate cognitive impairment required feeding assistance per a provider order, but the care plan was not updated to reflect this need. Staff observations showed the resident struggling to feed himself, and interviews revealed a lack of communication and awareness among nursing staff and the MDS Coordinator regarding the order and the resident's change in condition.
A resident with severe cognitive impairment and multiple medical conditions, who required staff assistance for ADLs, was observed with long, dirty fingernails despite facility policies and care plan interventions requiring daily cleaning and regular trimming. Staff interviews confirmed that nail care was the responsibility of care staff, but the necessary care was not provided.
A resident with Parkinson's Disease, muscle weakness, and moderate cognitive impairment was not provided with adaptive eating equipment or proper assistance during meals, despite observable difficulties with self-feeding and food spillage. Staff confirmed the need for assistive devices, but no referral or provision was made, contrary to facility policy.
A CNA failed to wear a gown and did not change gloves or perform hand hygiene while providing incontinent care to a resident on Enhanced Barrier Precautions, despite clear signage, available PPE, and facility policy requiring these measures for residents with indwelling devices and wounds. The resident was fully dependent on staff and had multiple comorbidities, increasing the importance of strict infection control practices.
A resident with multiple medical conditions and moderate cognitive impairment was left in a non-functioning bed, unable to use the bed remote to elevate the head as ordered. Despite staff awareness and documentation of the issue, the problem was not promptly addressed, resulting in the resident being unable to eat or sleep and refusing care due to the broken bed. Key facility staff were unaware of the malfunction until the following morning, and the resident remained in an unsafe and uncomfortable position.
Two residents with cognitive and physical impairments were found without access to their call light systems, as the call light buttons were on the floor and out of reach. Staff confirmed the issue during observations and interviews, and facility policy requires call lights to be easily accessible to residents at all times.
A resident with dementia and fluctuating cognitive impairment was able to leave the facility unsupervised and was found about a mile away near a freeway. The resident was not initially identified as an elopement risk, and staff supervision of residents outside was inconsistent, with no designated staff assigned to monitor. Documentation of the incident was incomplete, and facility protocols for investigating and reporting missing residents were not fully followed.
Multiple staff failed to follow infection control protocols, including hand hygiene, use of gloves and gowns during high-contact care, and disinfection of shared equipment, while caring for residents with wounds, indwelling devices, and incontinence. These lapses were observed during care activities and confirmed in staff interviews, despite facility policies and care plans outlining required precautions.
A resident with dementia and fluctuating cognitive impairment eloped from the facility and was found walking near a restaurant by an off-duty staff member. Despite the resident's history of wandering and poor judgment, the incident was not reported to the State Survey Agency as required. Staff and administration had conflicting views on the resident's cognitive status and the necessity of reporting, resulting in a failure to meet regulatory reporting requirements.
A resident who was frequently incontinent of bowel and bladder did not receive proper perineal care when a CNA failed to cleanse the external urethral orifice during hygiene, as required by facility policy. The CNA also did not perform hand hygiene between glove changes or after care, and admitted to keeping gloves in her pocket due to size availability. The resident was dependent on staff for all ADLs and had a care plan to prevent skin breakdown and UTIs, but the observed care did not meet these standards.
A CNA, not authorized to administer medications, applied two Lidocaine patches to a resident after being given the patches by a medication aide. The order for the patches was unclear regarding the specific site of application, and the medication aide did not clarify the order or report the discrepancy. Facility policy and job descriptions specify that only medication aides and nurses are permitted to administer medications, making this a medication error.
A resident with significant mobility and cognitive impairments, who required total assistance for transfers, sustained a severe leg laceration when two CNAs transferred her from a wheelchair to bed without following the care plan or referencing the Kardex. During the transfer, the resident's leg was caught on an exposed, uncapped metal part of the bed frame, resulting in a deep wound that required extensive medical treatment. The bed was found to have a hazardous, uncapped grab bar, and staff did not consult proper transfer instructions prior to the incident.
The facility failed to provide necessary ADL assistance and hygiene care for three residents. One resident with severe cognitive impairment did not receive scheduled showers, another resident with normal cognition but dependent on assistance also missed showers, and a third resident with severe cognitive impairment had neglected fingernail care. Staff had conflicting information about shower schedules, and nail care supplies were available but not utilized, leading to potential risks of infection and injury.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and a history of falls. The care plan required bilateral floor mats to prevent falls, but observations and interviews revealed the absence of these mats. Staff, including the DON, nurses, and CNAs, were unaware or did not adhere to the care plan, potentially placing the resident at risk of injury.
A facility failed to adhere to infection control protocols when an LVN administered IV antibiotics to a resident with a PICC line without wearing a gown, as required by Enhanced Barrier Precautions (EBP). The resident had a history of sepsis and other conditions, necessitating strict infection control measures. The LVN admitted to forgetting the gown, and facility leadership confirmed the expectation for staff to follow EBP to prevent infection spread.
A resident with a history of respiratory failure and other comorbidities was sent to an outside medical appointment with a portable oxygen tank that was not full and without an extra tank. The LPN responsible did not calculate the oxygen needs or confirm oxygen availability at the destination. The resident's oxygen supply ran out during the appointment, resulting in severe hypoxemia and emergency hospitalization.
A resident with severe cognitive impairment and atrial fibrillation experienced a sudden change in condition, including altered mental status and neurological deficits. Despite these symptoms, the resident was not transported to the ER until four hours later, due to a lack of urgency and unclear facility policies on emergency transport. The resident was later diagnosed with a suspected stroke and passed away.
Failure to Ensure Proper Communication and Acceptance Prior to Resident Transfer
Penalty
Summary
The facility failed to ensure appropriate communication and acceptance from the receiving health care institution prior to the transfer of a resident with severe cognitive impairment and aggressive behaviors. The resident, who had diagnoses including muscle wasting, gait abnormalities, muscle weakness, and dementia, was being considered for transfer due to aggressive actions such as kicking, biting, and threatening staff. The social worker submitted a referral to a behavioral hospital, but at the end of her shift, the resident had not yet been accepted. Despite this, the DON facilitated the resident's transfer to a medical center without confirmation of acceptance or proper communication regarding the resident's needs. Upon arrival at the medical center, staff there were unaware of the reason for the transfer and had not been informed of the resident's behavioral issues or need for psychiatric services. The resident was subsequently returned to the facility within a few hours. Interviews with facility staff, including the ADON and Clinical Services Director, confirmed that the transfer was not conducted according to policy, which requires prior acceptance and notification of the receiving facility. The administrator stated she was unaware the transfer occurred without acceptance and emphasized that the expectation is for acceptance to be obtained before any transfer.
Failure to Update Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including Parkinson's disease, type 2 diabetes, hypertension, anxiety disorder, muscle weakness, and lack of coordination. The resident had moderate cognitive impairment and required setup or clean-up assistance for eating, as indicated in the quarterly MDS assessment. Despite a primary care provider order instructing staff to attempt feeding assistance and elevate the head of the bed during meals, the care plan was not updated to reflect the resident's need for feeding assistance. Observations showed the resident struggling to feed himself, with food spilling and difficulty getting food onto utensils during meals. Interviews with staff revealed a lack of awareness of the provider's order and a breakdown in communication regarding the resident's change in self-feeding ability. The MDS Coordinator was unaware of the order and stated it was the nurses' responsibility to inform her of such changes. Nursing staff acknowledged the resident's need for assistance and the importance of reporting changes to the care team for care plan revision. The facility's policy required care plan updates when there is a significant change in a resident's condition, but this was not followed, resulting in the resident's care plan not reflecting his current needs.
Failure to Provide Necessary Fingernail Care for Dependent Resident
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including non-Alzheimer's dementia, cerebrovascular accident, hypertension, and muscle weakness, was identified as requiring assistance with activities of daily living (ADLs), including personal and oral hygiene. The resident's care plan specified the need for setup or clean-up assistance with oral hygiene and partial/moderate assistance with personal hygiene. During observation, the resident was found in bed with fingernails approximately 0.3 cm long and visibly dirty, containing a brown substance underneath. The resident expressed a preference for long nails but indicated a desire for them to be cleaned. Interviews with staff, including the CSD and the Administrator, confirmed that it was the responsibility of care staff to ensure residents' fingernails were cleaned and trimmed according to their preferences, with nurses responsible for trimming the nails of diabetic residents. The facility's policy required daily cleaning and regular trimming of nails to prevent infections and skin problems. Despite these policies and care plan interventions, the resident did not receive the necessary fingernail care, as evidenced by the observed condition of the nails and staff acknowledgment that care was needed.
Failure to Provide Adaptive Eating Equipment and Assistance
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them, as well as appropriate assistance during meals. The resident, a male with diagnoses including Parkinson's Disease, muscle weakness, lack of coordination, and moderate cognitive impairment, was observed multiple times struggling to get food onto his spoon and experiencing food spillage while eating both in the dining area and in bed. Despite these difficulties, the resident was served meals on a regular plate without any adaptive devices such as a plate guard, and there was no evidence of referral to occupational or speech therapy for assessment of assistive devices. Interviews with staff confirmed that the resident needed assistance with meals and that adaptive equipment, such as a divided plate, would be beneficial. The facility's policy required that residents who could benefit from adaptive devices be provided with them, but this was not followed in the resident's case. The care plan and provider orders did not address the need for assistive devices, and staff acknowledged the risk of inadequate nutrition due to the lack of proper assistance and equipment.
Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow established infection prevention and control protocols during incontinent care for a resident on Enhanced Barrier Precautions (EBP). The CNA entered the resident's room, which had EBP signage and available personal protective equipment (PPE), and performed incontinent care wearing only gloves but not a gown as required. During the care, the CNA did not change gloves or perform hand hygiene when transitioning from a contaminated to a clean area, contrary to facility policy and the resident's care plan. The CNA later acknowledged understanding the requirements but stated she forgot to wear a gown and to change gloves due to nervousness. The resident involved was an older male with multiple comorbidities, including heart failure, hypertension, diabetes mellitus, and a history of cerebrovascular accident, and was completely dependent on staff for incontinent care. His care plan specified the use of gloves and gowns during high-contact care activities due to the presence of indwelling medical devices and wounds, and to reduce the risk of infection. Facility policies reviewed confirmed the necessity of donning both gown and gloves for such care and performing hand hygiene when moving from dirty to clean tasks. Interviews with facility leadership confirmed these expectations for staff.
Failure to Maintain Safe and Functional Bed Equipment for Resident
Penalty
Summary
The facility failed to ensure that all patient care equipment was in safe operating condition for one resident with multiple medical conditions, including Parkinson's disease, hypertension, type 2 diabetes, anxiety disorder, muscle weakness, and lack of coordination. The resident, who had moderate cognitive impairment, was found lying flat in bed and unable to use the bed remote control to elevate the head of the bed as ordered by his primary care provider. The resident reported being unable to eat or sleep since the previous evening due to the malfunctioning bed, and staff observations confirmed that the bed remote was not working. The bed was also noted to be in the highest position, and the resident refused care because of the broken bed. Staff interviews revealed that while the issue was reported by the midnight nurse and logged in the electronic maintenance system by the morning nurse, the Assistant Director of Nursing (ADON), Maintenance Director, and Clinical Services Director were not aware of the problem until the morning. The Maintenance Director stated that staff should have moved the resident to a functioning bed and reported the issue directly to him. The facility's policy required the interdisciplinary team to assess the resident's sleeping environment for safety and comfort, but this was not followed, resulting in the resident being left in an unsafe and uncomfortable position for an extended period.
Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for residents in their rooms, specifically for two residents with significant cognitive and physical impairments. Observations revealed that the call light buttons for both residents were found on the floor under the head of their beds, making them inaccessible. Staff interviews confirmed that the call lights were not within reach, and staff acknowledged that this would prevent the residents from calling for help if needed. One resident, a male with moderate cognitive impairment, muscle weakness, and a history of falls, was observed lying in bed without access to his call light, which was on the floor. He was unaware of the location of his call light and expressed a desire to call for assistance. A staff member found the call light on the floor and placed it within his reach, noting that the resident would not have been able to call for help in case of an emergency or incontinence. Another resident, a female with severe cognitive impairment, muscle weakness, and a history of falls, was also found sleeping in bed with her call light on the floor and out of reach. A CNA entered the room, found the call light on the floor, and placed it within the resident's reach, stating that the resident would not have been able to call for help if needed. Facility leadership and policy confirmed the expectation that call lights should always be within reach of residents to allow them to request assistance.
Resident Elopement Due to Inadequate Supervision and Failure to Identify Elopement Risk
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, mood disorder, anxiety, and bilateral hearing loss was able to leave the facility unattended. The resident, who had moderate to severe cognitive impairment as evidenced by fluctuating BIMS scores and documented poor judgment, was not identified as an elopement risk on initial assessments. Despite a history of wandering at home and family reports of previous elopement behaviors, the resident was allowed to sit outside the facility unsupervised. On the day of the incident, the resident left the premises without staff knowledge and was later found approximately one mile away near a freeway by a staff member. Interviews and record reviews revealed that staff supervision protocols for residents sitting outside were inconsistent. There was no designated staff assigned to monitor residents on the patio, and staff relied on periodic checks or visual observation from inside the building. The resident was not signed out, and there was no documentation of his departure. Staff and family interviews confirmed that the resident was not capable of safely leaving the facility alone due to his cognitive impairment, and the area outside the facility included busy streets and a nearby freeway, increasing the risk of harm. Documentation of the incident was incomplete, with missing incident reports and inadequate nursing notes regarding the event. The facility's elopement policy required investigation, reporting, and documentation of missing residents, but these procedures were not fully followed. Staff interviews indicated confusion about supervision responsibilities and criteria for allowing residents to leave the building independently. The lack of adequate supervision and failure to implement appropriate safety measures for a cognitively impaired resident led to the resident's unsupervised departure from the facility.
Failure to Maintain Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices observed among staff caring for three residents with significant medical needs. Certified Nursing Assistants (CNAs) did not consistently perform hand hygiene after providing perineal care or before exiting resident rooms. For example, one CNA failed to wash or sanitize hands after pericare for a resident with a history of urinary tract infections and pneumonia, and another CNA did not perform hand hygiene between glove changes or after pericare, instead proceeding to touch common surfaces and assist the resident in communal areas. Staff also failed to adhere to Enhanced Barrier Precautions (EBP) as required for residents with wounds, indwelling medical devices, or other infection risks. Several CNAs did not wear gowns during high-contact care activities, such as changing briefs or emptying urinary catheters, despite EBP signage and care plans indicating the need for these precautions. In addition, a mechanical lift used for resident transfers was not sanitized between uses for different residents, increasing the risk of cross-contamination. Interviews with staff revealed misunderstandings about the application of EBP and inconsistent knowledge of proper infection control procedures. The residents involved had complex medical histories, including chronic wounds, indwelling catheters, colostomies, and frequent incontinence, placing them at increased risk for infection. Care plans and facility policies outlined specific interventions and precautions, such as regular hand hygiene, use of gloves and gowns, and disinfection of equipment, but these were not consistently followed. Staff interviews confirmed lapses in practice, with some CNAs citing being rushed or unaware of available supplies, and others misunderstanding the requirements for EBP. These failures were directly observed and documented by surveyors during the review period.
Failure to Timely Report Resident Elopement Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. Specifically, the facility did not report to the appropriate authorities when a resident with dementia and moderate to severe cognitive impairment was found to have eloped from the facility. The resident, who had a history of wandering and cognitive deficits, left the facility unsupervised and was later found walking near a restaurant by a staff member who was off duty. The incident was not reported to the State Survey Agency as required by regulations. The resident involved had diagnoses including dementia, mood disorder, anxiety, and bilateral hearing loss, and had a fluctuating BIMS score indicating moderate to severe cognitive impairment. Prior to the incident, the resident was not assessed as being at risk for elopement, despite a history of wandering at home. On the day of the incident, the resident was last seen by staff approximately 30 minutes before being observed outside the facility. Staff initiated a search and located the resident about an hour later, walking back toward the facility. Interviews and documentation revealed that the resident was confused, had poor judgment, and was not safe to be outside alone, especially given the proximity to a busy street and freeway. Despite the clear risk and the requirement to report such incidents, the facility did not submit a self-report to the appropriate authorities. Interviews with staff and administration indicated confusion and disagreement about the resident's cognitive status and whether the incident met the criteria for reporting. Some staff believed the resident was able to make his own decisions, while others recognized the severity of his impairment and the danger posed by his elopement. The lack of timely reporting was confirmed by a review of the Texas Unified Licensure Information Portal, which showed no incident report for the event.
Failure to Provide Proper Perineal Care and Hand Hygiene for Incontinent Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a male resident who was frequently incontinent of bowel and bladder. During an observed care episode, the CNA did not cleanse the external urethral orifice of the penis as required by facility policy, which specifies that perineal care for male residents should begin with cleansing the urethra and then moving outward. The CNA used disposable wipes to clean the groin and penis but did not specifically clean the urethral opening. The resident was dependent on staff for all activities of daily living, including perineal hygiene, and had a care plan in place to address incontinence and prevent urinary tract infections (UTIs). The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease (COPD), muscle weakness, mobility abnormalities, a history of stroke, anxiety, and depression. The resident was cognitively intact and required total assistance for personal hygiene. The care plan documented the need for regular checks and thorough cleaning to prevent skin breakdown and UTIs, with specific instructions to wash, rinse, and dry the perineum after episodes of incontinence. Despite these documented interventions, the observed care did not meet the established standards. Additionally, the CNA did not perform hand hygiene between glove changes or after completing perineal care, contrary to facility policy and infection control protocols. The CNA admitted to not sanitizing hands between glove changes and acknowledged that gloves were sometimes kept in her pocket due to glove size availability issues. The Director of Nursing confirmed that staff are expected to change gloves and perform hand hygiene to prevent infection, especially when moving from clean to dirty areas during care. The facility's perineal care policy, last revised in December 2011, outlines the steps for proper cleaning and hand hygiene, which were not followed during the observed incident.
Unauthorized Medication Administration and Unclear Physician Order for Lidocaine Patch
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) who was not authorized to administer medications applied two Lidocaine patches to a resident during morning care. The medication aide (MA) provided the patches to the CNA, instructing her to apply them while the resident was receiving peri care, as the MA was occupied dispensing medications to another resident. The CNA applied one patch to the resident's right hip and a second patch to the left thigh, despite not being trained or authorized to administer medications. The MA later acknowledged that it was not facility policy for CNAs to apply medication patches and that only medication aides and nurses were responsible for this task. The physician's order for the resident specified the application of a Lidocaine patch to the hip once daily for pain, but did not clarify which hip. The MA and the Director of Nursing (DON) both noted the lack of clarity in the order, with the DON stating that the order should have been clarified and that only one patch was expected to be applied. The physician was also unsure whether the patch was intended for one or both hips and indicated the need to clarify the order. The MA did not report the discrepancy in the order at the time of the incident. The facility's policies and job descriptions specify that only authorized staff, such as medication aides and nurses, are permitted to administer medications, and that CNAs are not trained or authorized to do so. The DON confirmed that the CNA had not been trained in medication administration and would not have known the rights of administration. The incident was considered a medication error, as the administration of the Lidocaine patches was not in accordance with the provider's order or facility policy.
Failure to Ensure Safe Transfer and Hazard-Free Environment Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, two CNAs transferred a resident from her wheelchair to her bed without following the resident's plan of care or referencing the Kardex for transfer instructions. The resident, who had significant medical conditions including muscle weakness, end stage renal disease, reduced mobility, and cognitive impairment, was dependent on staff for all activities of daily living and was identified as requiring a mechanical lift for transfers due to her high fall risk and inability to assist. During the transfer, the resident's right leg became caught on an exposed, uncapped metal part of the bed frame, resulting in a severe laceration that required 15 sutures and 18 staples. The incident was witnessed by staff and confirmed by the resident, who reported that her leg was caught on the bed during the transfer. The bed was later inspected and found to have a grab bar with a pipe sticking out without a cap, creating a rough and hazardous surface. The facility did not have a specific policy on accidents and hazards, and the staff involved did not consult the resident's care plan or seek guidance from nursing staff prior to the transfer. Interviews with staff and the resident's family confirmed that the injury occurred during the transfer and not prior to the resident's arrival at the facility. The CNAs involved did not notice any blood or injury before the transfer, and the resident was alert and able to communicate her needs. The failure to follow established protocols for safe resident transfers and to maintain equipment in a safe condition directly led to the resident's injury.
Removal Plan
- CR#1 involved in alleged deficient practice was discharged to the hospital due to a laceration sustained during a transfer from the wheelchair to the bed.
- The incident involving CR#1 was reported to Health and Human Services.
- The Administrator initiated the investigation, and blood was noted on the side of the bed frame on the square opening area.
- CNA D was in-serviced on Referring to Resident POC for Transfer Instruction.
- CNA W was in-serviced on Referring to Resident POC for Transfer Instruction.
- The Maintenance Director conducted an inspection of all beds, and bed frames. Beds that were missing caps on the side of the bed frame were sealed with either a cap or tape. These open areas are generally utilized to attach side rails to the bed frame.
- The Maintenance Director placed a tab in the open area identified on CR#1 bed and then aides changed the bed out per family request.
- The Administrator notified the Medical Director of the alleged deficient practice.
- The Corporate Clinical Service Director reviewed facility policy regarding Safe Lifting and Movement of Residents and no revisions were deemed necessary.
- Resident CR#1 returned from the hospital with 18 staples and 8 sutures.
- An audit of past incidents was conducted. Two incidents were identified and previously reported to Health and Human Services.
- An in-service was initiated by the Administrator and the Assistant Director of Nursing with the aides on Safe Lifting and Movement of Residents, Referring to Resident POC for Transfer Instruction, and Resident Abuse and Neglect. The aides were not allowed to return to work until they received this in-service.
- The Director of Rehab and the Assistant Director of Nursing completed a 100% checkoff on Resident Transfers with the certified nursing aides. The aides were not allowed to return to work until they received this in-service.
- Newly hired nurses will be in-serviced by the Assistant Director of Nursing or designee on Safe Lifting and Movement of Residents, Referring to Resident POC for Transfer Instruction, and Resident Abuse and Neglect.
- Nursing staff were in-serviced by the Assistant Director of Nursing on Reporting Hazardous Equipment Immediately Including Removing Hazardous Equipment.
- The openings identified by Surveyor were covered and a facility wide audit conducted. Areas of concern addressed immediately. Tape was applied to two Assist Bars that had openings.
- Ambassador Rounding Sheet that was implemented to monitor bed frames was updated to include the monitoring of the Assist Bars. Ambassadors will also check vacant rooms.
- Nurses were in-serviced by the Director of Nursing on referencing Kardex prior to directing staff including C.N.A.s and staff from other departments on how to transfer residents. The Charge Nurse and Nurse Managers will update the Kardex upon admissions and readmissions with any change(s) in status.
- Nurses were in-serviced by Director of Nursing instructing Charge Nurses to assess new and readmitted residents to determine transfer status and to communicate findings to the C.N.A.(s) on duty.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining nutrition, grooming, and personal and oral hygiene. Three residents were affected by this deficiency. One resident, a male with severe cognitive impairment and multiple health issues including osteomyelitis and diabetes, did not receive showers as per the facility's schedule. His records indicated he was supposed to receive substantial assistance with bathing, yet he reported not having a bath or shower since his admission. Another resident, a male with normal cognition but dependent on assistance for all ADLs due to conditions like acute respiratory failure and a stroke, also did not receive showers according to the schedule. His family filed a grievance about the lack of showers, and he confirmed not having received a shower in two weeks. The facility's staff had conflicting information about the shower schedule, and the resident's family had to intervene to address the issue. A third resident, a female with severe cognitive impairment and a right-hand contracture, did not receive proper fingernail care. Her nails were observed to be long and dirty, with a brown substance underneath. Staff interviews revealed that nail care supplies were available, but the resident's nails had not been clipped for one to two months. The facility's policy required regular nail care to prevent infections, but this was not adhered to, leading to concerns about potential injury and infection.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, a female with severe cognitive impairment and a history of falls, was supposed to have bilateral floor mats as an intervention to prevent falls. However, during observations and interviews, it was noted that the fall mats were not present at the bedside, contrary to the care plan. Interviews with the Director of Nursing (DON), the resident's assigned nurse, and certified nursing assistants (CNAs) revealed a lack of awareness and adherence to the care plan. The assigned nurse was unsure if the resident needed a fall mat and had not seen any in the room. Similarly, the CNAs confirmed the absence of fall mats and indicated that the resident had previously used them in a different room. The facility's policies on care planning and fall prevention were not followed, as the care plan interventions were not implemented, potentially placing the resident at risk of injury.
Failure to Follow Enhanced Barrier Precautions During IV Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN B, who did not adhere to Enhanced Barrier Precautions (EBP) while administering IV antibiotics to a resident. The resident, a male with a history of sepsis, type 2 diabetes mellitus, acute prostatitis, and acute metabolic acidosis, was admitted with a PICC line and was on EBP due to the presence of an indwelling medical device. The care plan for the resident required the use of gloves and a gown during high-contact care activities to prevent the spread of infections, particularly multidrug-resistant organisms (MDROs). During an observation, LVN B was seen administering IV antibiotics to the resident without wearing a gown, although she did wear gloves. This was contrary to the facility's policy on EBP, which mandates the use of both gloves and a gown during high-contact activities involving residents with indwelling medical devices. LVN B acknowledged forgetting to wear a gown, which was necessary to protect both the resident and staff from potential cross-contamination. Interviews with the facility's administration and Director of Nursing confirmed the expectation for staff to follow EBP policies to prevent infection spread.
Failure to Provide Adequate Oxygen During Resident Transport
Penalty
Summary
A deficiency occurred when a resident who required continuous oxygen therapy was not provided with sufficient oxygen during transport to and attendance at a medical appointment outside the facility. The resident, who had a history of acute respiratory failure with hypoxia, heart failure, pleural effusion, dementia, chronic kidney disease, and fluid overload, was documented as needing continuous oxygen via nasal cannula per physician orders and care plan interventions. On the day of the incident, the resident was prepared for an outside appointment and was sent with a portable oxygen tank. The portable oxygen tank provided to the resident was not adequately checked to ensure it was full, nor was an extra tank sent for the duration of the appointment. Staff interviews revealed that the nurse responsible did not receive instruction on how to calculate the resident's oxygen needs for the outing, and she only glanced at the tank, noting it was less than full when the resident left. The resident was on the tank for approximately 1.5 hours before leaving the facility, and no arrangements were made to confirm oxygen availability at the medical office. Upon arrival at the medical office, the resident's oxygen saturation was found to be critically low, and the tank was discovered to be empty. The resident developed cyanosis and required emergency intervention, including a rapid switch to a new oxygen tank and subsequent transfer to the hospital for acute hypoxic respiratory failure. Interviews with staff and documentation confirmed that the facility failed to ensure the resident had an adequate supply of oxygen for the duration of the appointment, consistent with professional standards of practice and the resident's care plan.
Delayed Response to Resident's Change in Condition
Penalty
Summary
The facility failed to provide timely treatment and care to a resident who experienced a sudden change in condition, including mental status and neurological deficits. The resident, who had a history of severe cognitive impairment and atrial fibrillation, showed signs of altered mental status and difficulty swallowing on the day of the incident. Despite these symptoms, the resident was not transported to the emergency room until approximately four hours after the initial change in condition was noted. Interviews with staff revealed that there was a lack of urgency in responding to the resident's condition. Nurse B, who was responsible for the resident at the time, did not suspect a stroke and opted for regular transport instead of calling 911, despite the resident's altered mental status and non-verbal behavior. The nurse communicated with the transportation company and was informed of a delay, but did not take further action to expedite the resident's transfer to the hospital. The Director of Nursing and other staff members were not adequately informed or involved in monitoring the resident's condition during the delay. The facility's policy on changes in a resident's condition did not clearly differentiate between situations requiring emergency versus regular transport, contributing to the delay in care. The resident was eventually transported to the hospital, where she was diagnosed with a suspected stroke and later passed away.
Removal Plan
- Resident CR#1 involved in alleged deficient practice was discharged to the hospital.
- Administrator notified the Medical Director of the alleged deficient practice.
- Nurse Managers completed a 100% assessment of all residents residing in the facility for changes in condition, and none were identified.
- LVN B was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the emergency room.
- The facility audited the change in conditions for the last 3 days for altered mental status concerns, monitoring of residents, and notification to the physician, no concerns were identified.
- LVN C was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the emergency room.
- The Corporate Clinical Service Director reviewed facility policy regarding change in condition and no revisions were deemed necessary.
- An in-service was completed by the Corporate Clinical Service Director with the Director of Nursing on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation.
- The Director of Nursing completed an in-service with the licensed nursing staff on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Licensed nurses will not be allowed to return to work until they receive this in-service.
- Newly hired nurses will be in-serviced by the Director of Nursing or designee on changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation.
- The Director of Nursing or designee completed an in-service with the licensed nursing on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility. Licensed nurses will not be allowed to return to work until they receive this in-service.
- Use non-emergency transport for stable residents requiring evaluation or treatment for non-urgent conditions, such as worsening chronic symptoms or mild infections.
- Call 911 for life-threatening emergencies or rapidly deteriorating conditions, such as chest pain, severe respiratory distress, unresponsiveness, or suspected trauma. Always assess vital signs, consult facility protocols or providers as needed, and document the decision-making process thoroughly to ensure appropriate and timely care.
- CNA's received in-services on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed. CNAs will not be able to work until they have completed this in-service.
- Newly hired CNA's will be in-serviced by the Director of Nursing or designee on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed.
- The 24-hour report will be reviewed daily by the Director of Nursing or designee to audit nurse documentation in progress notes of change in conditions and the documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Discrepancies noted during reviews will be immediately corrected by contacting the attending physician of the change of condition and completing documentation in the patient's progress note.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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