Eagle Pass Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Eagle Pass, Texas.
- Location
- 2550 Zacatecas Dr, Eagle Pass, Texas 78852
- CMS Provider Number
- 675617
- Inspections on file
- 21
- Latest survey
- May 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Eagle Pass Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to date prepared thickened beverages, refrigerate opened jars of jalapenos and salad dressing, properly seal a container of vanilla cream icing, and date a beverage container in the dining room. These actions were not in accordance with professional standards and facility policies for food storage and safety.
All resident rooms were found to be below the required 80 square feet per resident, with measurements and interviews confirming that each double-occupancy room provided less than the mandated space. The Administrator and Maintenance verified the deficiency after measuring the rooms and reviewing facility records.
A CNA did not receive the required annual training on resident rights, as confirmed by personnel record review and staff interviews. The facility uses a computer-based system to assign and track annual trainings, but there was no documentation that the CNA completed the resident rights training. When asked, the facility could not provide a policy outlining required annual trainings, including resident rights.
The facility did not accurately update and post daily nurse staffing information, as the staff posting incorrectly showed no Medication Aides present while one was working, and staff were observed making corrections to the posting during the shift. Responsibility for updating the posting was unclear, and there was no formal policy guiding this process.
A resident with severe cognitive impairment and a history of wandering was left unsupervised in a dining area, allowing him to exit through an unlocked door. The resident was found outside the facility after a fall, with no injuries noted. The door had not been properly secured, and exit doors were only checked once daily for security prior to the incident.
The facility failed to ensure proper catheter care and infection control for several residents, leading to potential risks of urinary tract infections. Catheter drainage bags and tubing were observed touching the floor, and staff did not follow proper infection control protocols.
The facility failed to ensure that three nurse aides who had been employed for more than four months completed a competency evaluation program. Despite their lack of certification, they were working as full-time staff members providing ADL assistance to residents. The HRD and DON confirmed that these nurse aides had attempted but failed to pass the competency evaluation program and were shadowed by CNAs.
The facility failed to maintain an effective infection prevention and control program. A Medication Aide did not perform hand hygiene between glove changes, did not sanitize the blood pressure cuff between residents, and did not use proper PPE for residents on contact isolation. Additionally, a housekeeper did not clean her hands before putting on new gloves and cleaning another room. These lapses in protocol could lead to cross-contamination and infection spread among residents.
The facility failed to inform a resident's Responsible Party of the risks, benefits, and options after a psychiatrist recommended discontinuing a medication. Despite regular visits and communication, the family member was unaware of the recommendation, and the medication continued to be administered. The MD and ADON were also not informed, and the DON claimed to have notified them verbally but did not document it.
The facility failed to develop and implement a comprehensive care plan for a resident's oxygen therapy, including self-administration and use of a pulse oximeter. Staff did not consistently document oxygen saturation levels or the administration of oxygen, despite the resident's multiple respiratory diagnoses and intact cognition.
A facility failed to ensure proper dialysis care and documentation for a resident with end-stage renal disease. Incomplete records and lack of communication with the dialysis center led to inadequate monitoring of the resident's condition.
The facility failed to ensure all dumpsters were equipped with drain plugs, posing a sanitary and safety hazard. Two out of three dumpsters lacked drain plugs, and the staff were unaware of the necessity of these plugs. The Maintenance Supervisor claimed the city removed the plugs during an inspection but had no evidence to support this.
The facility failed to maintain accurate medical records for a resident with multiple diagnoses, resulting in conflicting information about the resident's mobility status and risk assessments. The discrepancies were noted between the Admitting MDS, Elopement Risk Assessment, Fall Risk Assessment, and nursing progress notes.
The facility failed to submit accurate RN staffing information for 11 days in Fiscal Year Quarter 1 of 2024. The CCN, who was present on those days, did not complete timesheets due to her salaried status, leading to non-compliance with CMS guidelines.
The facility failed to provide mandatory QAPI training to three staff members (an LVN, another LVN, and a CNA). Record reviews showed no evidence of training, and interviews revealed that the HRD and ADM were unaware of the training deficiencies.
The facility failed to ensure that all staff received training in compliance and ethics, affecting five out of sixteen staff members reviewed. The HR Director confirmed that these staff members were assigned the training but had not completed it via the company's contracted training site, Relias. The Administrator was unaware of the lack of training and acknowledged the risk of staff being unaware of corporate compliance and ethics. The facility did not have a specific policy for ethics training.
The facility failed to implement policies and procedures to prevent abuse and neglect for three residents. Incidents involving resident altercations and a fall resulting in injury were reported late by the new administrator, exceeding the facility's two-hour reporting policy.
The facility failed to report alleged abuse and neglect within the required two-hour timeframe. In one case, a resident with severe cognitive impairment hit another resident, and the incident was reported over four hours later. In another case, a resident with moderate cognitive impairment fell and fractured her nose, and the incident was also reported after four hours. The Administrator admitted delays due to being new and needing time to complete the reporting process.
A resident with severe cognitive impairment did not receive timely treatment for a foot injury, which was noticed by a nursing assistant but not reported. The injury was later identified by another nursing assistant, leading to a delay in care. The resident was sent to the hospital and diagnosed with a laceration and a mildly displaced fracture.
The facility failed to ensure all nursing staff had the necessary competencies to care for residents, leading to incidents where a resident suffered a fractured toe and another experienced a fall with a potential head injury. In-service training was incomplete, and the facility relied on corporate assignments and quizzes without comprehensive oversight.
The facility failed to thoroughly investigate three reported incidents involving resident abuse, neglect, exploitation, or mistreatment. One resident sustained a foot laceration during a shower, another had a knee fracture discovered at the hospital, and an unoccupied shower room caught fire. Investigations were incomplete, lacking staff statements and detailed reports.
A resident with severe cognitive deficit fell during a mechanical lift transfer due to improper sling placement by a CNA. The incident was witnessed by another CNA, and the resident was taken to the hospital to rule out a head injury. The ADON recommended termination of the responsible CNA, who did not return to work.
The facility failed to maintain a fire watch from 10:00 PM through 8:00 AM while the fire alert system was offline, potentially placing residents at risk. The ADM and MS were aware of the issue but did not ensure continuous monitoring.
The facility failed to post current nurse staffing data, displaying outdated information from over a week prior. The ADON admitted to neglecting the update, and the facility's policy on postings was not provided to the investigation team.
The facility failed to ensure an active governing body and an engaged administrator responsible for managing the facility. The ADM was unfamiliar with state licensure and compliance requirements, deferring decision-making to department heads, and was not involved in investigating incidents or in-servicing staff. Interviews with staff confirmed the ADM's lack of interaction and hands-on management.
Failure to Properly Store, Date, and Refrigerate Food and Beverages
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and labeling of food and beverages. Specifically, a tray of prepared and poured glasses of thickened beverages was found in the walk-in refrigerator without any date labels. An opened jar of jalapenos, marked with a received date and labeled to refrigerate after opening, was found in the pantry instead of being refrigerated. Additionally, a large opened plastic container of vanilla cream icing was left with the lid open and not properly sealed, and a half-used bottle of salad dressing, which required refrigeration after opening, was also found unrefrigerated in the pantry. In the dining room, a beverage container with water was present on the counter without a date indicating when it was prepared. Interviews with the Dietary Manager (DM) and the Administrator confirmed that these items should have been properly dated, sealed, and refrigerated according to facility policy and food safety standards. The DM acknowledged that improper storage and lack of dating could result in food items going bad. Record reviews showed that staff had previously received in-service training on labeling, dating, and food storage, and facility policies required food to be covered, dated, and stored at appropriate temperatures. The observed deficiencies were in direct violation of these established procedures and professional standards for food service safety.
Failure to Provide Minimum Square Footage per Resident in All Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in all 46 resident rooms reviewed. Observations of rooms in multiple halls revealed that each room was set up for double occupancy, with beds positioned close to the doorframes and privacy curtains resting on the edge of the beds and in the doorway. Interviews with the Administrator and Maintenance confirmed that none of the rooms met the minimum square footage requirement, as all measured less than 160 square feet, resulting in less than 80 square feet per resident. Record reviews, including room measurements and Form 3740 Bed Classifications, further substantiated that all resident rooms were designated for double occupancy but did not meet the required space per resident. The Administrator acknowledged that the facility did not have a room size waiver and was unaware of the exact room sizes until measurements were taken, confirming the deficiency.
Failure to Provide Annual Resident Rights Training to CNA
Penalty
Summary
The facility failed to provide mandatory annual training on resident rights to one of its certified nursing assistants (CNA C). Review of personnel records showed that CNA C, hired in August 2023, did not have documentation of having completed the required annual resident rights training for the period reviewed. The facility utilizes Relias, a computer-based training program, to assign and track annual trainings, with notifications sent to both employees and their department heads when trainings are due. However, there was no evidence that CNA C completed the resident rights training as required. Interviews with the HR, DON, and Administrator confirmed that the facility's process relies on email notifications and that it is the responsibility of both employees and department heads to ensure completion of annual trainings. Despite these procedures, the required training for CNA C was not documented. Additionally, when requested, the facility was unable to provide a policy specifically addressing required annual training, including resident rights training, prior to the survey exit.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information at the beginning of each shift, as required. On the observed date, the daily staff posting was displayed in public view but incorrectly listed zero Medication Aides (MAs), despite an MA being present and working that morning. During the same period, a registered nurse was seen updating the staffing numbers on the board, indicating that the information had not been kept current. Interviews with staff revealed that responsibility for updating the posting alternated between office staff and charge nurses, with the Director of Nursing stating that charge nurses handled this task on weekends. The Administrator confirmed the importance of accurate daily postings and acknowledged that there was no formal policy in place for this process.
Failure to Prevent Elopement and Accident Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and a known risk for wandering. The resident, an 85-year-old male with diagnoses including unspecified dementia, anxiety disorder, and unspecified convulsions, had a BIMS score of 6, indicating severe cognitive impairment, and was identified as a significant elopement risk. Despite care plan interventions and a physician order for 30-minute monitoring, the resident was left unsupervised in the dining room while staff retrieved other residents. During this period of inadequate supervision, the resident exited the facility through an unlocked dining room door. The door was found to be unlocked at the time, and the facility was unable to determine which staff member had left it unsecured. The resident was discovered outside the facility, lying on the ground near the dining room door, having sustained a fall during the elopement. Upon assessment, the resident showed no signs of injury and reported no pain. Prior to the incident, exit doors were only checked once daily for lock and alarm functionality. Staff interviews confirmed that the resident was left alone in the dining room and that the elopement occurred during this lapse in supervision. The facility's failure to maintain a secure environment and provide adequate supervision directly led to the resident's elopement and fall.
Failure to Maintain Proper Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure appropriate treatment and services for residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. Resident #38's catheter drainage bag was observed touching the floor while the resident was eating lunch in the dining room. Despite being aware of the issue, the staff did not take immediate corrective action, which could lead to infection due to contamination from the floor. The resident's care plan specifically mentioned maintaining the drainage bag off the floor, which was not adhered to during the observation. Resident #11's catheter care was improperly managed by CNAs who did not follow proper infection control protocols. The catheter bag and tubing were observed touching the floor, and the CNAs did not change gloves appropriately during the catheter care process. The DON incorrectly stated that it was acceptable to touch the catheter tubing with contaminated gloves, which contradicts standard infection control practices. This negligence in following proper procedures could lead to infections. Similar issues were observed with Residents #55, #17, and #48, where their catheter drainage bags and tubing were found touching the floor. Despite the facility's policy and care plans indicating that catheter bags should be kept off the floor to prevent infections, these guidelines were not followed. Staff members acknowledged the problem but did not take adequate steps to rectify it, thereby increasing the risk of urinary tract infections for these residents.
Failure to Ensure Nurse Aides Complete Competency Evaluation Program
Penalty
Summary
The facility failed to ensure that three nurse aides (NA E, NA F, and NA G) who had been employed for more than four months completed a competency evaluation program. Nurse Aide E was hired on 09/19/2022, Nurse Aide F on 10/06/2022, and Nurse Aide G on 08/09/2023. None of these nurse aides had completed the required training and competency evaluation program approved by the state. Despite their lack of certification, they were working as full-time staff members providing ADL assistance to residents. The HRD confirmed that these nurse aides had attempted but failed to pass the competency evaluation program and were unaware if they completed tasks independently or under supervision. The DON confirmed that these nurse aides were shadowed by CNAs and had not worked independently, but acknowledged that the expectation was for all nurse aides to become certified within four months of hire. The deficiency places residents at risk of receiving care from individuals whose skill levels have not been adequately evaluated. The facility's failure to ensure that nurse aides become certified within the required timeframe indicates a lapse in compliance with state regulations. The job description for nurse aides, which was undated, stated that they were to complete a nursing and competency program but did not specify a precise timeframe for certification. This lack of clarity and oversight contributed to the deficiency identified by the surveyors.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Medication Aide and a housekeeper. The Medication Aide did not perform hand hygiene between glove changes, did not sanitize the blood pressure cuff between residents, and did not use proper PPE when providing services to residents on contact isolation. Specifically, the Medication Aide failed to wear a gown or gloves when entering the room of two residents on contact isolation, did not sanitize the blood pressure cuff between uses on multiple residents, and admitted to not noticing the isolation signage and PPE cart outside the room. The Director of Nursing (DON) confirmed that the Medication Aide did not follow proper infection control protocols, which could lead to cross-contamination and infection spread among residents. The housekeeper also failed to adhere to proper infection control practices. After cleaning the room of two residents on contact isolation, the housekeeper did not clean her hands before putting on new gloves and proceeding to clean the next room. The housekeeper stated that she thought it was acceptable to put on new gloves without sanitizing her hands because there was no hand sanitizer available on the PPE cart. The DON confirmed that all staff are expected to perform hand hygiene before and after care and that the housekeeper should have sanitized her hands between rooms to prevent infection. The facility's policy and procedure for infection control, updated in March 2024, requires staff to wash their hands after each direct contact, don and doff PPE before and after contact with residents on isolation, and disinfect resident care equipment between uses. The failure of both the Medication Aide and the housekeeper to follow these protocols indicates a significant lapse in the facility's infection control practices, potentially putting residents at risk for the transmission of communicable diseases and infections.
Failure to Inform Responsible Party of Medication Changes
Penalty
Summary
The facility failed to ensure that Resident #34's Responsible Party was informed of the risks, benefits, and options available after a psychiatrist recommended discontinuing the Ativan/Benadryl/Haldol Gel. Despite the recommendation made on 02/27/2024, the Responsible Party was not notified, and the medication continued to be administered. The resident's face sheet indicated a history of a stroke and moderately impaired cognition, and the resident had been receiving antipsychotics, antidepressants, and antianxiety medications. The comprehensive person-centered care plan did not reflect any information related to the administration of antipsychotic medications. Interviews with the family member, MD, ADON, and DON revealed a lack of communication regarding the psychiatric evaluation and the recommendation to discontinue the medication. The family member confirmed regular visits and communication with the facility staff but was unaware of the psychiatric recommendation. The MD and ADON were also not informed of the recommendation, while the DON claimed to have notified the family and MD verbally but did not document it in the clinical records. The facility's policy on notification to family and physician was requested but not provided upon exit.
Failure to Implement Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the use of oxygen therapy. The care plan did not reflect the resident's self-administration of oxygen or the use of a pulse oximeter, and it did not specify the active order for 2 liters per minute rate as needed for oxygen or the frequency for vital signs. This oversight was identified during a review of the resident's records and through interviews with the resident and staff members. The resident, a male with multiple diagnoses including pneumonia, diabetes mellitus, anemia, acute respiratory failure with hypoxia, emphysema, chronic obstructive pulmonary disease, and chronic atrial fibrillation, had a BIMS score of 15, indicating intact cognition. The resident reported using oxygen at night and checking his own oxygen levels with a pulse oximeter. Despite this, the care plan did not address these practices, and staff did not consistently document the resident's oxygen saturation levels or the administration of oxygen. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the staff were aware of the resident's self-administration of oxygen but did not document it because the order was PRN (as needed). The DON and the Regional Compliance Nurse stated that staff were not expected to document oxygen saturation levels daily for PRN orders, even though they were checking it. This lack of documentation and the incomplete care plan could lead to inadequate monitoring and care for the resident's respiratory needs.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. Specifically, the facility did not maintain adequate communication, coordination, and collaboration with the dialysis facility for a resident with end-stage renal disease. The resident's comprehensive care plan included specific interventions for dialysis-related care, but the facility's documentation was incomplete and inconsistent. Several records, including pre and post-assessments, were either blank or missing vital information, such as weights, skin assessments, and vital signs. The Director of Nursing (DON) acknowledged that the dialysis center was responsible for filling out certain portions of the form, but these were often left blank, and the facility did not consistently follow up to obtain the missing information. The resident, who had a central port for dialysis, attended treatments on Monday, Wednesday, and Friday. Despite the facility's policy requiring thorough documentation and monitoring of the resident's condition before and after dialysis, multiple records were incomplete. This lack of proper documentation and communication could lead to inadequate monitoring of the resident's health status and potential complications. The facility's policy emphasized the importance of maintaining comprehensive records and monitoring the resident's condition, but these procedures were not consistently followed, leading to the identified deficiency.
Failure to Equip Dumpsters with Drain Plugs
Penalty
Summary
The facility failed to ensure all facility dumpsters were equipped with a drain plug, posing a sanitary and safety hazard. During an observation and interview, it was revealed that 2 out of 3 facility dumpsters lacked a drain plug, with one having a soda bottle lodged in the drain outlet. The Dietary Manager (DM) confirmed that the dumpsters were her responsibility but was unaware of the necessity of drain plugs. The Maintenance Supervisor (MS), with interpreter assistance from the Director of Nursing (DON), acknowledged the lack of drain plugs and stated that they were removed by the city during a recent inspection, although he had no evidence or records to support this claim. The facility's policy on Waste Control and Disposal did not include specific guidelines related to dumpster maintenance.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for Resident #213, who was reviewed for accurate medical records. The resident, a male with multiple diagnoses including dementia, type 1 diabetes, and a left femur fracture, had conflicting information in his medical records regarding his mobility status. The Admitting MDS indicated that the resident required supervision or touching assistance for transfers and ambulation, while the Elopement Risk Assessment stated that the resident was non-ambulatory and not at risk for elopement. Conversely, the Fall Risk Assessment indicated that the resident was ambulatory and had a high risk for falls. Further discrepancies were noted in the nursing progress notes, which documented the resident walking in different halls at night, contradicting the Elopement Risk Assessment. During an interview, the DON confirmed that the resident could self-propel in his wheelchair and had improved since admission. However, the DON stated that walking around did not qualify the resident for a new elopement assessment. The facility's policy on documentation emphasized the importance of accuracy and completeness, which was not adhered to in this case, leading to misinformation about the resident's care needs.
Failure to Submit Accurate RN Staffing Information
Penalty
Summary
The facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format for 11 of 91 days in Fiscal Year Quarter 1 of 2024. Specifically, the facility did not submit RN staffing hours for the dates 11/24, 12/04, 12/05, 12/09, 12/10, 12/16, 12/17, 12/18, 12/21, 12/22, and 12/27. This failure was confirmed through interviews and record reviews, including the CMS Form-671 and the PBJ Staffing Data Report. The ADM confirmed that the staffing hours were submitted by the corporate office to CMS, but the days in question were likely staffed by the CCN, who, as a salaried staff member, did not complete timesheets and thus could not provide verifiable evidence of her presence at the facility. The CCN confirmed during an interview that she was present at the facility on the dates in question but did not complete timesheets due to her salaried status and had no personal schedule to evidence her presence. The facility's failure to submit accurate and complete staffing information as required by CMS guidelines could not confirm the presence of an RN during the specified dates, potentially impacting the quality of care provided to the residents. The CMS policy manual requires that direct care staffing and census data be collected quarterly and submitted timely and accurately, which the facility failed to comply with for the specified dates.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to include mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for three staff members (LVN H, LVN I, and CNA J). Record reviews showed no documented evidence that these employees received the required QAPI training. LVN H was hired on 07/18/2023, LVN I on 06/29/2022, and CNA J on 01/17/2024. During interviews, the Human Resources Director (HRD) confirmed that the training was assigned by corporate and that her role was limited to reminding department heads of late or non-compliant training. The Administrator (ADM) was also unaware that the staff had not been trained on the facility's QAPI plan and protocols, acknowledging the risk of staff being unaware of the facility's QAPI plan.
Failure to Ensure Staff Training in Compliance and Ethics
Penalty
Summary
The facility failed to ensure that all staff received training in compliance and ethics, affecting five out of sixteen staff members reviewed. Specifically, the Director of Nursing (DON), two Licensed Vocational Nurses (LVN H and LVN I), one Certified Nursing Assistant (CNA J), and one Registered Nurse (RN K) did not have documented evidence of completing the required training. The HR Director (HRD) confirmed that these staff members were assigned the training but had not completed it via the company's contracted training site, Relias. The HRD also noted that her responsibility was limited to reminding department heads of late or non-compliant training. The Administrator (ADM) was unaware of the lack of training and acknowledged the risk of staff being unaware of corporate compliance and ethics. The facility did not have a specific policy for ethics training.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for three residents. The first incident involved a resident with severe cognitive impairment who hit another resident multiple times, resulting in slight bruising. The incident was reported to the administrator (ADM) immediately by the Director of Nursing (DON), but the ADM, who was new, took over four hours to report the incident, exceeding the facility's policy of reporting within two hours. The second incident involved a resident who fell and sustained a fractured nose. The ADM was informed of the incident soon after it occurred, but again took over four hours to report it, failing to meet the two-hour reporting requirement for allegations of neglect. The residents involved had significant medical histories, including dementia, cognitive communication deficits, and cerebral infarction. The facility's failure to promptly report these incidents as per their policy could affect any resident and contribute to abuse and neglect. The ADM acknowledged understanding the reporting requirements but cited his newness to the role as a reason for the delay. The facility's policy mandates that all allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property must be reported within two hours if they involve abuse or result in serious bodily injury.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, as required by their policy. In the first incident, a resident with severe cognitive impairment hit another resident multiple times, resulting in slight bruising. The Director of Nursing (DON) informed the Administrator (ADM) about the incident right away, but the ADM reported the incident to the authorities over four hours later, exceeding the two-hour reporting requirement. The ADM admitted that he was new and took time to complete the reporting process, despite knowing the two-hour requirement for reporting resident abuse. In the second incident, a resident with moderate cognitive impairment fell off her bed and sustained a fractured nose. The incident was unwitnessed, and the resident was sent to the hospital immediately. The staff informed the ADM about the incident soon after it occurred, but the ADM reported the incident to the authorities after four hours, again exceeding the two-hour reporting requirement for resident neglect. The ADM acknowledged that he was new and took time to complete the intake documentation, despite understanding the reporting requirements.
Failure to Provide Timely Treatment for Resident's Foot Injury
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who was eventually diagnosed with a laceration and a fracture to the left foot. The incident occurred when a nursing assistant (NA AD) noticed the resident's foot bleeding before the end of her shift but did not report it to a charge nurse. The injury was only identified later by another nursing assistant (NA AC) during a transfer to bed, leading to a delay in treatment. The resident was subsequently sent to the hospital, where an x-ray revealed a mildly displaced fracture of the fifth toe proximal phalanx and a soft tissue defect. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 03, and required total assistance with activities of daily living (ADLs). The resident's care plan specified the need for a two-person lift for transfers and total care for showering. On the day of the incident, the resident had a shower recorded at 1:59 PM by NA AD, who noticed the bleeding but did not report it. The injury was not identified until around 4 PM when NA AC observed the bleeding during a transfer. Interviews with staff revealed that the injury was likely sustained during the shower with NA AD, who failed to report it. The charge nurse (LVN N) and the Assistant Director of Nursing (ADON) confirmed that the injury was not identified during the day shift and was only reported during the evening shift. The facility conducted in-service training on abuse, neglect, safe handling, reporting, and transfers on the same day as the incident, but there was no evidence of staff statements or findings in the investigation folder.
Inadequate Staff Training and Competency in Resident Care
Penalty
Summary
The facility failed to ensure that all nursing staff had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. This was evident in the cases of two residents who experienced reportable incidents. Resident #1, who had a primary diagnosis of Nutritional Marasmus and Cognitive Delays and Dementia, suffered a fractured 5th toe on her left foot. The incident was discovered by a nurse aide who noticed bleeding and reported it to an LVN, leading to the resident being sent to the ER for x-rays. The facility's in-service training following this incident was incomplete, with only 15 of 38 direct care staff receiving the necessary training on abuse, neglect, exploitation, reporting, safe handling, and transferring residents. The alleged perpetrator did not receive this training. Resident #3 experienced a fall and potential head injury due to an improper mechanical transfer. Following this incident, only 12 of 38 direct care staff were in-serviced on Hoyer Lift Transfers and safe resident handling. Interviews with the ADON and ADM revealed that the facility's in-service training was limited to specific shifts and staff, and there was no comprehensive classroom setting for return demonstrations. The ADM relied on corporate assignments and quizzes to confirm staff competencies, and the QA committee's audits were conducted by department heads without centralized oversight. The ADM did not identify concerns with the investigations until the state investigation began.
Failure to Investigate Alleged Violations Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate three reported incidents involving resident abuse, neglect, exploitation, or mistreatment. In the first incident, a resident with severe cognitive impairment sustained a foot laceration during a shower, which was not reported to nursing staff for at least two hours. The investigation lacked staff statements and was deemed insufficient. In the second incident, a resident with dementia complained of knee pain, and a subsequent hospital visit revealed a knee fracture. The investigation also lacked staff statements and other necessary investigative components. In the third incident, an unoccupied shower room caught fire due to an electrical issue. The investigation included invoices for repairs but lacked detailed reports on smoke inhalation assessments and risk assessments for residents. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) and the Administrator (ADM) were responsible for the investigations. The ADON admitted to only partially completing in-service training for staff, believing the incidents were isolated. The ADM acknowledged shortcomings in the investigation process, particularly in determining the cause of the fire and assessing resident harm. The facility's policy indicated that the ADM was the final responsible party for completing and determining the sufficiency of investigations, but the investigations were found to be incomplete and inadequate during the state investigation.
Resident Falls During Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide an environment free from accident hazards and adequate supervision, resulting in a resident falling during a mechanical lift transfer. Resident #3, who has a primary diagnosis of cerebral infarction and severe cognitive deficit, fell to the ground during a transfer due to improper placement of the Hoyer sling by a CNA. The incident was witnessed by another CNA who confirmed the sling was incorrectly placed, causing the resident to fall when the lift was raised. The resident was subsequently taken to the hospital to rule out a head injury, but no injuries were found. Interviews with staff revealed that the ADON was informed of the incident and recommended the termination of the CNA responsible, who did not return to work following the incident. The ADM was unaware of the specifics of the investigation and relied on the nursing administration to handle the follow-up. The facility did not provide a specific policy on accidents and hazards when requested by the investigation team.
Failure to Maintain Fire Watch During Fire Alert System Outage
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not completing a fire watch from 10:00 PM on 05/30/2023 through 8:00 AM on 05/31/2023 while the fire alert system was offline. This lapse in protocol could place residents at risk of encountering fire. The fire watch was initially started on 05/29/2023 at 9:00 AM and was documented in 15-minute increments until 05/31/2023 at 1:30 PM, except for the period when the fire alert system was offline. The ADM was aware of the fire panel issue and was notified by the fire prevention vendor that a fire watch might be required until the problem was corrected. However, the ADM did not have further details and deferred to the MS for more information. The MS confirmed that he began the fire watch after being notified of the fire prevention outage on 05/29/2023 and instructed the staff to continue the fire watch forms until the system was repaired. The MS did not evaluate whether the fire watch was being continued and noted that the staff responsible for the overnight shift on 05/30/2023 through 05/31/2023 was no longer employed and could not be interviewed. The MS also mentioned that he was not interviewed by the ADM or anyone else regarding this incident. The facility's policy related to fire prevention and fire watches was requested but was not provided to the investigation team before their exit.
Failure to Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to post the current nurse staffing data, as required, which was observed on 02/06/2024. The posted nurse staffing information was outdated, showing data from 01/29/2024. During an interview, the Administrator (ADM) stated that general postings were his responsibility, but the nurse staffing data was managed by the nursing department. The Assistant Director of Nursing (ADON) admitted that updating the nurse staffing data was her responsibility in the absence of the Director of Nursing (DON) and acknowledged that she had neglected to update it. The ADON also mentioned that residents and visitors could access the staff schedules at the nurses' station upon request. The facility's policy on nurse staffing data postings was requested but not provided to the investigation team before their exit.
Lack of Active Governing Body and Administrator Involvement
Penalty
Summary
The facility failed to ensure that it has an active and involved governing body responsible for establishing and implementing policies regarding the management of the facility. The administrator (ADM) appointed by the governing body was not actively engaged in the management of the facility, particularly in the investigation and in-servicing of staff following incidents. The ADM admitted to being unfamiliar with state licensure and compliance requirements and deferred decision-making to department heads, particularly in cases involving resident falls, choking incidents, or unwitnessed injuries. This lack of involvement and familiarity with the facility's operations was corroborated by interviews with direct care and administrative staff, who noted that the ADM was not interactive or hands-on in daily operations and relied heavily on department heads for recommendations and decisions. The ADM's personnel file indicated that he was hired in August 2022 and had a valid LNFA license. However, the facility's policy on the administrator's job description, which dates back to 2014, states that the administrator is accountable for the total operation of the nursing home in compliance with standards and regulations. Despite this, the ADM was not familiar with individual staff members, the medical director's expectations, or the specifics of self-reported incidents, leading to a deficiency in the facility's management and potentially affecting the health and safety of all residents.
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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