Edinburg Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Edinburg, Texas.
- Location
- 5215 S Sugar Rd, Edinburg, Texas 78539
- CMS Provider Number
- 675785
- Inspections on file
- 28
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Edinburg Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hemiplegia, and multiple comorbidities had an MDS significant change assessment in which sit-to-stand and chair/bed-to-chair transfers were incorrectly coded as 88 (not attempted due to medical condition or safety concerns), despite the care plan documenting a need for two staff and a mechanical lift with substantial/maximal assistance. During interviews, the MDS nurse and DON both confirmed the resident was not bedbound, used a wheelchair during the day, and should have been coded as 01 (dependent) for these ADLs, consistent with the facility’s RAI guidance that requires a dependent code when two helpers perform all the effort.
A resident with severe cognitive impairment, dysphagia, and multiple comorbidities had a diet order changed from mechanical soft with regular liquids to a no added salt, pureed diet with nectar thickened liquids following a speech evaluation, but the comprehensive care plan was not updated to reflect this new diet. The existing care plan continued to list a mechanical soft texture and regular liquids despite documentation in the order summary of the revised pureed, nectar-thick diet. Interviews with the MDS nurse, ADONs, DON, and administrator confirmed that the team was responsible for updating care plans, that the diet change had occurred, and that the care plan should have been revised to show the current diet, in accordance with facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
A resident with Alzheimer’s disease, CKD, and heart failure, and a history of ESBL in the urine and MRSA in a sacral wound, was care planned to remain on Enhanced Barrier Precautions (EBP) with door signage and use of gown and gloves for high-contact care. However, review of the electronic medical record by the MDS-RN and IP showed there was no active EBP order, as a prior order had been discontinued in error, despite staff believing the resident should remain on EBP. This lack of an active order conflicted with facility policy requiring complete and accurate documentation of assessments and services in the medical record.
A resident with Alzheimer's disease and moderately impaired cognition was able to leave the facility multiple times without staff awareness or proper sign-out, including driving a personal vehicle offsite and becoming lost. The care plan did not initially address the resident's access to a vehicle or driving capability, and staff failed to implement adequate supervision or follow sign-out protocols, despite the resident's known cognitive deficits.
A resident with Alzheimer's disease and moderately impaired cognition left the facility in his own vehicle, became lost, and was returned by police. The incident was not reported to the Administrator or the state agency within the required timeframe, despite facility policy mandating such reporting. Documentation and interviews confirmed the event and the lack of timely notification, resulting in a deficiency for failure to comply with reporting requirements.
Multiple residents with histories of aggression and cognitive impairment engaged in verbal and physical altercations, resulting in injuries such as skin tears and scratches. Despite care plans and interventions, staff were not always able to prevent or immediately intervene in these incidents, and residents with supervision needs were involved in altercations in common areas and resident rooms.
Three residents did not have complete, person-centered care plans with measurable objectives and timeframes. Two residents involved in repeated verbal and physical altercations did not have care plans addressing their ongoing verbal conflicts, despite documentation of these incidents. Another resident with a surgical wound did not have wound care interventions included in her care plan, even though wound care was ordered and documented. Staff interviews confirmed these omissions and the facility's policy requires such care planning.
A resident with a history of falls and multiple medical conditions was readmitted after a hospital stay for a hip fracture caused by a fall. The MDS assessment completed upon reentry failed to document the recent fall and resulting major injury, despite clear evidence in medical records. The MDS nurse acknowledged the omission and noted that this affected the resident's care plan risk triggers. The facility lacked a specific policy for MDS accuracy, relying instead on the RAI manual.
A resident with a suprapubic catheter did not have her urine output documented for four days, despite physician orders and care plan requirements to record this information every shift. Staff interviews confirmed awareness of the documentation requirement, but no explanation was provided for the missing entries. The resident had multiple medical conditions requiring close monitoring, and the facility's in-service training did not address documentation of urine output.
A resident with multiple chronic conditions, including severe cognitive impairment and hypotension, received Midodrine outside of the physician-ordered time parameters on several occasions. Despite clear orders to avoid administration after the evening meal, staff administered the medication late in the evening and did not consistently document administration times accurately, contrary to facility policy and physician instructions.
A resident with multiple chronic conditions, including diabetes, dementia, and coronary artery disease, did not have vital signs documented in the MAR for several weeks, despite physician orders and care plan requirements. Staff interviews confirmed issues with the documentation process and acknowledged the importance of accurate record-keeping for medication management.
Surveyors found that the kitchen failed to maintain proper sanitation and food safety standards, with a juicer nozzle containing slimy substances and cucumbers stored uncovered in a refrigerator showing signs of spoilage. The Dietary Manager was unaware of these issues, and cleaning logs indicated the equipment had been marked as cleaned despite the deficiencies.
A resident with chronic respiratory failure and COPD did not receive oxygen therapy as ordered, with the oxygen flow set higher than prescribed and the humidifier left empty. An LVN acknowledged not checking the oxygen settings or humidifier during her shift, and the DON confirmed staff responsibility for these tasks, noting the absence of a facility policy on oxygen administration.
A resident with multiple medical conditions was discharged without a required MDS discharge assessment. Although staff provided clinical information and reports to the receiving facility, the discharge MDS was not completed as confirmed by record review and staff interviews, resulting in a deficiency in the assessment process.
A facility did not develop or implement a comprehensive care plan for a resident with an active PTSD diagnosis, despite documentation in the medical record and facility policy requiring individualized interventions for trauma survivors. Staff did not include PTSD in the care plan because the resident had not displayed symptoms or triggers and was not receiving treatment, even though the diagnosis was present and the resident was severely cognitively impaired.
A facility failed to include a resident's refusal of care, specifically showering, in their care plan. The resident, with multiple diagnoses including dementia, consistently refused showers, but this behavior was not documented or addressed in the care plan. Interviews revealed that the refusal was known to staff, but the care plan did not include interventions to address the resident's needs, leading to a deficiency in meeting the resident's well-being.
Inaccurate MDS Coding of ADL Status for Dependent Resident
Penalty
Summary
The facility failed to conduct a comprehensive and accurate assessment using the CMS-specified Resident Assessment Instrument (RAI) for one resident. The resident was an elderly female admitted with diagnoses including cerebral infarction due to embolism, osteoarthritis of the left shoulder, and flaccid hemiplegia affecting the left nondominant side. Her significant change MDS assessment showed a BIMS score of 6, indicating severely impaired cognition. In this assessment, her ADLs for chair/bed-to-chair transfer were coded as 88, meaning the activity was not attempted due to medical condition or safety concerns, while sit-to-lying and lying-to-sitting on the side of the bed were coded as requiring substantial/maximal assistance. However, the resident’s care plan documented that she required two staff for chair/bed-to-chair transfers and substantial/maximal assistance with two staff for lying to sitting on the side of the bed and sit to lying. During interviews and record review, the MDS nurse acknowledged that the code 88 for sit to stand and chair/bed-to-chair transfer was entered in error and stated that the correct code should have been 01, dependent, because the resident required two helpers and was not bedridden. The DON confirmed that the resident liked to sit in her wheelchair during the day, was not bedbound, and that the 88 code on the MDS was incorrect. The DON stated it was the MDS nurse’s responsibility to ensure ADL codes were correct so staff would know the resident’s level of care. Review of the facility’s RAI guidance showed that GG170D (sit to stand) and GG170E (chair/bed-to-chair transfer) should be coded 01, dependent, when two helpers complete all the effort, further demonstrating that the resident’s MDS assessment was not accurately coded for these ADLs.
Care Plan Not Updated to Reflect Resident’s Current Therapeutic Diet
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that reflected a resident’s current diet order. The resident was an elderly male with multiple diagnoses including cerebral infarction, chronic heart failure, type 2 diabetes, dementia, urinary tract infection, hypertension, muscle wasting and atrophy, dysphagia, and lack of coordination. His MDS assessment showed a BIMS score of 1, indicating severe cognitive impairment, and documented the need for a mechanically altered and therapeutic diet. The care plan, initiated earlier, identified a potential nutritional problem related to diet restrictions and listed interventions of a no added salt, mechanical soft texture diet with regular liquid consistency. Record review showed that the physician’s order for the resident’s diet had been changed to no added salt, pureed texture, with nectar thickened liquids, with a start date of 02/03/26, but the care plan dated 03/11/26 was not updated to reflect this change. Multiple staff interviews, including with the MDS nurse, ADONs, DON, and administrator, confirmed that the resident’s diet had been changed following a speech evaluation and that the care plan should have been updated to show the pureed texture and nectar thickened liquids. Staff acknowledged that the kitchen and staff followed the diet orders rather than the care plan and reported no negative outcome for the resident, but consistently stated it was important for the care plan to contain the current diet information because it communicates the resident’s needs and how to care for him. The facility’s own Comprehensive Care Plans policy required comprehensive care plans with measurable objectives and timeframes to meet residents’ needs as identified in the assessment.
Failure to Maintain Accurate EBP Orders in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident who required Enhanced Barrier Precautions (EBP). The resident was an elderly female with Alzheimer’s disease, chronic kidney disease, and heart failure, with a severely impaired cognition reflected by a BIMS score of 4 on a quarterly MDS. Her care plan, updated on 01/18/26, identified a need for EBP due to a history of ESBL in the urine and MRSA in a sacral wound, and included interventions such as placing her on EBP, posting signage on the door, and using gown and gloves for high-contact care activities, with additional use of mask and eye protection as indicated. The MDS did not address any care issues that would require EBP. During observations and interviews on 02/04/26, the MDS-RN, Infection Preventionist (IP), and DON each confirmed that the resident had a history of ESBL and MRSA and should remain on EBP, and that signage and supplies were in place. However, review of the electronic medical record by the MDS-RN and IP revealed there was no active physician order for EBP; the prior EBP order had been discontinued on 01/23/26, and the IP did not know why it had been discontinued and stated it may have been in error. The IP acknowledged it was his responsibility to ensure all residents on EBP had an order and that he had missed this during his weekly reviews. The facility’s “Documentation in Medical Record” policy required that each resident’s medical record contain an accurate representation of the resident’s experiences and complete, accurate, and timely documentation of assessments, observations, and services, which was not met in this case because the resident’s ongoing need for EBP was not supported by an active order in the clinical record.
Failure to Supervise Cognitively Impaired Resident with Vehicle Access
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for a resident with Alzheimer's disease and moderately impaired cognition. The resident, who had a history of forgetfulness and required assistance with activities of daily living, was able to leave the facility multiple times without staff awareness or proper sign-out procedures. On several occasions, the resident left the premises in a personal vehicle, including one incident where he traveled to another city and another where he was found lost and returned by police. Despite these incidents, the resident's care plan did not initially include interventions addressing his access to a vehicle or his ability to drive. The facility's records showed that the resident's cognitive impairment and diagnosis of Alzheimer's were known, and staff were aware that he required supervision and cues for safety. However, after the resident left the facility and drove significant distances without staff knowledge, there were no immediate updates to his care plan to address the risk associated with his access to a vehicle. Interviews with staff and family confirmed that the resident was able to leave the facility unsupervised, and staff were not consistently verifying sign-out and return procedures. The resident's responsible party and staff expressed concerns about his ability to drive safely due to his cognitive deficits. The facility's policy required assessment and care planning for residents at risk of elopement or unsafe wandering, but these measures were not effectively implemented for this resident. Staff interviews revealed gaps in communication and understanding of protocols related to resident supervision and sign-out procedures. The lack of timely interventions and supervision allowed the resident to repeatedly leave the facility and operate a vehicle, despite clear risks associated with his medical condition and cognitive status.
Removal Plan
- Resident #1 received a head-to-toe assessment.
- Resident #1 was placed on 1:1 monitoring.
- The physician was notified and lab orders were obtained with no abnormalities noted.
- The care plan was updated with updated interventions of 1:1 monitoring, documenting exit seeking behaviors, and laboratory studies were completed.
- The vehicle belonging to Resident #1 which was on the premises was removed by resident's Relative Z and moved to her premises.
- Resident #1 has not driven a vehicle.
- The employee monitoring the reception desk was suspended and returned to work.
- Staff member was provided with 1:1 education on following proper out on pass process.
- Nursing administration conducted a facility wide audit of all current residents to determine if any residents were operating personal vehicles that were on the facility's premises.
- The facility completed an audit of all residents wandering evaluations.
- No new residents found at risk for wandering/elopement.
- The center developed and implemented a process to ensure safe and proper leaves of absence for residents: the center developed and implemented a Front Door Safety & Sign-Out Procedure.
- Staff members who assist with front desk reception duties were educated on the new process of Front Door Safety & Sign-Out Procedure to include competency check off.
- The facility initiated 100% reeducation on Elopement Protocols and the supervision of residents and ANE.
- The facility initiated 100% reeducation with the Charge Nurses on the process of Front Door Safety & Sign-Out Procedure.
- The training of direct care staff was completed in person or via telephone.
- Those that were not scheduled completed reeducation prior to accepting assignment for the next scheduled work.
- Verification of 100% of direct care staff education was verified by the Director of Nursing/ designee.
- Employee roster was utilized to validate completion.
Failure to Timely Report Resident Incident to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving a resident with Alzheimer's disease, moderately impaired cognition, type 2 diabetes, malnutrition, and hypertension. The resident left the facility in his own vehicle, became lost, and was returned by a police officer. Upon return, the resident was unable to recall the incident, and his responsible party was notified by the police officer. The incident was documented in the resident's progress notes and care plan, which was updated to address the resident's inability to return to the facility without assistance and to remove access to vehicle keys. Despite facility policy requiring all alleged violations involving abuse, neglect, or exploitation to be reported to the Administrator and state agency within specified timeframes, the Director of Nursing (DON) did not notify the Administrator of the incident, citing the resident's safe return and lack of injury as reasons. The Administrator was not made aware of the incident until days later and did not report the event to the state survey agency (HHSC) for similar reasons. Review of the Texas Unified Licensure Information Portal (TULIP) confirmed that no incident report corresponding to this event was submitted by the facility. Interviews with facility staff and the resident's responsible party confirmed the sequence of events and the lack of timely notification to both the Administrator and the state agency. Facility policy specifically required reporting of such incidents within 24 hours, even if the event did not involve abuse or result in serious bodily injury. The failure to report the incident as required constituted a deficiency in the facility's compliance with state regulations regarding the reporting of alleged violations.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse, neglect, and exploitation, as evidenced by several resident-to-resident altercations resulting in physical injuries. Two residents with a history of verbal and physical aggression toward each other engaged in altercations on more than one occasion, leading to minor injuries such as skin tears and scratches. Documentation shows that both residents had care plans identifying their potential for aggression, but despite interventions such as environmental modifications and medication reviews, altercations still occurred in common areas like the hallway and dining room. Staff interviews confirmed that these incidents were witnessed, and that the residents involved would taunt and provoke each other, with staff sometimes intervening only after the altercations had escalated. Another incident involved a resident with severe cognitive impairment who wandered into another resident's room and was struck by an electric wheelchair, resulting in a skin tear. The resident who operated the wheelchair had intact cognition but significant physical limitations and required supervision when using the motorized device. Despite care plans noting the need for supervision and the potential for physical aggression, the incident occurred when the resident with cognitive impairment became confused and entered the wrong room. Staff interviews indicated that the cognitively impaired resident frequently wandered and became confused, and that she had been involved in other incidents that required investigation. The report details that the facility's policies require protections against abuse, neglect, and exploitation, including screening prospective residents and implementing interventions for those at risk. However, the documented events show that these measures were insufficient to prevent resident-to-resident altercations and injuries. Staff accounts reveal that attempts to separate residents or modify their environment did not always prevent further incidents, and that some staff were not immediately available to intervene during altercations.
Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for three residents. For two residents with a history of escalating verbal altercations that progressed to physical altercations, the care plans did not address the earlier verbal incidents, despite documentation in progress notes and incident reports. The care plans were only updated after physical altercations occurred, omitting interventions or objectives related to the ongoing verbal conflicts that had been documented for months prior. One resident, with diagnoses including cerebral infarction and altered mental status but intact cognition, was involved in multiple verbal and physical altercations with another resident. Despite progress notes and investigation reports documenting these incidents, the care plan failed to address the verbal altercations that preceded the physical events. Similarly, the other resident involved, who had moderate cognitive impairment and multiple mental health diagnoses, also had a care plan that did not address the ongoing verbal altercations, even though these were documented in progress notes and incident logs. Additionally, a third resident with a recent surgical wound following hip fracture repair did not have wound care interventions included in her care plan, despite physician orders for specific wound care and documentation of the surgical wound in her assessment. Interviews with facility staff confirmed that wound care should have been included in the care plan and that its omission could lead to communication breakdowns regarding the resident's care. The facility's policy requires comprehensive care plans to include measurable objectives and interventions for all identified needs, but this was not followed for the residents in question.
Inaccurate MDS Assessment Following Resident Fall with Major Injury
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status, specifically for one resident who had experienced a fall resulting in a major injury. The resident, an elderly female with multiple diagnoses including a displaced intertrochanteric fracture of the left femur, vascular dementia, and a history of falling, was readmitted to the facility following a hospital stay. Hospital records indicated that she had sustained a ground-level fall and subsequently underwent surgery to repair a left hip fracture caused by another unwitnessed fall in her room. Upon review, the resident's admission MDS assessment did not indicate that she had a fall resulting in a major injury, despite clear documentation in hospital and facility records. The MDS nurse responsible for completing the assessment acknowledged that she had coded the fall with major injury on the discharge MDS, but did not answer affirmatively to the fall-related questions on the reentry MDS. The nurse stated that these questions should have been answered "yes" and recognized that failing to do so could affect the resident's care plan, as falls not triggered on the MDS for a new resident would not appear as high risk on the care plan. The facility did not have a specific policy for ensuring the accuracy of MDS assessments and instead referred to the Resident Assessment Instrument (RAI) manual for guidance. The RAI manual requires a thorough review of the resident's history, including falls and fractures in the six months prior to admission, using information from the resident, family, transfer records, and medical documentation. In this case, the required information was available but not accurately reflected in the MDS assessment.
Failure to Document Suprapubic Catheter Output as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a suprapubic catheter, as required by accepted professional standards and physician orders. Specifically, the urine output for the resident was not documented for four consecutive days, despite clear orders to check and record catheter output every shift. The resident's care plan and physician orders both specified the need for regular monitoring and documentation of urine output, but review of the Medication Administration Record (MAR) and progress notes confirmed the absence of this documentation for the specified period. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and a CNA revealed that staff were aware of the documentation requirements but could not explain the lack of entries for those days. The resident involved had a history of neuromuscular dysfunction of the bladder, chronic heart failure, and type 2 diabetes, and required substantial assistance with activities of daily living. She had a suprapubic catheter and colostomy bag due to incontinence, and her care plan included specific interventions for catheter care and monitoring. Despite in-service training on catheter changes and PPE, there was no evidence that staff were trained on the importance of documenting urine output. The DON confirmed that no documentation could be found for the missing days and acknowledged the facility followed the Lippincott Manual of Nursing Practice for catheter care procedures.
Failure to Administer Blood Pressure Medication Within Prescribed Time Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering a blood pressure and pulse-altering medication, Midodrine, within the prescribed time parameters as ordered by the physician. The physician's order specified that Midodrine should be given three times daily for hypotension, held if systolic blood pressure was 130 or above, and not administered after the evening meal or within four hours of bedtime. Despite these clear instructions, documentation showed that the medication was administered on multiple occasions late in the evening, well after the designated time frame following the evening meal. Record review indicated that the resident had significant medical conditions, including Type 2 diabetes, dementia with severe cognitive impairment, high blood pressure, coronary artery disease, and acute kidney failure. The resident's care plan included interventions to administer hypotension medications as ordered and to monitor for side effects and effectiveness. However, medication administration records and blood pressure logs revealed that Midodrine was given outside the prescribed parameters on several dates, with administration times ranging from approximately 8:30pm to 9:20pm, despite dinner being served at 5:00pm. Interviews with medication aides and the DON confirmed that staff were aware of the physician's orders and the importance of timely administration and accurate documentation. Both staff members acknowledged that the medication should not have been given after 6:00pm and that accurate documentation was necessary for monitoring the resident's response to the medication. The DON also noted that the facility's system did not alert staff if the medication was given late, and that audits were conducted, but the issue persisted. Facility policies required medications to be administered as ordered and documentation to be accurate and timely, but these were not followed in this case.
Failure to Document Vital Signs in MAR for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain complete and accurate clinical medical records for one resident, specifically by not documenting vital signs in the Medication Administration Record (MAR) over a period of several weeks. The resident in question was an elderly female with multiple diagnoses, including Type 2 diabetes, dementia, high blood pressure, coronary artery disease, and acute kidney failure. Her care plan required monitoring and documentation of blood pressure due to her condition and prescribed medications, including Midodrine, which was to be held if systolic blood pressure was 130 or above. Record review showed that vital signs were not documented in the MAR from 10/01/25 to 10/24/25, despite physician orders and care plan interventions requiring this information. Interviews with medication aides and the Director of Nursing confirmed that there were issues with the documentation system and that staff were aware of the importance of accurate and timely documentation of vital signs. The facility's own policy required factual, complete, and timely documentation in the medical record, which was not followed in this instance.
Failure to Maintain Sanitation and Food Safety in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation and food safety standards in the kitchen. Specifically, the juicer's nozzle dispenser was found to have red, yellow, and white slimy substances present, indicating it was not adequately cleaned. Additionally, the vegetable refrigerator contained an uncovered clear plastic box with a label, holding 12 cucumbers that exhibited brown, white, and black spots, as well as soft spots that made them difficult to handle. The box did not have a lid, and the cucumbers were not properly stored. During interviews, the Dietary Manager (DM) acknowledged difficulties in removing the juicer nozzle for cleaning but stated it was supposed to be cleaned daily. The DM was unaware of the slimy substances and did not recognize the potential negative outcomes for residents. The DM also had not noticed the spoiled cucumbers and stated they would be discarded. Review of cleaning schedules indicated that the juice machine and refrigerators were marked as cleaned, and the facility's food storage policy required all refrigerated foods to be dated, labeled, and tightly sealed in covered containers, which was not followed in this instance.
Failure to Provide Ordered Oxygen Therapy and Maintain Humidifier
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure, hypoxia, and COPD, who was dependent on supplemental oxygen, did not receive respiratory care consistent with professional standards. The resident had a physician's order for oxygen at 3 liters per minute (lpm) via nasal cannula, but during observation, the oxygenator was set at 5 lpm and the humidifier was empty. The resident was awake, using the nasal cannula, and did not display signs of respiratory distress at the time of observation. A licensed vocational nurse (LVN) confirmed the oxygen setting was incorrect and the humidifier was empty, acknowledging she had entered the resident's room twice earlier in her shift but failed to check the oxygen settings and humidifier. The Director of Nursing (DON) stated it was the nursing staff's responsibility to ensure oxygen was set as ordered and the humidifier was filled, and also noted that the facility did not have a policy regarding oxygen administration.
Failure to Complete Discharge MDS Assessment for Resident
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment for one resident who was reviewed for resident assessments. The resident, a female with multiple diagnoses including hypertension, dementia, aphasia, epilepsy, myocardial infarction, and muscle contracture, was admitted and later discharged to another facility. Record review showed that while her annual MDS was completed, no discharge MDS was found in her records. Interviews with MDS staff confirmed that the discharge MDS was not completed, despite acknowledging that it is a required process for all residents upon discharge. Staff members, including MDS coordinators, the ADON, DON, and the Administrator, indicated that they did not believe the lack of a discharge MDS would negatively affect the resident's care at the receiving facility, as other clinical information and reports were provided during the transfer. However, the absence of the required discharge MDS assessment was confirmed through both record review and staff interviews, constituting a failure to conduct a complete assessment of the resident's functional capacity at discharge as required by regulations.
Failure to Develop Comprehensive Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an active diagnosis of post-traumatic stress disorder (PTSD). Despite the resident's admission records and quarterly MDS assessment reflecting an active diagnosis of PTSD, the care plan did not include any problems, goals, or interventions related to this condition. Interviews with staff revealed that the diagnosis was not care planned because the resident had not displayed symptoms or triggers since admission and was not receiving treatment for PTSD. The social worker and MDS staff both indicated that, in the absence of observed behaviors or reported triggers, they did not include PTSD in the care plan, even though the diagnosis was present in the medical record. The resident in question was an elderly male with severe cognitive impairment, as indicated by a BIMS score of 5, and additional diagnoses of age-related physical debility and depression. Observations and record reviews confirmed that the resident was bed bound, non-interviewable, and had not exhibited any PTSD-related behaviors since admission. Staff interviews further confirmed that no triggers or symptoms had been identified by the resident, family, or staff, and no interventions had been implemented to address PTSD. The facility's own policy required individualized interventions for trauma survivors, but this was not reflected in the resident's care plan.
Failure to Address Resident's Refusal of Care in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's physical, mental, and psychosocial needs. The deficiency was identified for a resident who had a history of refusing care, specifically showering, which was not addressed in the care plan. The resident, who had diagnoses including heart failure, neuromuscular dysfunction of the bladder, delusional disorders, dementia, cellulitis, and dermatitis, required substantial assistance with activities of daily living (ADLs) such as toileting, showering, dressing, and personal hygiene. The resident's care plan, initiated in April 2024, did not include a plan for the specific behavior of shower refusal or other ADLs. The bathing logs for November and December 2024 indicated that the resident consistently refused showers, yet this behavior was not documented in the care plan. Interviews with the treatment nurse and CMS nurse revealed that the resident's refusal of care was known, but the behavior was not incorporated into the care plan. The CMS nurse acknowledged that the refusal behavior should have been care planned and that interventions should have been included to address the resident's needs. The facility's policy required comprehensive care plans to describe services to be furnished to attain or maintain the resident's well-being, including services not provided due to the resident's refusal. However, the care plan for the resident did not reflect these requirements, leading to a deficiency in meeting the resident's needs. The CMS nurse and DON recognized the importance of care planning for refusal behaviors to ensure appropriate care and interventions, but this was not executed in the resident's care plan.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
