Five Points Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Desoto, Texas.
- Location
- 1901 N Hampton Rd, Desoto, Texas 75115
- CMS Provider Number
- 745006
- Inspections on file
- 27
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Five Points Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, bilateral lower extremity impairment, prior left femur fracture, sickle cell disease, and osteoporosis was transported from a medical appointment in a wheelchair using the facility van. While the van was parked, the resident began to slide from the wheelchair, and the CNA driver guided the resident to the floor of the van. Instead of obtaining immediate nursing assessment or emergency assistance at the appointment site, the CNA drove back to the facility with the resident unsecured on the van floor. Upon arrival, an LVN assessed the resident, who reported dull left thigh pain, and staff assisted her back into the wheelchair. Facility documentation and staff interviews showed that this sequence of actions did not follow the facility’s safe patient handling and fall procedures, leading to a cited deficiency for failure to ensure adequate supervision and proper use of assistance devices to prevent accidents.
The facility failed to ensure residents were treated with dignity and respect when staff did not respond promptly or appropriately to call lights. Several residents with conditions such as dementia, stroke with paralysis, malnutrition, diabetes, muscle weakness, and end-stage renal disease reported or were associated with long waits for assistance, sometimes up to an hour or more. Resident council minutes documented repeated complaints that staff would enter rooms, turn off call lights, and leave without meeting residents’ needs, and grievance logs reflected ongoing concerns about delayed call light response across multiple months.
The facility failed to accurately document physician-ordered wound care for three residents with pressure injuries or at risk for pressure injuries. Each resident had multiple comorbidities, incontinence, and care plans specifying skin integrity goals and interventions such as repositioning, incontinence care, and adherence to pressure injury prevention/treatment protocols. Review of TARs for a given month showed multiple missed entries for scheduled wound care for each resident. In interviews, the ADON, DON, and Administrator confirmed that staff are expected to document wound care at least once per shift and that undocumented care is considered not done, despite acknowledging that staff may sometimes perform treatments without charting. Facility policy required the treatment nurse or designee to sign off on treatment sheets for any completed wound care, which was not consistently reflected in the records.
A resident with severe cognitive impairment, incontinence, and multiple pressure ulcers required total assistance with toileting and repositioning. During observed incontinence care, a CNA reused the same soiled wipe multiple times on the perineal area and used a soiled, gloved hand to adjust his clothing before continuing care without changing gloves or performing hand hygiene. The DON later confirmed that staff were expected to discard wipes after a single use and perform hand hygiene after touching their clothing, consistent with the facility’s infection control policy emphasizing hand hygiene as the primary means of preventing infection transmission.
After the departure of the Activity Director, two residents with significant medical needs did not receive scheduled or individualized activities as required by their care plans. Staff and family interviews confirmed that regular activities like bingo and birthday parties had not occurred for over a month, and residents were mostly observed watching TV. The facility did not maintain an updated activity calendar or provide documentation of recent activity programming.
Multiple residents with complex medical needs reported receiving cold and unappetizing meals that were frequently served late. Observations confirmed that food was delivered to some halls well after scheduled mealtimes, with only one staff member distributing trays per hall and non-insulated carts used for delivery. Staff interviews and grievance records indicated ongoing issues with meal quality and timeliness, and management was aware of the problems but had not implemented effective interventions.
A resident with intellectual disability and severe cognitive impairment did not receive required day habilitation services because the facility failed to submit the necessary application within the required timeframe. Staff interviews revealed confusion about responsibility for completing the paperwork and a lack of follow-up with the resident's family, resulting in the resident missing out on specialized services as outlined in their care plan.
The facility failed to develop effective discharge plans for five residents, focusing on their specific needs and goals. Record reviews showed that care plans lacked discharge interventions, potentially affecting safe and orderly discharges. Interviews with staff revealed inconsistent discharge planning practices, with the social worker not completing plans for long-term residents and the DON unaware of protocols. The facility's policy emphasized regular re-evaluations and interdisciplinary planning, which were not followed.
A resident with dementia and other health issues experienced a fall, resulting in a dislocated shoulder. The facility failed to promptly notify the physician of the x-ray results, which were available two days before the physician was informed. The resident continued to receive pain medication during this period. Interviews revealed a lack of clear procedures for checking and communicating diagnostic test results.
The facility failed to provide activities to meet the interests and support the well-being of residents due to the absence of an Activity Director. Four residents reported missing group activities, musical programs, and other events, leading to increased boredom and isolation.
The facility failed to follow enteral feeding protocols for two residents, including not checking for residual volume, not flushing the G-tube between and after medication administration, and not maintaining the head of the bed at 30 degrees elevation during medication administration. Medications were also not administered through the gravity method as required.
A resident with a history of cerebral infarction, multiple sclerosis, and muscle weakness was left unattended during breakfast, leading to a coffee spill. Despite requiring supervision for eating, the resident did not receive the necessary assistance, as indicated in his care plan. Interviews and observations confirmed the lack of staff presence and adherence to the care plan, resulting in the incident.
The facility had a medication error rate of 22% due to a nurse improperly administering medications via G-tube by combining them and not flushing with water between each medication, contrary to physician orders and facility policy. The resident involved had multiple diagnoses, including intracranial injury and GERD.
The facility failed to provide food that accommodated residents' preferences, leading to dissatisfaction with meals and potential weight loss. Two residents reported not being informed about alternate meal options and receiving meals they did not like. Staff interviews revealed inconsistencies in how meal preferences were communicated, and an anonymous group interview confirmed that residents were often not informed about alternate meals.
A facility failed to maintain an infection control program when a CNA did not perform proper hand hygiene during incontinence care for a resident. The CNA did not change gloves or wash hands after cleaning the resident, which was against the facility's infection control policy and training. The DON confirmed the expectations for hand hygiene and glove changes to prevent infection spread.
Failure to Provide Adequate Supervision and Safe Transport After Resident Slid From Wheelchair in Van
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper fall procedures for a resident during transportation in the facility van. The resident was an older female with multiple significant diagnoses, including a displaced supracondylar fracture of the left femur, sequelae of cerebral infarction, muscle weakness, lack of coordination, sickle cell anemia, age-related osteoporosis, and a cognitive communication deficit. Her admission MDS documented moderate cognitive impairment (BIMS 11), use of a wheelchair and a manual lift for transportation, need for assistance with self-care and mobility, and bilateral lower extremity impairment. Her care plan identified her as being at risk for falls due to decreased mobility and unstable balance, and noted a potential for uncontrolled pain related to sickle cell disease and a history of fracture. On the date of the incident, the resident was being transported back from a medical appointment by a CNA who was driving the facility van. According to the facility’s Provider Investigation Report and witness statements, the CNA loaded the resident into the van in her wheelchair using the lift. While the van was parked, the resident began to slide out of her wheelchair. The CNA reported that as the resident began to slide, she guided the resident to the floor of the van. The CNA’s witness statement indicated that after assisting the resident to the floor, she then transported the resident back to the facility with the resident remaining on the floor of the van. The administrator’s statement confirmed that the CNA acknowledged the resident was a two-person lift, that she knew she should have called for help, and that she nonetheless drove back to the facility with the resident on the floor. Nursing documentation and interviews further described the sequence of events once the van returned to the facility. A LVN stated that the van driver came into the building and said she needed help getting a resident up who had slid out of her chair and was on the floor of the van. The LVN assessed the resident, documented that the resident had slid out of the wheelchair and been assisted to the floor by staff, and that staff assisted her back into the wheelchair. The LVN’s progress note recorded that the resident appeared and/or stated she was in pain, describing it as dull pain in the left thigh, and that PRN pain medication was given. The resident later reported in interview that she started to slip while in the van, that the driver helped her to the floor, then left her on the floor and drove back to the facility, and that her leg hurt but had been broken before the incident. Subsequent documentation showed that x‑rays were obtained, a possible fracture was reported, and the resident was sent to the hospital, where no new fractures were found. The facility’s own policies on safe patient handling and fall risk required staff to report inability to safely complete lifting or transfers and to ensure immediate assessment after a fall, but the CNA did not contact a nurse for immediate assessment at the time of the incident and transported the resident unsecured on the van floor, leading to the cited deficiency for failure to provide adequate supervision and assistance devices to prevent accidents. Additional staff interviews highlighted the expectations for handling such situations. An RN stated that if a CNA found a resident on the floor, the CNA should get a nurse immediately so the nurse could assess whether the resident could be safely assisted up or if 911 should be called, and that the MD and family member would then be informed. Another CNA, who had received transportation training, described the proper loading procedure as pushing the resident up the ramp, latching the wheelchair, and applying a seat belt, and stated that if a resident began to slide, she would have gone back into the doctor’s office for help or called 911. These accounts contrasted with the actions taken by the CNA driver, who did not seek immediate assistance at the appointment site or call for emergency help, but instead drove back to the facility with the resident on the floor of the van. This sequence of actions and inactions formed the basis of the survey finding that the facility failed to ensure adequate supervision and proper use of assistance devices to prevent accidents for this resident. The facility’s incident log recorded the event as a fall incident, and progress notes and investigation documents consistently described the resident as having slid from her wheelchair and been assisted to the floor. The administrator’s differing descriptions in interviews—first stating that the CNA got a nurse to assess and get the resident back into the wheelchair, and later stating that the aide helped the resident back into the wheelchair while going up into the van—were inconsistent with the CNA’s written statement and the LVN’s account that the resident was on the floor of the van upon return to the facility. The documented facts in the PIR, witness statements, and nursing notes collectively demonstrate that the resident, who had known fall risk factors and significant musculoskeletal and neurological conditions, was not provided with adequate supervision and proper fall procedures during transport, resulting in her sliding from the wheelchair, being placed on the van floor, and being transported back to the facility unsecured, without immediate nursing assessment at the time of the incident.
Failure to Respond Promptly and Appropriately to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to dignity, respect, and timely response to call lights. Multiple residents with varying levels of cognitive and physical impairment reported or were associated with delayed call light responses. One resident, an elderly female with severe cognitive impairment, dementia, stroke with left-sided paralysis, and protein-calorie malnutrition, was dependent on staff for repositioning and had no skin conditions on admission; her family member reported that staff took 45 minutes to answer call lights and over two hours to attend to her during rounding. Another resident, an elderly female with intact cognition and diagnoses including malnutrition, difficulty walking, and lack of coordination, stated that it could take staff up to an hour to respond to her call bell, occurring on all shifts depending on which staff were working. Additional residents with intact or moderately impaired cognition and diagnoses such as type 2 diabetes, muscle wasting, lack of coordination, muscle weakness, cerebral infarction, vascular dementia, and end-stage renal disease were included in the review for resident rights. Resident council meeting minutes from two consecutive months documented complaints about call light response times, including reports that staff would enter rooms, turn off call lights, and leave without assisting with residents’ needs. The facility grievance logs for January and February recorded concerns related to call light response times. These interviews, resident council minutes, and grievance records collectively showed that residents’ call lights were not answered promptly and that staff sometimes silenced call lights without providing assistance, resulting in residents not being treated with respect and dignity as required.
Failure to Accurately Document Physician-Ordered Wound Care Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records and document wound care treatments as ordered for three residents with pressure injuries or risk for pressure injuries. For one resident, an elderly female with severe cognitive impairment, dementia, Alzheimer’s disease, stroke, and malnutrition, the MDS and care plan showed she was dependent on staff for repositioning and incontinent care, with identified risk for pressure ulcers. Her care plan interventions included heel offloading, turning and repositioning at least every two hours, and assistance with bed mobility, dressing, and toileting. However, review of her Treatment Administration Record (TAR) for a specified month showed multiple dates on which her scheduled wound care was not documented as given. A second resident, an elderly male with moderately impaired decision-making, heart failure, malnutrition, muscle weakness, difficulty walking, and end-stage renal disease, was also always incontinent and required maximal assistance with toileting hygiene. His care plan documented that he had a pressure ulcer or risk for pressure ulcer development, with goals for intact skin and interventions including administering medications as ordered, following facility skin breakdown protocols, providing incontinence care after each episode with moisture barrier, and notifying nursing of any new skin issues. His February TAR similarly showed numerous dates where his scheduled wound care was not documented as completed. A third resident, an elderly female with intact cognition and diagnoses including type 2 diabetes, difficulty walking, muscle weakness, heart failure, and protein-calorie malnutrition, was always incontinent and dependent on staff for toileting. Her care plan identified potential for pressure ulcer development and decreased mobility, with goals for intact skin and interventions including following facility skin breakdown prevention protocols and assisting with turning and repositioning at least every two hours. Her February TAR also showed several dates with no documentation of scheduled wound care. In interviews, the ADON, DON, and Administrator each stated that the expectation was that staff document completed wound care at least once per shift, and that if wound care was not documented in the electronic health record, it was considered not done, even though staff might have performed the care and forgotten to chart it. The facility’s pressure injury policy required the treatment nurse or designee to sign off on the treatment sheet for any treatment completed, which was not consistently reflected in the records reviewed.
Improper Hand Hygiene and Wipe Use During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during incontinence care for one resident. The resident was an elderly female with severe cognitive impairment due to dementia, Alzheimer’s disease, stroke, and malnutrition, who was always urinary and bowel incontinent and dependent on staff for toileting hygiene and repositioning. Her care plan identified existing or potential pressure ulcers with a goal that ulcers show signs of healing and remain free from infection, and interventions included following facility policies for prevention and treatment of skin breakdown. Skin assessments documented intact skin initially, followed by multiple new pressure ulcers on the feet, toes, heels, and sacral area over time, and the resident was assessed as having a moderate/high risk for skin breakdown due to incontinence of urine and stool. During an observation of incontinence care, a CNA washed his hands and donned gloves, then removed the resident’s brief and cleaned the perineal area. While doing so, he used the same soiled wipe multiple times on the perineal area instead of discarding it after a single use, and he used his soiled, gloved hand to pull up his own sleeve before continuing incontinence care without changing gloves or performing hand hygiene. In a subsequent interview, the CNA stated he was unaware he had reused the same wipe and had adjusted his sleeve with a soiled glove, and he acknowledged this was not the facility’s standard practice. The DON stated staff were supposed to use one wipe and discard it before obtaining a new one, and that staff should perform hand hygiene after touching any part of their clothing. The facility’s infection control policy identified hand hygiene as the primary means of preventing transmission of infection and required hand hygiene after handling soiled or used linens and dressings.
Failure to Provide Ongoing Resident Activity Program After Loss of Activity Director
Penalty
Summary
The facility failed to provide an ongoing program of activities based on comprehensive assessments, care plans, and resident preferences for at least two residents. After the Activity Director (AD) left the facility at the end of October, there was no replacement, and scheduled activities were not consistently provided. Multiple interviews with residents, family members, and staff confirmed that regular activities such as bingo, movie matinees, and birthday parties had not occurred for over a month. Residents were observed spending time watching TV in their rooms or in common areas, with limited engagement in group or individual activities. One resident with severe cognitive impairment and multiple medical conditions, including a history of stroke and dementia, was found lying in bed watching TV and had not participated in preferred activities like dominoes or bingo in recent weeks. Another resident, who was cognitively intact but medically complex, also reported not seeing any activities offered and spent most of her time watching TV. Family members and other residents corroborated the lack of activities, noting that previously scheduled events had not taken place and that the activity calendar was outdated. Staff interviews revealed that, in the absence of an AD, some group therapy sessions and occasional music or church services were provided, but these did not follow the established activity calendar or meet the individualized needs and interests of all residents. The facility's own policy required ongoing activity programming tailored to resident assessments and preferences, but this was not maintained. Documentation for recent months, such as resident council meeting minutes and updated activity calendars, was missing or unavailable, further indicating a lapse in the facility's activity program.
Failure to Provide Palatable, Timely, and Safe-Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported that their meals were consistently cold and served late, with some stating that they did not like the taste or quality of the food. Observations confirmed that meal trays were often delivered to certain halls significantly later than scheduled mealtimes, and that only one staff member was distributing trays per hall, resulting in further delays. The facility used non-insulated metal carts for meal delivery, which contributed to the food cooling before reaching residents, especially those served last. Several residents with complex medical histories, including malnutrition, diabetes, and cardiovascular conditions, were affected by these deficiencies. One resident with paraplegia and protein-calorie malnutrition reported always receiving cold food and not informing management, while another resident with severe cognitive impairment was noted by family to have ongoing complaints about late and cold meals. A third resident with multiple chronic illnesses stated that her food was usually cold and not to her liking, and that staff refused to reheat meals due to concerns about cross-contamination. Staff interviews corroborated these complaints, with dietary aides and CNAs acknowledging that meals were frequently late and cold, and that there was a shortage of dietary aides, particularly on certain shifts. Documentation review revealed a pattern of grievances related to cold and unappetizing food, with several residents reporting cold or burnt meals over multiple months. Resident council minutes also reflected ongoing concerns about meal timeliness, with no documented follow-up. Staff interviews indicated that management was aware of the issues, but there were no effective interventions in place to address delays in meal service or to ensure that food was served at appropriate temperatures. The facility's food temperature control policy required hot foods to be held at 140°F or above, but observations and interviews indicated that this standard was not consistently met due to operational and staffing challenges.
Failure to Provide Required Specialized Rehabilitative Services Due to Missed Application Deadline
Penalty
Summary
The facility failed to provide required specialized rehabilitative services, specifically day habilitation, for a resident with a PASRR positive status for mental illness and intellectual disability. The resident's care plan included a goal for specialized services as recommended by the local authority, and the resident had expressed interest in attending day habilitation. Documentation showed that the resident and their family had selected a day habilitation facility, and the need for these services was discussed in care plan and interdisciplinary team meetings. Despite these documented needs and expressed preferences, the facility did not submit the required day habilitation application within the 20-day timeframe. Interviews with staff revealed confusion regarding responsibility for completing and submitting the admission paperwork, with both the social worker and MDS nurse unsure of the process and timeline. The family was given the paperwork but did not return it, and there was no documented follow-up by facility staff to ensure the paperwork was completed and submitted on time. As a result, the resident was unable to access day habilitation services and would have to wait until the next quarterly meeting to reapply. The resident, who had severe cognitive impairment and was dependent on staff for most activities of daily living, confirmed interest in participating in day habilitation activities. Staff interviews acknowledged that the failure to secure these services was due to lack of clarity and follow-up regarding the application process. The administrator was unable to provide a PASRR policy when requested.
Failure in Discharge Planning for Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for five residents, focusing on their specific needs and goals. The deficiency was identified through interviews and record reviews, which revealed that the facility did not include discharge plans or interventions in the residents' care plans. This lack of planning could affect the residents' ability to discharge safely and orderly, ensuring all discharge needs were identified and addressed. Resident #1, a male with aphasia and chronic obstructive pulmonary disease, did not have a discharge plan or interventions in his care plan. Similarly, Resident #2, a female with dementia, malnutrition, and lack of coordination, also lacked a discharge plan. Resident #3, a female with no cognitive impairment, and Resident #4, a female with Alzheimer's Disease and hypertension, both had care plans without discharge plans or interventions. Resident #5, a male with a cerebrovascular accident and dementia, also did not have a discharge plan included in his care plan. Interviews with facility staff, including the social worker (SW), Director of Nursing (DON), and Administrator (ADM), revealed a lack of consistent discharge planning practices. The SW reported not completing discharge care plans for every admission, especially for long-term residents. The DON was unaware of the company's protocol for discharge planning, and the ADM stated that discharge planning should start upon a resident's arrival. The facility's policy on discharge planning emphasized regular re-evaluations and interdisciplinary team planning, which were not followed in these cases.
Delayed Notification of X-Ray Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of x-ray results for a resident, which revealed a left shoulder dislocation. The resident, an elderly female with dementia, malnutrition, and lack of coordination, was found on the floor in her bedroom and complained of pain on the left side of her body. Although pain medication was administered, the x-ray results indicating a dislocated shoulder were not communicated to the physician until two days later. The x-ray was ordered on the day of the fall, and the results were available in the computer system and faxed to the facility the same day. However, the results were not viewed by the facility until two days later, and the physician was not notified until the morning of the second day. During this time, the resident continued to receive pain medication as needed. Interviews with facility staff revealed a lack of clear procedures for checking and communicating diagnostic test results. The Licensed Vocational Nurse (LVN) responsible for the resident's care did not recall seeing the faxed results and only checked the computer system intermittently. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were not aware of specific requirements for checking results, and the Administrator (ADM) expected results to be checked every shift but was unsure of the facility's process.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents. This deficiency was observed in four residents who were not provided activities since the Activity Director's (AD) last day of employment. The facility did not have an AD on staff, which could result in a decline in social and mental well-being for all residents requiring activities. Resident #49, who was cognitively intact and enjoyed group activities and musical programs, reported missing birthday parties and other activities. The resident mentioned that the facility could not retain an AD due to budget constraints. Similarly, Resident #26, who also enjoyed group activities and church services, stated that she stayed in her room most of the time due to the lack of activities. She used her iPad to pass the time. Resident #20, who had a history of participating in bingo and church programs, revealed that the facility had several ADs in the past two years, but the last AD left in March and did not return. The resident mentioned that the bingo store for prizes was taken away. Resident #45, who had severe vision impairment and required substantial assistance with daily activities, reported that she used to be taken to various activities but had not been asked to participate in any activities recently. The facility did not have an activity policy and followed CMS guidelines for the activity program.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that residents who were fed by enteral means received appropriate treatment and services to prevent complications. Specifically, the facility did not check for residual volume prior to medication administration for two residents. Additionally, the facility did not flush the G-tube between and after medication administration for one resident, and did not maintain the head of the bed at 30 degrees elevated during medication administration for the same resident. Medications were also not administered through the gravity method for both residents, contrary to the facility's policy and physician orders. For Resident #6, the Licensed Vocational Nurse (LVN) administered medications via the feeding tube without checking for residual volume, despite the physician's order to do so. The LVN also pushed fluids with a syringe instead of using the gravity method. The LVN admitted to not being aware of the facility's policy regarding pushing medication and water flushes via a feeding tube. This resident had severe cognitive impairment and required extensive assistance with activities of daily living. For Resident #36, the Registered Nurse (RN) also failed to check for residual volume before administering medications via the G-tube. The RN did not flush the G-tube after medication administration and did not maintain the head of the bed at the required 30 degrees elevation. The Director of Nursing (DON) confirmed that medications should not be mixed and should be administered one at a time with appropriate flushing in between. The DON also stated that medications should be given through gravity to avoid complications such as increased peristalsis and diarrhea. This resident had multiple diagnoses, including brain injury and dysphagia, and required enteral feeding and medication administration through a G-tube.
Failure to Provide Adequate Assistance During Meal Consumption
Penalty
Summary
The facility failed to ensure the safety of a resident by not providing adequate assistance during meal consumption, leading to the resident spilling coffee on himself. The resident, who had a history of cerebral infarction, multiple sclerosis, tremors, and muscle weakness, required supervision or touching assistance for eating, as indicated in his care plan. Despite these needs, the resident was left unattended during breakfast, resulting in the coffee spill incident. The coffee was observed to be warm, not hot, and the resident did not sustain burns or indicate pain from the spill. Interviews with the Director of Nursing (DON) and the resident's family revealed that the resident frequently experienced similar issues due to a lack of assistance, which the family attributed to staffing problems. The resident's family had repeatedly requested assistance for him, especially since he struggled with using his right hand after a stroke. The resident's care plan and assessments indicated that he could not consume hot liquids without special interventions, such as lids on cups and staff assistance, which were not provided during the incident. Further observations and interviews with staff confirmed that the resident needed assistance with meals and that the coffee served was at a safe temperature. However, the lack of staff presence and failure to follow the care plan's interventions led to the incident. The facility's policy on food temperature control and hot liquid/food spills was reviewed, highlighting the need for proper supervision and assistance to prevent such accidents.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that it was free of a medication error rate of 5 percent or greater, resulting in a medication error rate of 22%. This was based on 6 out of 27 opportunities involving one resident observed for medication administration. Specifically, the facility failed to ensure that RN D administered medications to a resident via G-tube according to the physician's orders and standard practice. RN D crushed six different medications, combined them into one mixture, and pushed them through the G-tube instead of administering them by gravity and flushing with water between each medication as required by the physician's orders and facility policy. The resident involved was a male with multiple diagnoses, including unspecified intracranial injury, protein-calorie malnutrition, aphasia, and GERD. The resident's care plan included specific interventions to administer medications as ordered, which were not followed. During the medication pass, RN D prepared and administered the medications incorrectly by combining them and not flushing the G-tube with water between each medication. This was contrary to the physician's orders and the facility's policy on enteral medication administration. Interviews with RN D and the DON revealed a lack of adherence to proper medication administration protocols. RN D acknowledged that medications should be crushed separately but believed it was acceptable to combine them for administration. The DON confirmed that medications should not be mixed and should be administered through gravity, with appropriate flushing before, between, and after each medication. The facility's policy also specified these procedures, which were not followed during the observed medication pass.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodated residents' preferences for two residents, leading to dissatisfaction with meals and potential weight loss. Resident #45, a [AGE] year-old female with multiple diagnoses including stroke, diabetes, and heart failure, reported that she was not informed about alternate meal options and was only offered a grilled cheese sandwich as an alternative. Her family member corroborated this, stating that staff used to ask about meal preferences but had stopped doing so. Resident #45 expressed a preference for fish, which she was unaware was available as an alternate meal option. Resident #53, a [AGE] year-old female with severe cognitive impairment and a history of significant weight loss, also reported dissatisfaction with the facility's food. She mentioned that the food was often too salty or spicy and that she was not informed about alternate meal options. Despite discussing her food preferences with the dietician, she continued to receive meals she did not like. She expressed a preference for fish and tuna salad but was not aware that fish was available as an alternate meal option. Interviews with staff revealed inconsistencies in how meal preferences were communicated to residents. Some staff members stated that they no longer asked residents about their meal preferences before serving meals, while others mentioned that residents could request alternates if they did not like the meal provided. The facility's dietary manager and dietician were not fully aware of the residents' preferences, leading to a lack of appropriate meal options being offered. An anonymous group interview with residents confirmed that they were often not informed about alternate meals or that the facility ran out of alternate food options.
Failure to Maintain Proper Infection Control During Incontinence Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for a resident observed for infection control. During an observation, CNA A was seen providing incontinence care to a resident without performing proper hand hygiene. Although CNA A completed hand hygiene and gloved before starting the care, she did not change gloves or perform hand hygiene after cleaning the resident's soiled areas. Instead, she continued to apply a clean brief and barrier cream, and touched the resident's clean linen and bedside table with the same gloves. This action was contrary to the facility's infection control policy and the training CNA A had received the previous day. CNA A admitted in an interview that she forgot to change gloves during care and was aware of the requirement to perform hand hygiene and change gloves to prevent cross-contamination. The Director of Nursing (DON) confirmed that staff are expected to complete hand hygiene before and after care, and to change gloves during incontinence care to prevent the spread of infection. The facility's policy on infection control emphasizes the importance of hand hygiene, stating that it is the primary means of preventing infection transmission. The policy also notes that wearing gloves does not replace the need for hand washing, as gloves can have defects or become contaminated during use. Despite being in-serviced on infection control, CNA A failed to adhere to these guidelines, leading to a potential risk of infection for the resident.
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.
