Five Points Nursing & Rehabilitation Of College St
Inspection history, citations, penalties and survey trends for this long-term care facility in College Station, Texas.
- Location
- 3105 Corsair Drive, College Station, Texas 77845
- CMS Provider Number
- 745051
- Inspections on file
- 13
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 8 (3 serious)
Citation history
Health deficiencies cited at Five Points Nursing & Rehabilitation Of College St during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, reduced mobility, repeated falls, and dependence for ADLs was care planned to have a fall mat beside the bed and the bed kept in a low position when in bed. On a morning shift, staff found the resident on the floor next to the bed with bleeding from the head and mouth; documentation and hospital records confirmed scalp and lip lacerations. Multiple staff reported that at the time of the fall the bed was not in the lowest position, the resident was not on a fall mat, and the mats were rolled up against the wall, despite prior knowledge that the resident was a fall risk who required these interventions, and the night-shift CNA stated she was unaware he needed fall mats even though the Kardex contained this information.
A resident with significant mobility and medical needs was transferred from the toilet to a wheelchair by only one CNA, despite care plan and policy requiring a two-person assist and use of a mechanical lift. The resident fell and sustained a femur fracture, with interviews and records confirming that staffing shortages and lack of adherence to transfer protocols led to repeated one-person transfers for residents needing two-person assistance.
A resident with heart failure and other chronic conditions was given nearly double the prescribed amount of IV Sodium Chloride due to a breakdown in communication and handoff procedures among nursing staff. The error occurred when a 1000 ml IV bag was used instead of a 500 ml bag, and the infusion was not stopped at the correct volume, resulting in a medication error and subsequent hospital transfer for shortness of breath.
A resident with diabetes and a history of skin ulcers did not receive prescribed wound care for a skin tear on the lower leg due to incorrect order entry and documentation errors by nursing staff. The wound care treatments were missed over several days, and the issue was discovered after the resident's family raised concerns about an outdated bandage. Nursing staff and leadership confirmed the lapse in care, which was attributed to mistakes in the electronic medical record and failure to follow facility policy.
Medication Cart #1 was found unlocked on two separate occasions, once with an RN present who was unaware the cart was unsecured, and once with no nurse present for approximately ten minutes. The RN admitted to forgetting to lock the cart both times and could not recall the date of her in-service training on medication security. The ADON confirmed that staff had been in-serviced on this policy but did not remember when the last training occurred. Facility policy requires medications to be stored securely and accessible only to authorized personnel.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility did not post daily nurse staffing information in a prominent and accessible location for several consecutive days. The DON, who was responsible for this task, acknowledged the lapse and stated that the information had not been updated. The ADM confirmed the expectation for daily posting and noted the absence of a facility policy on this requirement.
A resident with severe cognitive impairment and high dependence on staff was observed twice with his call light out of reach while seated in a recliner. Staff interviews confirmed that ensuring call lights are within reach is a shared responsibility, but the assigned CNA was not present and the replacement was unaware of the issue. The facility lacked a policy on call lights, resulting in the resident being unable to request assistance as required by his care plan.
Two residents who required staff assistance for bathing did not consistently receive showers or baths according to their scheduled care plans, as documented in the EMR and confirmed by resident interviews. Staff and leadership acknowledged responsibility for providing these services, and the facility's policy outlined the importance of regular bathing, but scheduled baths and showers were missed on multiple occasions.
A resident with a stage 4 pressure ulcer did not receive prescribed wound care treatments on three scheduled days, despite clear physician orders and care plan interventions. Documentation showed the treatments were missed, and staff interviews confirmed that wound care orders were expected to be followed and tracked in the electronic medical record. The wound physician noted no decline or infection in the ulcer following the missed treatments.
The facility did not submit required Payroll Based Journal (PBJ) staffing data to CMS for a full quarter, as confirmed by record review and staff interviews. The Administrator and Regional Clinical Nurse were aware of the missing submission but were unclear on the cause, citing recent receipt of a federal number and pending clarification from corporate staff. No policy on PBJ reporting was provided.
Several residents with significant medical needs did not receive scheduled showers or adequate assistance with activities of daily living, including bathing and hygiene. Residents and their representatives reported missed showers, long wait times for care, and inconsistent staff response. Observations confirmed that some residents remained unwashed and in the same clothes for days. Staff interviews revealed confusion about assignments, documentation, and equipment responsibilities, with chronic understaffing cited as a major barrier. Documentation of ADL care was inconsistent or missing, and supervisory staff were unaware of the extent of the deficiencies.
Multiple residents with complex medical needs did not receive timely assistance with ADLs such as bathing, toileting, transfers, and medication administration due to insufficient nursing staff. Residents and their families reported long waits for care, missed showers, and delayed medications, while staff confirmed frequent short staffing, especially on weekends, and difficulties providing two-person assistance. Documentation showed gaps in required care, and staff indicated that administration was aware of the ongoing staffing issues but had not resolved them.
Surveyors found that kitchen staff failed to discard an expired ham and did not properly seal, label, or date an opened bag of rolls in the freezer. Staff interviews confirmed a lack of awareness about these items, despite facility policy requiring regular checks and proper labeling of food to prevent spoilage and contamination.
A resident with significant physical and cognitive impairments was not provided the necessary assistance to get out of bed daily, despite repeated requests and a care plan requiring a mechanical lift with two staff. Observations and interviews confirmed the resident remained in bed for seven days, with staff citing shortages and equipment limitations as barriers to honoring the resident's choices, resulting in unmet needs for mobility and self-determination.
A deficiency was identified when an ADON left a computer screen displaying a resident's confidential medical information, including name and insulin order, open and visible in a hallway. The resident had severe cognitive impairment and Type 2 Diabetes. The ADON was aware of the expectation to close screens but could not recall receiving formal or HIPAA training. Facility leadership confirmed that this action violated confidentiality policies.
Two residents had care plans that incorrectly included anticoagulant therapy, despite only being prescribed antiplatelet medication. The care plans failed to reflect the actual physician orders and included interventions for anticoagulant complications, which were not relevant. Staff interviews confirmed that care plans are the basis for resident care and that such inaccuracies could lead to improper care.
A bottle of expired Glucosamine and Chondroitin was found in the medication storage room, and staff interviews revealed that monthly audits sometimes failed to catch expired medications. The staff responsible for audits, as well as the ADM and DON, confirmed that expired medications should be removed, but there was no specific policy in place for handling expired drugs.
A resident with multiple complex medical conditions was prescribed Quetiapine, and the pharmacy consultant recommended a gradual dose reduction. The facility did not document that this recommendation was communicated to the physician or acted upon, due to process discrepancies and staff turnover. Staff interviews confirmed the breakdown in communication and the responsibility of the DON to ensure pharmacy recommendations reach the physician.
A medication cart was left unlocked and unattended by a CMA during medication administration, contrary to facility policy and training. Facility leadership confirmed that medication carts must be locked when not attended, and the facility's pharmacy manual requires carts to be secured after use.
Staff failed to follow Enhanced Barrier Precautions during wound care for a resident with stage 4 pressure ulcers and an indwelling catheter. Despite facility policy and posted instructions requiring gowns and gloves for high-contact care, the wound care nurse, MDSC, and DON performed wound care without gowns, allowing their uniforms to come into contact with the resident and bedding, and acknowledged in interviews that this was not in compliance with infection control protocols.
The facility did not post daily nurse staffing information in a prominent location as required, with the designated notice holder found empty and staff confirming the omission. The ADON reported forgetting to post the information due to other duties, and the facility lacked a policy on staffing postings.
A long-term care facility failed to provide sufficient nursing staff, resulting in delayed care and unmet hygiene needs for several residents. One resident experienced prolonged exposure to diarrhea without assistance, while another was unable to receive timely help to the bathroom. The facility's outdated staffing assessment and poor scheduling practices contributed to these deficiencies, impacting the quality of care for 76 residents.
The facility failed to provide adequate staffing, resulting in residents experiencing prolonged exposure to incontinence and missed showers. One resident waited three hours for assistance after a diarrhea episode, while another was unable to use the bathroom due to a lack of CNAs. Multiple residents did not receive their scheduled showers, highlighting significant staffing shortages.
The facility failed to provide scheduled showers to residents, impacting their hygiene and well-being. Several residents, including those with cognitive impairments and physical disabilities, did not receive showers as per their care plans. Staffing shortages were cited as a reason for this deficiency, with staff acknowledging the inability to meet residents' needs. The facility's administration recognized the issue but had not fully addressed it.
Failure to Maintain Fall Prevention Interventions Resulting in Resident Fall and Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents. A male resident with severe cognitive impairment (BIMS score of 3), dementia, reduced mobility, repeated falls, gait and mobility abnormalities, history of TIA and cerebral infarction, and lack of coordination was care planned as being at risk for injury from falls. His comprehensive care plan, revised in January 2026, specified that he required a fall mat beside the bed whenever he was lying in bed and that his bed should be kept in the low position at night. The care plan also documented that he was dependent or required significant assistance for ADLs and transfers, used a wheelchair, and was totally dependent on staff for locomotion. On the morning of 02/12/2026, the resident was found on the floor beside his bed with bleeding from his head and mouth. An activity note documented that staff were called to the room, found that he had fallen from bed onto the floor, and that he stated he had been trying to get up. Nursing documentation and hospital records showed that he sustained a laceration to the scalp requiring three staples and a laceration to the lower lip closed with skin glue. A weekly skin assessment recorded abrasions to the right side of the lip and inside the mouth, and a laceration on the top right side of the head with three staples, though no measurements were documented. A neuro assessment later that day showed vital signs within normal limits, confused but coherent verbal responses at his baseline, and no new neurological changes requiring physician notification. Multiple staff interviews and observations established that the resident’s fall prevention interventions were not in place at the time of the fall. A CNA who discovered the resident on the floor around the beginning of the day shift reported that his bed was in a high position, he was not on a fall mat, and the fall mats were rolled up and leaning against the wall near the window, despite her understanding that he was a fall risk who was required to have his bed in low position with fall mats beside the bed whenever he was in bed. Another CNA who responded to the incident also stated that there were no floor mats beside the bed, that the mats were rolled up against the wall, and that the bed was in a high position. The LVN who assessed the resident after the fall confirmed that he was lying on the floor without fall mats beside the bed and that the bed was not in the lowest position, estimating it to be mid-position. The night-shift CNA who had put the resident to bed the evening before stated she did not see any fall mats in the room and was not aware he required them, although she acknowledged that the Kardex was available for CNAs to review resident care needs. Other CNAs interviewed stated that, prior to this incident, the resident was known as a fall risk who required fall mats and a low bed per the Kardex. The administrator stated that all staff were expected to follow care plan interventions and that nurses were responsible for ensuring CNAs followed residents’ care plans.
Failure to Provide Required Two-Person Assistance During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, a 93-year-old woman with a history of left femur fracture, peripheral vascular disease, and congestive heart failure, was not provided with the required level of assistance during a transfer from the toilet to her wheelchair. The resident's care plan and clinical assessments specified that she required a two-person assist and the use of a mechanical lift for transfers. On the date of the incident, only one CNA assisted the resident off the toilet, despite the care plan requirements. The resident's knee gave out during the transfer, causing her to fall and hit her knee on the toilet paper dispenser. She complained of pain, and subsequent x-rays revealed a broken femur, necessitating hospitalization and surgery. Interviews and record reviews revealed that the facility had ongoing staffing shortages, which led to frequent instances where only one staff member performed transfers that required two people. Multiple staff members, including CNAs and the ADON, acknowledged that one-person transfers for residents requiring two-person assistance were common due to inadequate staffing. Video evidence provided by the resident's representative also showed several instances where the resident was transferred by one staff member, both with and without a mechanical lift, in violation of facility policy and the resident's care plan. Further investigation indicated that some staff were unaware of how to access the resident's transfer requirements in the electronic Kardex, and communication lapses contributed to the failure to provide adequate assistance. The facility's own policies required two staff members for mechanical lift transfers and for residents assessed as needing two-person assistance. Despite these requirements, staff routinely performed one-person transfers, and the incident in question was directly linked to these practices. The deficiency was identified as Immediate Jeopardy due to the risk and actual harm caused to the resident.
Removal Plan
- Assess all residents requiring 2 person assist during transfer for any injuries.
- Provide 1:1 in-service to the CNA involved on Abuse and Neglect Policy, Mechanical Lifts Transfer, and use of the Electronic Medical Record for ADL Care Plan.
- Provide CNA retention checks, including written in-service cheat sheets for quick reference, obtain signature and verbal acknowledgements, and require return demonstration from CNA with all transfers with rehab director.
- Provide 1:1 in-service to the administrator, DON, and ADONs by the Regional Compliance Nurse and ADO on Abuse and Neglect Policy, Mechanical Lift Transfers, and use of the Electronic Medical Record for ADL Care Plan, and determine competency by post test.
- Assess and determine staffing levels daily in accordance with the census and facility assessment, offer extra shift bonuses to staff as needed, provide sign on bonuses to attract new employees, contact company sister facilities for staffing assistance as needed, and build out the schedule at least 1 week in advance.
- Provide employee retention checks to Administrator and DON, including written in-service cheat sheets for quick reference, obtain signature and verbal acknowledgements.
- In-service all certified and licensed staff on Abuse and Neglect Policy, Mechanical Lift Transfers, and use of the Electronic Medical Record for ADL Care Plan, require all staff not present for the in-services to complete them before working, in-service all new hires during orientation, require staff to sign the in-service sheet, in-service all agency staff before scheduled shift, provide a posttest to confirm understanding, and require return demonstration for mechanical transfer check-off.
- Notify the Medical Director of the immediate jeopardy citation.
- Conduct ADHOC QAPI meeting with the IDT Team and the Medical Director to review the immediate jeopardy citation and plan of removal.
Medication Error: Excess IV Fluid Administration Due to Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, chronic obstructive pulmonary disease, and morbid obesity was administered approximately 900 ml of Sodium Chloride 0.9% intravenously, instead of the prescribed one-time dose of 500 ml. The order specified that the infusion should be run at 75 ml/hour and reassessed at both 250 ml and 500 ml. The facility did not have a 500 ml IV bag available and used a 1000 ml bag, with a mark made at the 500 ml level to indicate where to stop the infusion. However, the infusion was not stopped at the correct volume, resulting in the resident receiving nearly double the ordered amount. The error was precipitated by a breakdown in communication and handoff procedures between nursing staff. The nurse who hung the IV bag reported the order and treatment plan to another nurse, who was assigned to a different hall and did not directly communicate with the nurse responsible for the resident. The oncoming nurse did not receive a verbal or written report about the IV order and did not check the resident's IV during her shift. Multiple staff interviews confirmed that the order was not properly communicated, and the nurse responsible for the resident did not review new orders or verify the IV status. As a result, the infusion continued beyond the prescribed amount. The resident subsequently developed shortness of breath and was transferred to the hospital, where she was diagnosed with pneumonia. The facility's documentation and staff interviews acknowledged that the administration of excess IV fluids constituted a medication error. The facility's policy required medications to be administered in accordance with written physician orders, which was not followed in this instance.
Missed Wound Care Treatments Due to Documentation and Order Entry Errors
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including diabetes, dementia, heart failure, and a history of skin ulcers, did not receive prescribed wound care for a skin tear on the right shin over a period of several days. The resident was dependent on staff for several activities of daily living and was identified as being at risk for pressure ulcers and skin injuries. Physician orders specified that the skin tear should be cleansed and dressed on a set schedule, but these treatments were not administered as ordered between 10/03/2025 and 10/09/2025. The failure to provide wound care was due to a combination of documentation errors and incorrect order entry in the electronic medical record. The treatment nurse entered the order with the wrong timing, specifying treatments at night rather than once daily, which led to missed treatments. Additionally, another nurse mistakenly documented that treatments had been completed on certain dates when they had not been performed. These errors were discovered after the resident's family noticed an outdated bandage and contacted the facility, prompting a review of the medical record and identification of the missed treatments. Interviews with nursing staff and facility leadership confirmed that the resident did not receive the required wound care during the specified period. The treatment nurse acknowledged responsibility for entering the incorrect order and failing to ensure treatments were completed, while the ADON and DON were identified as responsible for monitoring treatments. The facility's policy required prompt treatment of skin concerns, but this was not followed in this instance, resulting in a lapse in care for the resident.
Failure to Secure Medication Cart and Restrict Access to Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys for medication storage. Specifically, Medication Cart #1 was observed unlocked on two separate occasions in front of the nurses' station. During the first observation, a registered nurse (RN) was present behind the nurses' station but did not realize the cart was unlocked. The RN acknowledged that all medication carts were supposed to be locked except when a nurse was obtaining medications and confirmed she had received in-service training on this requirement, though she could not recall when. On the second occasion, the same medication cart was found unlocked with no nurse present in the area. The RN returned approximately ten minutes later and admitted she had walked away to assist a resident, mistakenly believing she had locked the cart. She acknowledged this was the second time that day she had forgotten to lock the cart and could not provide an explanation for her oversight. The Assistant Director of Nursing (ADON) confirmed that staff had been in-serviced on securing medication carts but could not recall the last in-service date. Facility policy requires that medications and biologicals be stored safely and securely, accessible only to licensed nursing personnel or staff authorized to administer medications.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily and readily accessible to residents and visitors, as required. Observations revealed that the posted nursing staffing information outside the DON's office was outdated, displaying information from 08/25/2025, and was not updated for the following three days reviewed. During interviews, the DON acknowledged responsibility for posting the staffing information and admitted it had not been updated since 08/25/2025. The DON also stated that the purpose of posting was to show transparency regarding staff presence for each shift. The ADM confirmed that posting the staffing information daily was the responsibility of the DON or ADON and that the facility did not have a policy regarding this requirement.
Failure to Ensure Call Light Accessibility for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility expectations. On two separate observations during the same day, the resident was seen sitting in a recliner with the call light on the ground approximately two feet away, making it inaccessible. The resident, who had severe cognitive impairment and was dependent on staff for several activities of daily living, was unable to be interviewed due to his condition. The care plan specifically included an intervention to keep the call light within reach and encourage its use for assistance. Interviews with staff, including a CNA, the DON, and the ADM, confirmed that it was the responsibility of all staff to ensure call lights were within reach at all times. The CNA assigned to the resident during the observed times was not present, and the replacement CNA was unaware of the call light's position. The facility did not have a policy regarding call lights. This inaction resulted in the resident not having reasonable accommodation for his needs and preferences, as he was unable to call for assistance when needed.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, for two residents who were unable to perform these tasks independently. Both residents were care planned to receive staff assistance with bathing according to individualized schedules documented in their electronic medical records (EMR). However, record reviews revealed that scheduled baths and showers were missed on multiple occasions for both residents, with no documentation to explain the omissions. Resident #1, an elderly female with multiple chronic conditions including COPD, heart failure, and osteoarthritis, was scheduled to receive baths on Monday, Wednesday, and Friday evenings. The EMR showed missed baths on several scheduled days, and the resident confirmed during interview that she did not receive a bath the previous week except when provided by her hospice provider. Resident #2, an elderly male with diabetes, muscle weakness, and mobility issues, was scheduled for showers on Tuesday, Thursday, and Saturday day shifts. His EMR also reflected missed showers on several scheduled days, and he reported dissatisfaction with the facility's adherence to his shower schedule. Interviews with CNAs and facility leadership confirmed that staff were responsible for providing scheduled baths and showers, and that failure to do so could result in residents developing odor or skin issues. Both the Director of Nursing and the Administrator stated their expectation that residents receive bathing as scheduled. The facility's own policy emphasized the importance of regular bathing for comfort, cleanliness, and skin integrity, but the documented care and staff interviews demonstrated that this standard was not consistently met for the two residents reviewed.
Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
A deficiency occurred when the facility failed to provide pressure ulcer treatments as ordered for a resident with a stage 4 pressure ulcer on the left heel. The resident, who had multiple diagnoses including cellulitis, diabetes with neuropathy, and sepsis, was dependent on staff for most activities of daily living. The care plan and physician orders required wound care treatments three times per week, including cleansing, application of methylene blue, and appropriate dressings, as well as the use of pressure-reducing devices such as an air mattress, pillows to float heels, and a podus boot. Despite these orders, documentation revealed that the resident did not receive the prescribed wound care treatments on three specific dates. The Treatment Administration Record (TAR) for April and May showed missed treatments on two consecutive scheduled days and one additional day. Weekly wound assessments indicated the presence of a stage 4 ulcer with slough, granulation tissue, and moderate exudate, but no signs of infection or pain were noted. The wound physician confirmed that the wound had not declined after the missed treatments and that there was no infection present. Interviews with facility staff, including the Administrator and Director of Operations, confirmed that the expectation was for nurses to follow physician orders and that wound treatments due each day were visible in the electronic medical record system. The treatment nurse was responsible for executing orders, and oversight was provided by the DON and other managers. The facility had regular meetings to discuss wound care, but the missed treatments were not addressed prior to the survey. The facility's checklist for treatment dressing changes referenced verifying orders from the TAR and chart.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the first quarter of fiscal year 2025, specifically for the period from October 1, 2024, to December 31, 2024. This included a failure to report Payroll Based Journal (PBJ) data, which encompasses information for agency and contract staff, as required by CMS specifications. Record review confirmed that no PBJ data was submitted for the specified quarter. During interviews, the Administrator (ADM) and Regional Clinical Nurse (RCN) acknowledged awareness of the missing PBJ submission but were initially unsure of the reason for the failure. The ADM indicated that responsibility for submission lay with the corporate office and was awaiting further clarification from corporate staff. The ADM later reported that the facility had only recently received its federal number from CMS in mid-October, and the next scheduled reporting date had not yet occurred since receiving the number. No policy regarding PBJ data reporting was provided by the facility prior to the survey exit.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary services to maintain grooming, personal, and oral hygiene. Specifically, nine residents reviewed for ADL care did not receive scheduled showers or adequate assistance with hygiene. Documentation and interviews revealed that showers were missed or not provided as scheduled, and in several cases, residents went a week or more without a bath. Residents and their representatives reported long wait times for assistance, lack of staff availability, and instances where staff did not return to provide care after initially responding to call lights. Multiple residents with significant medical conditions, such as acute respiratory failure, diabetes, cognitive deficits, paralysis, and pressure ulcers, were affected by these lapses. For example, one resident with total dependence for toileting and bathing reported only receiving one shower per week instead of the scheduled three, and another resident with quadriplegia and a stage 4 pressure ulcer stated that he had not received a bath in a week. Observations confirmed that some residents remained in the same clothes for several days, had unkempt hair, and appeared unwashed. Staff interviews indicated confusion about shower assignments, documentation procedures, and responsibility for equipment maintenance, such as charging mechanical lifts. Record reviews showed inconsistent or missing documentation of ADL care, including bathing, toileting, and repositioning. Staff interviews further revealed that CNAs were often unsure of their duties, lacked supervision, and cited chronic understaffing as a barrier to providing scheduled care. The Director of Nursing and other supervisory staff acknowledged that showers and baths were to be documented and monitored but were unaware of the extent of missed care and documentation lapses. No ADL policy was provided upon request during the survey.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of multiple residents, as evidenced by observations, interviews, and record reviews. Several residents with significant medical conditions, such as acute respiratory failure, dementia, chronic kidney disease, quadriplegia, and severe mobility impairments, did not receive timely assistance with activities of daily living (ADLs) including bathing, toileting, transfers, and medication administration. Documentation showed missed or delayed showers and bed baths, with some residents receiving only one bath per week despite being scheduled for more frequent care. There were also instances where residents waited extended periods for assistance with toileting and transfers, and medication administration was delayed until late in the day or night. Residents and their representatives reported concerns about inadequate staffing, particularly on weekends and holidays, leading to delays in care and unmet needs. Some residents described waiting several hours for call lights to be answered, not being assisted out of bed as requested, and not receiving scheduled showers or baths. Family members corroborated these concerns, noting that they or other families stayed late to ensure care was provided, and that medication administration was sometimes delayed until a DON intervened. Staff interviews confirmed frequent short staffing, with only one CNA per hall instead of the scheduled two, and difficulties in providing two-person assist for residents requiring mechanical lifts. Staff also reported confusion about shower assignments, lack of training, and unclear supervisory structures. Documentation in the facility's electronic record system often lacked entries for required ADL care on multiple days, and there were no documented refusals from residents to explain these omissions. Staff consistently reported that administration was aware of the staffing shortages but only responded that they were working on the issue, with no resolution provided. The lack of sufficient staff directly resulted in delayed or missed care for residents, as confirmed by both staff and resident interviews, as well as gaps in care documentation.
Failure to Properly Store, Label, and Discard Expired Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly store, label, and discard food items in accordance with professional standards for food service safety. Specifically, a ham that had expired and was stored in a freezer bag with ice particles was not discarded, and an opened bag of rolls in the freezer was found unsealed and without a label. These issues were identified during a kitchen inspection, where it was noted that the ham was not in its original packaging and the rolls were not properly sealed or dated. Interviews with dietary staff and the dietary manager revealed a lack of awareness regarding the expired ham and improperly stored rolls. Staff stated that it was their responsibility to check for and discard expired or unlabeled food items, and that food should be labeled and dated when received. The facility's policy and FDA guidelines require proper labeling and storage of food to prevent spoilage and contamination, but these procedures were not followed in this instance.
Failure to Support Resident Self-Determination in Daily Mobility
Penalty
Summary
The facility failed to promote and facilitate a resident's right to self-determination by not providing the necessary support for the resident to get out of bed daily. The resident, an elderly female with a history of cerebral infarction, muscle weakness, abnormal posture, anemia, muscle wasting, hyperlipidemia, depression, anxiety, and hemiparesis, was assessed as having moderately impaired cognition and required substantial to maximal assistance for self-care, including the use of a mechanical lift with two staff for all transfers. Despite her care plan indicating these needs, the resident reported not being assisted out of bed for seven consecutive days, despite making daily requests to staff. Observations over two days confirmed the resident remained in bed, wearing the same pajamas and in the same position, and staff interviews corroborated that staffing shortages and equipment limitations contributed to delays or failures in meeting resident requests for assistance with mobility. The resident expressed dissatisfaction with the care received, specifically noting that her requests to get out of bed were acknowledged but not acted upon in a timely manner, often only being addressed late in the day when it was nearly time to return to bed for dinner and nightly care. Staff interviews further revealed an awareness of resident rights and the importance of self-determination, but also acknowledged that staffing and equipment constraints impeded their ability to honor resident choices consistently. The facility's policy on resident rights emphasized the importance of dignity, respect, and participation in care, including the right to receive necessary care to achieve the highest possible level of health. However, the failure to provide timely assistance for the resident to get out of bed as requested demonstrated a lack of support for resident choice and self-determination, as required by both facility policy and regulatory standards.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A deficiency occurred when the Assistant Director of Nursing (ADON) left a computer screen displaying a resident's confidential medical information open and facing the hallway while she entered the resident's room. The exposed information included the resident's name and insulin order, and the ADON could not recall if the diagnosis was also visible. The resident involved was a male with Type 2 Diabetes and severe cognitive impairment, as indicated by a BIMS score of 5. The ADON acknowledged that she had received on-the-floor training regarding medication pass and was aware that computer screens should be closed when unattended, but she could not remember receiving formal or HIPAA-specific training since starting at the facility two months prior. Interviews with facility leadership, including the Administrator (ADM) and Director of Nursing (DON), confirmed that the expectation was for resident information to be kept confidential and that leaving such information exposed could constitute a HIPAA violation. Review of facility policy also reflected the requirement for privacy and confidentiality of residents' personal and medical records. The incident was identified through observation, interview, and record review, and it was determined that the facility failed to ensure the confidentiality of the resident's medical information.
Inaccurate Care Plans for Anticoagulant and Antiplatelet Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents reviewed. Specifically, the care plans for both residents inaccurately included anticoagulant therapy, despite there being no physician order or recommendation for such therapy. Instead, both residents were prescribed and receiving antiplatelet therapy (Aspirin), which was not reflected in their care plans. The care plans also included interventions related to monitoring for anticoagulant complications, which were not relevant to the residents' actual medication regimens. For one resident, a female with multiple complex diagnoses including senile degeneration of the brain, atrial fibrillation, and polycythemia vera, the care plan was initiated and revised to state she was on anticoagulant therapy, with goals and interventions related to anticoagulant use. However, review of her medical orders and assessments confirmed she was only receiving antiplatelet therapy and had no orders for anticoagulants. The resident was observed to have severe cognitive impairment and was unable to participate in conversation or confirm her care plan details. A second resident, also a female with a history of cerebral infarction, muscle weakness, and other chronic conditions, had a care plan similarly indicating anticoagulant therapy, with associated goals and interventions. Her medical records showed she was only prescribed antiplatelet therapy, with no anticoagulant orders. Staff interviews confirmed that care plans are used as the basis for resident care, and that inaccuracies or contradictions in care plans, physician orders, or assessments should be cross-referenced and corrected. The deficiency was attributed to incorrect focus areas being triggered in the care planning process, resulting in care plans that did not accurately reflect the residents' current medication regimens.
Expired Medication Not Removed from Storage Room
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the removal of expired medications from the medication storage room. During an observation, a bottle of Glucosamine and Chondroitin with an expiration date of 3/2025 was found in the medication storage room. Interviews with staff revealed that the responsibility for removing expired medications belonged to a staff member who performed monthly audits, but acknowledged that expired medications could sometimes be missed. The staff member confirmed that expired medications should be disposed of and that administering expired medications could potentially cause harm. Further interviews with the Administrator (ADM) and Director of Nursing (DON) confirmed that nursing staff are expected to check expiration dates before administering medications and that expired medications should be discarded and replaced. However, the ADM stated there was no specific policy or procedure in place regarding the handling of expired medications. The failure to remove expired medications from storage was directly observed and acknowledged by multiple staff members.
Failure to Act on Pharmacy Consultant's Psychotropic Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacy consultant recommendations regarding a gradual dose reduction (GDR) for a psychotropic medication were received and acted upon for a resident. Specifically, the pharmacy made a recommendation on 1/28/25 for a GDR of Quetiapine, but there was no documentation that this recommendation was communicated to the physician for review. The resident's medical record, including progress notes and medication administration records, did not reflect any physician notification or action taken in response to the pharmacy's recommendation. The resident involved was an older female with multiple complex diagnoses, including dementia, type 2 diabetes, atrial fibrillation, cognitive communication deficit, chronic pain, Parkinson's disease, and other significant health conditions. She was receiving Quetiapine 50 mg at bedtime as part of her treatment plan. The care plan indicated the need for regular monitoring of psychotropic medications, consultation with pharmacy and physician, and consideration of dose reduction when appropriate. However, the process for reviewing and acting on pharmacy recommendations was not followed in this case. Interviews with facility staff revealed that the failure to communicate the pharmacy's recommendation was due to staff turnover and discrepancies in the process of uploading recommendations for physician review. The responsibility for ensuring pharmacy recommendations were communicated to the physician was identified as belonging to the DON. Both the RCN and ADM acknowledged that the lack of communication could negatively affect residents, but there was no evidence that the required actions were taken for this resident.
Medication Cart Left Unlocked and Unattended During Administration
Penalty
Summary
A medication cart on A Hall was observed to be intermittently left unlocked and unattended by a certified medication aide (CMA) during medication administration rounds. The cart was left facing the hallway and unattended from 7:15 AM to 7:43 AM while the CMA entered resident rooms to dispense medications. The CMA, who was a prn employee and had not worked at the facility for a month, stated this was her third time passing medications alone at the facility. She acknowledged being trained to lock the medication cart and recognized the risks associated with leaving it unlocked. Interviews with facility leadership, including the ADON, DON, and Administrator, confirmed that facility policy requires medication carts to be locked whenever unattended. They each stated that an unlocked cart could allow residents, visitors, or staff to access medications, which could result in ingestion of medications without supervision. Review of the facility's Pharmacy Policy and Procedure Manual also indicated that the medication cart must always be in full view of the nurse during administration and must be completely locked after the process is completed.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple risk factors. The resident in question was an older male with multiple sclerosis, two stage 4 pressure ulcers, and an indwelling catheter, all of which required EBP according to facility policy and posted signage. Despite clear care plan interventions and posted instructions at the resident's room, staff did not adhere to required infection control measures. During wound care, three staff members, including the wound care nurse, MDSC, and DON, entered the resident's room and performed high-contact care activities without donning gowns as required by EBP protocols. Their uniforms came into direct contact with the resident's bedding and gown, and at times, soiled gloves were used to touch room surfaces. The wound care nurse and other staff acknowledged in interviews that they should have worn gowns to prevent cross-contamination, and that failure to do so could result in the spread of infection. Record reviews confirmed that the facility's infection control and EBP policies required the use of gowns and gloves during high-contact care for residents with wounds or indwelling devices. Despite these policies and staff training, the required precautions were not followed during the observed wound care, as staff failed to don gowns and allowed their uniforms to become contaminated during the procedure.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information at the beginning of each shift in a prominent and accessible location for residents and visitors. On the day reviewed, the designated notice holder outside the DON office was found empty, and the daily staffing data was not posted. Interviews with the ADM, DON, and ADON confirmed that the posting was not completed, with the ADON stating she had forgotten to do so due to working as a floor nurse. The ADM acknowledged that posting staffing information was expected and important for staff and family awareness. Additionally, the facility did not have a policy or procedure regarding daily nurse staffing postings when requested by the surveyor.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the necessary competencies and skills to ensure resident safety and well-being. This deficiency was evident in the care of nine residents, where the lack of adequate staffing led to significant delays in providing essential care. For instance, one resident experienced prolonged exposure to diarrhea for three hours without assistance, leading to feelings of helplessness and discomfort. Another resident was unable to receive timely assistance to the bathroom, resulting in discomfort and distress. The facility also failed to adhere to the shower schedules for multiple residents, with several residents not receiving the scheduled number of showers over a month-long period. This lack of adherence to personal hygiene schedules was attributed to insufficient staffing, as staff members were unable to provide the necessary assistance due to being overburdened with other tasks. Interviews with residents and their family members revealed dissatisfaction with the care provided, highlighting the impact of staffing shortages on the quality of care. The facility's staffing issues were further compounded by inadequate scheduling practices and a lack of communication among staff. The acting Director of Nursing and the facility Administrator were unaware of the staffing shortages on specific shifts, which led to situations where only two nurses were available to care for 76 residents. This inadequate staffing level raised concerns about the facility's ability to provide safe and effective care, as well as its capacity to respond to emergencies. The facility's assessment tool, which was outdated and did not reflect the current resident population or staffing needs, contributed to the deficiency.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in inadequate staffing and care for residents. On one occasion, a resident experienced prolonged exposure to diarrhea for three hours due to insufficient staff to respond to her call light. This resident, who had a history of knee issues and hypertension, was unable to get out of bed independently and felt helpless and in pain. The situation escalated to the point where the resident called the non-emergency 911 for assistance, leading to the arrival of firefighters and police at the facility. Another incident involved a resident who was unable to receive assistance to use the bathroom due to a lack of CNAs on duty. The resident's family member had to intervene, and upon arrival, found that many call lights were on, indicating a widespread issue of unmet needs. The facility's staffing records confirmed that there were only two nurses and one CNA scheduled for a shift that typically required more staff, leading to significant delays in care and unmet resident needs. Additionally, the facility failed to adhere to residents' shower schedules, with multiple residents not receiving the scheduled number of showers over a month-long period. This was attributed to staffing shortages, with CNAs and nurses prioritizing other care tasks over showers. Interviews with staff and residents confirmed that the lack of adequate staffing led to residents not receiving showers as scheduled, contributing to concerns about hygiene and resident comfort.
Facility Fails to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene, nutrition, grooming, and personal and oral hygiene. This deficiency was identified for nine out of eleven residents reviewed for activities of daily living (ADLs). The facility did not provide showers to these residents in compliance with their scheduled shower times, which could place them at risk of a decline in hygiene, skin breakdown, and affect their level of satisfaction with life and feelings of self-worth. Resident #1, a female with chronic kidney disease and moderate cognitive impairment, was scheduled to receive showers three times a week but had no showers documented over a month. She expressed that there was not enough staff to assist her with showering. Similarly, Resident #2, a male with mild dementia and anxiety, was dependent on staff for showering but only received five out of thirteen scheduled showers. Resident #3, with dementia and heart failure, had four showers documented and four refusals, indicating a lack of consistent care. The report also highlights the experiences of other residents, such as Resident #4, who received only six out of thirteen scheduled showers, and Resident #5, who had four showers documented. Resident #6, who had intact cognition, reported not having a shower since admission, and Resident #7 expressed discomfort due to not receiving showers as promised. The facility's staff, including CNAs and nurses, acknowledged the issue, citing staffing shortages as a reason for not providing showers as scheduled. The facility's administrator and DON recognized the concern but had not fully addressed the issue at the time of the report.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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