Focused Care At Crane
Inspection history, citations, penalties and survey trends for this long-term care facility in Crane, Texas.
- Location
- 699 Campus Dr, Crane, Texas 79731
- CMS Provider Number
- 675927
- Inspections on file
- 26
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Focused Care At Crane during CMS and state inspections, most recent first.
The facility did not ensure the Medical Director or a representative attended required quarterly QAPI meetings, as shown by attendance records and staff interviews. The Medical Director attended only one meeting in the past year, despite policy requiring quarterly participation. This failure resulted in the QAPI committee not meeting regulatory requirements for membership and attendance.
Surveyors found that two medication carts contained improperly stored and labeled medications, including undated open insulin pens for two residents with diabetes and bottles with dried drippings. Staff interviews confirmed that insulin pens were not dated as required and medication bottles were not cleaned before storage, contrary to facility policy.
Three residents with severe cognitive impairment and dependence on staff were not provided adequate supervision or safe assistance devices. One resident was not assessed or care planned for safe vaping and was found with unsecured vaping devices, while two others were transferred unsafely by staff who did not use gait belts or proper techniques, contrary to facility policy.
A resident with severe cognitive impairment, hemiplegia, and a history of malnutrition experienced weight loss and was unable to access the main portion of a meal because staff did not place the plate within reach. Despite care plan interventions for nutritional support, staff failed to notice the issue during the meal, and there was no facility policy to ensure food was accessible to residents needing assistance.
A resident with severe cognitive impairment and a history of dementia was not assessed or care planned for nicotine or vape use, despite possessing vapes and discussing vaping behaviors. Nursing documentation noted an elopement attempt to obtain a vape, but the care plan and assessments did not address these needs, contrary to facility policy requiring individualized plans for residents who smoke or vape.
A CNA failed to change gloves and perform hand hygiene after providing perineal care to a resident with severe cognitive impairment and incontinence, then assisted the resident with a clean brief and pants while still wearing contaminated gloves. This action was observed and confirmed to be inconsistent with the facility's infection control and perineal care policies.
A resident with cognitive impairments alleged that a CNA pushed him during a disagreement over a smoke break. The facility conducted an investigation, finding no injuries, but failed to report the investigation results to state officials within the required timeframe. The CNA involved did not return to the facility, and the incident was deemed inconclusive.
The facility failed to notify a resident's representative and physician of changes in the resident's psychosocial status and medication depletion. The resident exhibited aggressive behavior and refused medication multiple times, but the family and physician were not informed in a timely manner, leading to a lapse in care and communication.
The facility failed to provide pharmaceutical services, resulting in a resident missing fifteen doses of Risperidone. The resident, with a history of traumatic brain injury and quadriplegic cerebral palsy, experienced increased aggression and behavioral issues due to the missed medication. Miscommunication between the facility and the family, along with inadequate procedures for obtaining medications, contributed to this deficiency.
The facility failed to ensure residents received adequate supervision to prevent accidents, with water temperatures in shower rooms and resident sinks found to be excessively high. Residents reported the water was too hot, and temperature readings confirmed this, posing a risk of burns. Staff were unaware of the correct temperature range, and maintenance used an inaccurate thermometer, leading to incorrect readings.
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for two residents who were incontinent of bladder. CNAs did not follow proper hand hygiene and peri-care techniques, leading to potential cross-contamination and increased infection risk. Interviews revealed a lack of training and competency checks in peri-care procedures.
The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails for three residents. Observations and interviews revealed a lack of necessary assessments, physician orders, and informed consents, putting residents at risk.
The facility failed to conduct annual competency evaluations for four CNAs, potentially leading to inadequate care for residents. The DON admitted to not performing any staff competencies since her hire and was unaware of the requirement for annual evaluations.
The facility failed to ensure that residents with PRN orders for Lorazepam were limited to 14 days, affecting six residents with various diagnoses. The PRN orders had no stop dates, and there was no documented rationale for the continued provision of the medication in the physician progress notes.
The facility failed to honor the smoking preferences of two residents, restricting them to one cigarette per smoke break despite no formal policy supporting this rule. This action was inconsistent with the facility's documented policies on resident rights and self-determination.
The facility failed to maintain a safe, clean, and homelike environment for three residents, with issues including non-functional hot water faucets, missing closet doors, and a malfunctioning sink drain. Residents had reported these issues, but no corrective actions were taken.
The facility failed to ensure the dry food storage was not past their use-by dates, placing residents at risk for foodborne illnesses. Expired packages of marshmallows, shredded coconut, and black-eyed peas were found in the pantry. Both the Dietary Manager and Administrator acknowledged the oversight and the potential negative impact on residents.
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This included not maintaining required hospice forms and documentation, such as the hospice plan of care and certificate of terminal illness, and lacking physicians' orders for hospice care. Interviews revealed a lack of awareness and understanding of the requirement to maintain hospice documentation, potentially leading to inadequate end-of-life care for residents.
The facility failed to ensure that four CNAs received the required minimum 12 hours of annual in-service training. The DON admitted to not conducting any staff in-service competencies since her hiring and was unaware of the training requirements, leading to a deficiency in staff training and potential negative impacts on resident care.
A facility failed to obtain a physician's order and consent before placing a resident with severe cognitive impairment in a secure unit. The necessary documentation was missing, and staff admitted the consent form might have been lost, violating the facility's policy.
The facility failed to lock a medication cart, leaving it unattended with various medications accessible. RN A admitted to leaving the cart unlocked due to distraction during shift change, and the DON confirmed that all medication carts should be locked when unattended.
Failure to Ensure Required QAPI Committee Membership and Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members, specifically not ensuring the Medical Director or a representative attended at least quarterly QAPI meetings. Record review of attendance sign-in forms for QAPI meetings over the past year showed that the Medical Director attended only one meeting, despite the requirement for quarterly attendance. Interviews with the Administrator and Regional RN Consultant confirmed that the Medical Director's participation was infrequent, and the RN Consultant was unaware of the lack of attendance. The facility's policy required the Medical Director to attend quarterly, but this was not followed. The deficiency was identified through interviews and review of meeting attendance records, which documented the absence of the Medical Director from the majority of QAPI meetings. The Administrator acknowledged that while the Medical Director and Nurse Practitioner were regularly present in the building for resident care, they did not participate in the required QAPI meetings. The facility's QAPI policy, effective since 2017, outlines the responsibility of the Administrator to ensure compliance with regulatory requirements, including the proper composition and functioning of the QAPI committee.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors identified failures in the facility’s pharmaceutical services related to the labeling, storage, and cleanliness of medications on two medication carts. On the 200 hall medication cart, a bottle of milk of magnesia was found with dried drippings on the lid, and on the 300 hall medication cart, an empty bottle of Pro Stat liquid collagen with dried drippings was observed. Additionally, two open insulin pens for two residents were found undated in the 300 hall medication cart. According to interviews with the DON and nursing staff, insulin pens are required to be dated upon opening, and medication bottles should be cleaned before storage to prevent cross contamination, as per facility policy. The residents involved had significant medical needs, including diabetes mellitus managed with insulin therapy. One resident had a history of Type 2 diabetes mellitus with hyperglycemia and severe cognitive impairment, while another had Type 2 diabetes with complications and diabetic polyneuropathy, also with severe cognitive impairment. Physician orders for both residents included specific insulin regimens. The lack of dating on insulin pens and improper storage of medication bottles were confirmed through observation and staff interviews, indicating non-compliance with facility policy and accepted professional standards for medication management.
Failure to Prevent Accidents Due to Inadequate Supervision and Unsafe Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents. One resident with severe cognitive impairment and a history of elopement was not assessed or care planned for safe vaping. The resident's baseline care plan and assessments did not address nicotine or vaping use, and the resident was found with multiple vapes at his bedside outside of supervised smoking times. Facility policy required all vaping materials to be secured and individualized plans for safe storage and supervision, but these were not implemented for this resident. Two other residents with severe cognitive impairment and dependence on staff for transfers were transferred unsafely by staff. In one case, two CNAs transferred a resident from a shower chair to bed by applying a gait belt too loosely and hooking their arms under the resident's arms, resulting in the resident's weight being supported by her arms rather than her legs. The staff were unaware of the increased risk of injury from this method and did not recognize the resident's non-weight bearing status as requiring a different transfer method. The care plan and Kardex were not updated to reflect the resident's needs, and staff did not follow safe transfer protocols as described by facility leadership. In another instance, two CNAs transferred a resident from a wheelchair to bed by grabbing her under the armpits and by the back of her pants, without using a gait belt. The resident was unable to assist with the transfer, and staff acknowledged that this method could lead to injuries. The staff were not certain of the resident's transfer status and did not have gait belts available at the time of transfer, despite facility policy requiring their use. Observations and interviews confirmed that staff did not follow established safe transfer procedures, and documentation indicated the resident was totally dependent on staff for transfers.
Failure to Ensure Food Was Accessible to Resident with Nutritional Risk
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with multiple medical conditions, including malnutrition, dementia, hemiplegia, and a history of weight loss. The resident was on a large portion, regular texture diet with specific interventions outlined in the care plan, such as providing fortified cereal, monitoring intake, and offering snacks. Despite these interventions, the resident's weight remained below the recommended Body Mass Index, and a slight weight loss was documented over a two-month period. During a lunch meal observation, the resident was placed in a geri-chair with his functional side against the table, but his main plate was positioned out of reach. The resident was only able to access a salad and not the main components of his meal. Staff, including the DON, did not notice that the plate was out of reach, and the resident verbally expressed hunger and his inability to reach the food. Only after the surveyor moved the plate did the resident begin eating the rest of his meal. The DON later assisted with eating, but the initial lack of access to food was not addressed by staff. Interviews with facility staff revealed there was no policy in place to ensure food was placed within reach of residents. The MDS Coordinator and Regional RN acknowledged the issue, and the VP of Regional Operations stated it was common sense for aides to leave food within reach. The deficiency was further highlighted by the lack of staff awareness and the absence of a formal policy to address the placement of food for residents who require assistance or supervision during meals.
Failure to Develop Comprehensive Care Plan for Nicotine Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing nicotine use for a resident with severe cognitive impairment and a history of dementia. Upon admission and re-admission, the resident was not identified as a tobacco user, and no smoking or vaping assessments were completed. The resident's baseline and comprehensive care plans did not address nicotine or vape use, despite facility policy requiring individualized plans for residents who smoke or vape. Multiple observations and interviews revealed the resident possessed vapes at the bedside and discussed vaping, yet these behaviors were not reflected in the care plan or assessments. Nursing notes documented an incident where the resident attempted to elope from the facility to obtain a vape, resulting in the application of a wander guard. Interviews with the DON and Corporate RN confirmed that no assessments or care plans for vaping were present in the resident's record, despite the expectation that such needs would be addressed during the care planning process. Facility policies required the interdisciplinary team to develop individualized plans for safe storage and supervision of smoking materials, but this was not completed for the resident in question.
Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper glove use and hand hygiene during incontinent care for one resident. During an observation, a CNA performed perineal care for a resident who was always incontinent of urine and frequently incontinent of bowel, and who had severe cognitive impairment. The CNA's gloved hands came into contact with the resident's skin while cleaning the perineal area, but the CNA did not change gloves or wash hands before fastening a clean brief and assisting the resident with pants, despite facility policy requiring glove removal and hand hygiene after contamination. Interviews with the CNA, the Administrator, and the DON confirmed that gloves should have been changed and hands washed after contamination to prevent cross contamination. Review of the resident's care plan and the facility's infection control and perineal care policies further supported the requirement for proper glove use and hand hygiene. The failure to follow these procedures was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection control practices.
Failure to Report Abuse Investigation Results Timely
Penalty
Summary
The facility failed to report the results of an investigation into an alleged abuse incident involving a resident and a CNA to the appropriate state officials within the required five working days. The incident involved a resident who alleged that a CNA had pushed him back into his wheelchair during a disagreement about a smoke break. The resident, who has a history of schizophrenia, depression, and cognitive impairment, reported the incident to a nurse, who found no physical injuries upon assessment. The facility's administrator self-reported the incident to the Health and Human Services Commission (HHSC) but did not complete and submit the required Provider Investigation Report (Form 3613A) within the specified timeframe. The incident occurred when the resident became verbally aggressive with the CNA over a delay in being taken outside for a smoke break. The CNA reportedly told the resident he would take him out after finishing his charting, but the resident became upset and attempted to take himself outside. During the altercation, the resident claimed the CNA pushed him, although the CNA and another resident witness stated that the CNA only assisted the resident back into his scooter to prevent a fall. The facility's Licensed Vocational Nurse (LVN) assessed the resident and found no signs of injury, and the incident was reported to the facility's abuse coordinator and Director of Nursing (DON). Despite conducting an investigation and gathering statements from involved parties, the facility's administrator did not complete the necessary documentation to report the investigation's findings to the state within the required period. The administrator acknowledged the oversight, stating that the incident was deemed inconclusive, and the CNA involved did not return to the facility after the incident. The facility's policy requires that all allegations of abuse be thoroughly investigated and reported using the appropriate forms within five calendar days, which was not adhered to in this case.
Failure to Notify Resident's Representative and Physician of Changes in Condition
Penalty
Summary
The facility failed to notify the resident's representative and physician when there was a change in the resident's psychosocial status and when the resident ran out of the medication Risperidone. The resident, who had a history of Traumatic Brain Injury and Quadriplegic Cerebral Palsy, exhibited aggressive behavior and refused medication multiple times. Despite these significant changes, the facility did not inform the resident's family or physician in a timely manner, leading to a lapse in care and communication. The resident's care plan included administering psychotropic medications as ordered and obtaining consent from the resident or responsible party prior to medication use. However, the facility did not follow these interventions, as evidenced by the resident's refusal to take medication and the lack of documentation that the family was notified of the ongoing behaviors or the depletion of Risperidone. The facility's policy required notifying the resident's representative within 24 hours of a significant change, but this was not adhered to. Interviews with staff and the resident's family revealed that the facility had issues with medication management and communication. The family was only notified once about the resident's behaviors and medication depletion, despite multiple instances of aggression and refusal to take medication. The facility's failure to communicate effectively with the family and physician resulted in the resident not receiving the necessary medication and care, which could have been mitigated with proper notification and intervention.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of Resident #1. Specifically, the facility did not obtain and administer the antipsychotic medication Risperidone fifteen times between 4/23/24 and 5/1/24, as per the physician's orders. This failure was identified through interviews and record reviews, revealing that the resident did not receive the prescribed medication, which was critical for managing his traumatic brain injury and associated behaviors. Resident #1, a male with a history of traumatic brain injury and quadriplegic cerebral palsy, was admitted to the facility for respite care. The resident's care plan included the administration of Risperidone to manage potential adverse consequences from psychotropic medications. Despite this, the facility ran out of the medication and failed to notify the family in a timely manner. The facility's pharmacy did not provide the liquid form of Risperidone, and there was a lack of documentation and communication regarding the medication's unavailability and the steps taken to address it. Interviews with the facility's staff, including the Administrator and the Director of Nursing (DON), revealed inconsistencies and a lack of clarity regarding the procedures for obtaining medications for respite care residents. The staff believed that the family was responsible for providing the medication, while the family assumed the facility would manage it. This miscommunication led to Resident #1 missing multiple doses of Risperidone, resulting in increased aggression and behavioral issues. The facility's policy on unavailable medications was not effectively followed, contributing to the deficiency in care provided to Resident #1.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to ensure residents received adequate supervision to prevent accidents in three of four halls reviewed for accidents and supervision. Specifically, the water temperatures in the shower rooms and resident sinks were found to be excessively high, posing a risk of burns to the residents. The temperatures recorded were significantly above the safe range, with readings as high as 141.3°F in Hall 400 and 136°F in Hall 500. These high temperatures were confirmed through observations and interviews with residents and staff, who reported that the water was too hot and could potentially cause burns. Resident #51, a male with severe cognitive impairment, reported that the showers on Hall 500 were too hot, and despite his complaints to the CNA, the water temperatures were not adjusted. Similarly, Resident #12, who had moderately impaired cognition and required limited staff assistance with bathing, also reported that the water in the Hall 500 shower was too hot and could burn someone if they were not careful. These reports were corroborated by temperature readings taken by the surveyors, which showed dangerously high water temperatures in multiple locations within the facility. Interviews with the Director of Nursing (DON) and other staff revealed a lack of awareness and proper monitoring of water temperatures. The DON acknowledged that the water could have burned residents, and a CNA admitted not knowing the correct water temperature range. The facility's maintenance staff used an inaccurate infrared thermometer, leading to incorrect temperature readings. The facility's policy required water temperatures to be between 100-110°F, but this was not adhered to, resulting in an Immediate Jeopardy situation being identified. The facility's failure to maintain safe water temperatures placed residents at risk of severe injury, serious harm, hospitalization, impairment, and/or death.
Failure to Provide Appropriate Peri-Care and Hand Hygiene
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for two residents who were incontinent of bladder. Specifically, the facility did not ensure proper hand hygiene and peri-care techniques were followed by CNAs. CNA B and CNA C did not wash their hands before, during, or after performing peri-care, and they did not follow the correct procedure of wiping from front to back. Instead, they used a zig-zag motion and did not change gloves between handling dirty and clean briefs, which could lead to cross-contamination and increased risk of infections for the residents involved. Resident #17, a female with severe cognitive impairment and frequent incontinence, was observed receiving improper peri-care from CNA C, who did not wash hands or change gloves during the procedure. Similarly, Resident #38, a female with dementia and complete incontinence, was observed receiving improper peri-care from CNA B, who also failed to follow proper hand hygiene and peri-care techniques. Both residents' care plans included specific interventions to prevent skin breakdown and urinary tract infections, but these were not adhered to during the observed care. Interviews with the CNAs revealed a lack of training and competency checks in peri-care procedures. CNA C admitted to not knowing the correct procedures and not having been trained or checked off on peri-care since employment. CNA B cited issues with access to handwashing facilities and also lacked skills competency checks. The Director of Nursing (DON) confirmed that no staff competencies had been performed since she started and was unaware of the required frequency for staff performance evaluations and training. The facility's policy on perineal care was not followed, contributing to the deficiencies observed.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails for three residents. Resident #26, a female with severe cognitive impairment, had bed rails installed without any documented assessment for entrapment risks, attempts at less restrictive measures, or informed consent. Observations confirmed the presence of bilateral half side rails, and the resident was unable to be interviewed due to her condition. Resident #59, also with severe cognitive impairment, had bed rails installed without a physician's order, risk assessment, or informed consent. The care plan mentioned the use of side rails for bed mobility, but no documentation supported the necessary assessments or consents. Observations and interviews with staff revealed that the bed rails were present in the resident's room, and the responsible party refused to be interviewed. Resident #68, a female with multiple diagnoses including blindness and Down's syndrome, had bed rails installed with a physician's order but lacked documentation for risk assessment, attempts at less restrictive measures, or informed consent. Observations confirmed the presence of bilateral half side rails, and the resident was unable to be interviewed. Interviews with staff indicated a lack of awareness and adherence to the facility's policy on bed rail use, including the need for assessments and consents prior to installation.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to review the work of each Certified Nurse Aide (CNA) every 12 months for four CNAs (CNA-D, CNA-E, CNA-F, and CNA-G) out of five reviewed. The personnel files for these CNAs, who were hired between October and November 2021, showed no evidence of competency evaluations conducted at least every 12 months after their hire dates. This lack of evaluation could result in inadequate CNA performance while providing care for residents. During an interview, the Director of Nursing (DON) admitted that she had not performed any staff competencies since her hire in February 2024. She also stated that she was unaware of the requirement for annual competency evaluations and had not followed up to ensure that CNAs had the necessary training and documentation. The facility's policy, dated August 2017, mandates that competency evaluations be conducted initially and annually, and that a performance review of each nurse aide be conducted at least once every 12 months.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that residents with PRN orders for psychotropic drugs, specifically Lorazepam, were limited to 14 days. This deficiency was observed in six residents, all of whom had ongoing PRN orders for Lorazepam without a stop date. The residents involved had various diagnoses, including anxiety, depression, dementia, Alzheimer's, bipolar disorder, and other medical conditions. Despite the presence of these PRN orders, there was no documented rationale for the continued provision of Lorazepam in the physician progress notes from January 2024 to April 2024 for any of the residents involved. Resident #45, a female with severe cognitive impairment, had a PRN order for Lorazepam dated February 2022 with no stop date. Her MAR for April 2024 showed no evidence of Lorazepam being administered, and her physician progress notes lacked any documented rationale for the continued provision of the medication. Similarly, Resident #10, a female with bipolar disorder and anxiety, had a PRN order for Lorazepam dated February 2024 with no stop date. Her MAR indicated that Lorazepam was administered on two occasions in April 2024, but there was no documented rationale for its continued use in her physician progress notes. Other residents, including Resident #18, Resident #58, Resident #2, and Resident #52, also had PRN orders for Lorazepam without stop dates and no documented rationale for the continued provision of the medication. The Director of Nursing (DON) acknowledged awareness of the regulation on PRN psychotropic medications and admitted to missing the orders due to being very busy. The facility's policy emphasized the importance of regular review and appropriate use of psychotropic medications, but this was not adhered to in these cases.
Failure to Honor Resident Smoking Preferences
Penalty
Summary
The facility failed to ensure that residents had the right to choose their schedule, specifically regarding the number of cigarettes they could smoke during their smoke breaks. This deficiency was identified for two residents, both of whom had a history of tobacco use and other medical conditions. Resident #12, a male with coronary artery disease and depression, was restricted to one cigarette per smoke break despite his previous habit of smoking two packs a day. Similarly, Resident #63, a male with major depressive disorder and anxiety, was also limited to one cigarette per break, even though he could safely manage his smoking materials independently. Interviews with staff revealed inconsistencies and a lack of awareness regarding the facility's smoking policy. The housekeeper and social worker both mentioned that residents were only allowed one cigarette per break, citing a supposed corporate policy. However, the facility's actual smoking policy did not contain any such restriction. The administrator admitted that the one-cigarette rule was a decision made by the department heads to manage residents' budgets and prevent theft, rather than a formal policy. The facility's documentation, including the Resident Smoking Council Meeting Minutes and the official smoking policy, showed no evidence supporting the one-cigarette rule. This discrepancy between the facility's practices and its documented policies led to the deficiency, as it restricted residents' rights to self-determination and choice, contrary to the facility's stated policies on resident rights and self-determination.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for three residents. In Resident #4's room, the hot water faucet did not work, and the left closet door was missing, leaving the resident's clothing exposed. Resident #4, who had multiple diagnoses including chronic obstructive pulmonary disease, dementia, and diabetes, expressed that he had informed the staff about the non-functional hot water, but no action had been taken. In Resident #22's room, the sink only had cold water available. Resident #22, who had moderate cognitive impairment and required assistance with various daily activities, stated that she had not had hot water since moving into the facility. Additionally, the closet doors were missing, leaving the resident's clothing exposed. In Resident #32's room, the sink would not drain without the resident holding up the drain plug, and the hot water temperature was below 100°F. Resident #32, who had diagnoses including encephalopathy and dementia, mentioned that she did not mind the water not being hot but was unsure how long the drain had been malfunctioning. The facility's maintenance log showed no evidence that these issues were addressed, and the Director of Plant Operations admitted to delays and difficulties in obtaining parts to fix the problems.
Expired Food in Dry Storage
Penalty
Summary
The facility failed to ensure the dry food storage was not past their use-by dates, which placed residents at risk for foodborne illnesses. During an observation, it was found that the dry storage pantry contained six packages of sealed marshmallows, one opened box of shredded coconut, and one sealed box of black-eyed peas, all of which were past their use-by dates. The Dietary Manager (DM) acknowledged that there should have been no expired food in the pantry and admitted that the product dates should have been checked on a weekly basis as well as when new products arrived. Despite previous in-services for food safety, the DM admitted to not monitoring the stored food and incoming products closely enough, attributing the failure to the kitchen department head's oversight. The Administrator (ADMN) also confirmed that expiration dates on food products should have been checked daily and updated weekly, with food products being rotated accordingly. The ADMN stated that she would only go into the kitchen when necessary and relied on the DM to monitor the products. However, she acknowledged that ultimately, she was responsible for monitoring the DM. Both the DM and ADMN recognized that the failure in adhering to the chain of command and training protocols could have negatively impacted residents by potentially making them sick. The facility's food manager training and FDA Food Code guidelines were reviewed, emphasizing the importance of proper food labeling and rotation to prevent such deficiencies.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services. This failure was observed in 11 residents, where the facility did not maintain the required hospice forms and documentation, including the hospice plan of care and certificate of terminal illness. Additionally, the facility lacked physicians' orders for hospice care for several residents, which could place them at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. For Resident #45, the facility did not have a binder containing the required hospice forms and documentation, despite the resident being on hospice services for Alzheimer's Disease. Similarly, Resident #10, who had a terminal prognosis related to Huntington's Disease, did not have an order for hospice care or the necessary hospice documentation. Resident #18, with severe cognitive impairment and on hospice services for hemiplegia and hemiparesis following a cerebral infarction, also lacked the required hospice documentation. Other residents, including Resident #58, Resident #2, Resident #52, Resident #26, Resident #19, Resident #21, Resident #35, and Resident #34, were found to be in similar situations where the facility did not maintain the necessary hospice documentation and physicians' orders. Interviews with the Director of Nursing (DON), Registered Nurse (RRN), and Social Services Director (SSD) revealed a lack of awareness and understanding of the requirement to maintain hospice documentation, which could lead to residents not receiving the care they needed due to a lack of continuity of care.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs) received the required minimum 12 hours of annual in-service training. The CNAs in question, identified as CNA-D, CNA-E, CNA-F, and CNA-G, had no evidence of completing the mandatory training since their hire dates in October and November 2021. This lack of training was confirmed through a review of their personnel files, which showed no documentation of the required in-service hours. During an interview, the Director of Nursing (DON) admitted that she had not conducted any staff in-service competencies since her hiring in February 2024. She also revealed that she was unaware of the frequency and requirements for staff in-service training. The DON acknowledged that the failure to ensure proper training could negatively impact resident care, as untrained staff might not perform their duties correctly. The facility's policy mandates that nurse aide competencies be evaluated initially and annually, but this was not adhered to, leading to the identified deficiency.
Failure to Obtain Physician's Order and Consent for Secure Unit Placement
Penalty
Summary
The facility failed to ensure resident records were maintained with accepted professional standards and practices for completeness and accurate documentation for one resident. Specifically, the facility did not obtain a physician's order or consent from the resident or their representative before placing the resident in a secure unit. The resident, a [AGE] year-old female with severe cognitive impairment, was admitted to the facility with diagnoses including acute posthemorrhagic anemia, unspecified dementia, anxiety, and diabetes. Despite the resident's cognitive and behavioral issues, there was no documentation of a physician's order or consent for her placement in the secure unit. Interviews with the Director of Nursing (DON) and the Registered Nurse (RN) revealed that both were aware of the requirement for a physician's order and consent prior to placing a resident in a secure unit. However, they were unable to provide the necessary documentation and admitted that the consent form might have been lost. The facility's policy requires an assessment, consent, and a physician's order for placement in the Memory Care Unit, but these steps were not followed in this case. This failure could result in residents being placed in secure units without proper authorization or consent, potentially leading to involuntary seclusion.
Failure to Lock Medication Cart
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments, as observed with one of the four medication carts reviewed. During an observation, an unlocked medication cart was found unattended by the nurses' station between the 200 and 400 halls, with a resident approximately six feet away. The cart contained various medications, including prescription drugs like Zoloft, trazodone, Singulair, Buspar, Baclofen, Keppra, lactulose, Sinemet, and Megace, as well as over-the-counter medications such as Aspirin, Tylenol, and Colace. RN A, who was responsible for the cart, admitted to leaving it unlocked due to being nervous and distracted during shift change. She acknowledged that she knew the cart should be locked when unattended and recognized the potential adverse reactions that could occur if a resident accessed the medications. The Director of Nursing (DON) confirmed that medication carts should always be locked when unattended and highlighted the potential negative impact, including allergic reactions or death, if residents accessed the medications. The DON noted that all nursing staff should monitor the medication carts to ensure they are locked. The facility's policy on the storage of medications, revised in August 2020, mandates that medications and biologicals be stored safely and securely, with access limited to authorized personnel. The policy also specifies that medication carts and supplies should be locked when not attended by authorized individuals.
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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
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.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
