Focused Care At Midland
Inspection history, citations, penalties and survey trends for this long-term care facility in Midland, Texas.
- Location
- 2000 N Main, Midland, Texas 79705
- CMS Provider Number
- 675985
- Inspections on file
- 33
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Focused Care At Midland during CMS and state inspections, most recent first.
Surveyors found unsanitary and unsafe conditions throughout the facility, including trash and food debris on floors, overflowing trashcans, broken window blinds, and damaged floor tiles in resident rooms and common areas. The administrator attributed the issues to a late floor tech and acknowledged that staff are responsible for cleaning, but could not provide a policy on maintaining a homelike environment.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
The facility did not ensure food was prepared safely and attractively, as a Dietary Aide was observed not following puree recipes, not measuring ingredients, and lacking training on proper food preparation. Multiple residents reported dissatisfaction with the food's taste and temperature, and observations showed unappetizing meals. The Dietary Manager confirmed staff were untrained in pureed food preparation and that no specific policy on food palatability existed.
Surveyors found that three resident smoking areas were not adequately cleaned or maintained, with high grass, overflowing trash, scattered litter, and cigarette butts present throughout. Maintenance logs showed the last cleaning occurred several days prior, and mowing was delayed due to contractor issues. The areas also contained items such as cat food and bedding covered in debris.
Surveyors observed that two dumpsters had open lids and trash, including a toilet and wooden items, was found outside the dumpsters. The area was not kept free of garbage and debris, and no policy on garbage and refuse disposal was provided during the survey. The Administrator stated that the expectation was for dumpster lids to remain closed and the area to be clean.
Staff failed to maintain resident dignity by instructing a resident with cognitive impairment to urinate in her brief instead of assisting her to the bathroom, and multiple residents reported that staff frequently used personal cell phones during direct care, including wound care and medication administration. Facility leadership confirmed these actions were not consistent with policy, which requires prompt toileting assistance and prohibits personal cell phone use during care.
Surveyors found that staff failed to document the administration of controlled medications immediately after giving them, resulting in discrepancies between medication records and actual pill counts for several residents with conditions such as epilepsy, chronic pain, and anxiety. The medication aide typically signed out controlled substances during shift changes rather than at the time of administration, contrary to facility policy and expectations stated by the DON and Administrator.
A resident who was assessed as safe to smoke independently was found with a lighter left unattended on his bedside table, in violation of facility policy and his care plan, which required all smoking materials to be stored by staff. This failure to secure incendiary devices resulted in the environment not being as free from accident hazards as possible.
A resident with multiple chronic conditions was taken to the emergency room after being locked out of the facility and seeking help at a nearby restaurant. Although an LVN performed an assessment upon the resident's return, no documentation of the emergency room visit, the circumstances, or the assessment was entered into the medical record, as the LVN was instructed not to document by a Regional Compliance RN. Facility staff and leadership confirmed that documentation was expected but not completed, resulting in incomplete medical records.
A resident with severe cognitive impairment and a known risk for elopement was able to leave a secured unit by following a contract worker out during construction, exiting the facility undetected, and was later found by police nearly a mile away. The incident was marked by inadequate supervision at the secured door, lack of staff assignment to monitor exits during increased risk, and missing documentation and incident reporting, leading to an Immediate Jeopardy finding.
A resident with severe cognitive impairment and a history of elopement did not have their care plan updated after new elopement incidents. The existing care plan addressed general wandering but lacked specific, measurable interventions following actual elopements, and no incident report was completed. Staff interviews revealed a lack of awareness and follow-through in updating the care plan as required by facility policy.
A resident with a history of schizophrenia and diabetes, at risk for pressure ulcers, did not receive weekly skin assessments from mid-July to late September due to frequent absences on scheduled assessment days. On one occasion, the resident was observed with pitting edema and seeping fluid on his legs, but no treatment orders were in place. The facility's policy requiring weekly skin assessments was not followed, resulting in untreated skin issues.
The facility failed to maintain a clean and safe environment, with surveyors observing dirt and food crumbs along the walls in six hallways, the dining room, and the kitchen. The Administrator acknowledged the issue, citing new housekeeping staff and the potential risks of unclean floors. The facility's policy requires daily cleaning of floors.
A facility failed to maintain accurate records for a resident who frequently left the premises. Despite being cognitively intact and having permission to leave, the resident did not consistently sign in or out, leading to incomplete documentation. Interviews revealed that while staff reminded residents to sign in and out, the procedure was not always followed, resulting in a deficiency in maintaining clinical records.
A resident requiring total assistance for toileting was subject to improper infection control practices by CNA A and Hospitality Aid B, who failed to perform hand hygiene between glove changes during incontinence care. Despite recent training, the staff members admitted to forgetting the procedure due to nervousness. The DON confirmed that this was against facility policy, which mandates hand hygiene after every glove change.
The facility failed to implement comprehensive care plans with enhanced barrier precautions (EBP) for three residents, leading to increased infection risk. A resident with pressure ulcers and a catheter lacked EBP in his care plan. Another resident with severe cognitive impairment and a feeding tube also lacked EBP interventions. Similarly, a third resident's care plan did not include EBP for his catheter and pressure injury. The MDS Coordinator admitted the oversight, highlighting a lack of understanding of EBP's importance.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and indwelling medical devices, as evidenced by the lack of documentation, signage, and PPE availability. Observations and staff interviews revealed inconsistencies in understanding and applying EBP protocols, with some staff unaware of its existence. This deficiency increased the risk of cross-contamination and infection spread among residents.
A facility failed to complete post-dialysis assessments for a resident with end-stage renal disease, despite having a care plan in place. The resident, who had severe cognitive impairment, did not receive necessary post-dialysis evaluations, including vital signs and AV shunt checks. Interviews with staff revealed a lack of follow-up and documentation, and no dialysis policy was provided.
The facility failed to post required contact information for State agencies and advocacy groups in an accessible manner for residents and their representatives. The ADON and DON were unable to locate the postings, which had been removed during repainting and not replaced. The Administrator was aware of the requirement but did not know why the postings were missing, and a temporary 1-800 number was posted instead.
The facility failed to develop and implement comprehensive care plans for five residents, leading to deficiencies in catheter care, PEG tube management, unplanned weight loss, and psychotropic medication use. The CRC and DON acknowledged the oversight and inconsistencies in care plan documentation.
The facility failed to ensure that secure unit exit doors had alarms to alert staff when residents went outside to the patios. Observations and interviews revealed that staff monitored residents by physically checking the patios, and the facility lacked a specific policy regarding secured doors in the secure unit.
The facility failed to maintain a clean kitchen and ensure proper food storage, preparation, and distribution. Observations revealed pooled water, grime buildup, and improperly labeled and stored food items. Interviews confirmed awareness of the issues, with ongoing efforts to address them.
The facility failed to maintain an effective pest control program, resulting in a rodent infestation. Despite weekly treatments by a new pest control vendor, residents continued to feed the mice, complicating eradication efforts. A dead rat was found in a supply closet, and the issue persisted despite multiple discussions with residents about the health risks.
The facility failed to ensure the dignity and privacy of two residents by not covering their urinary catheter drainage bags with privacy bags. Observations revealed that the urine content of the bags was visible to others, and neither resident had a comprehensive care plan for their urinary catheters. Staff interviews confirmed that the facility's policy required privacy bags, but they often fell off or were removed by residents.
The facility failed to ensure the accurate administering of drugs by having two expired insulin pens in a medication cart. LVN A did not notice the expired pens, and the ADON confirmed it was each nurse's responsibility to check and dispose of expired medications. The Administrator acknowledged that no specific person was assigned to check for expired medications, leading to this oversight.
The facility failed to store drugs and biologicals in locked compartments, as the medication cart for halls A, B, and C was found unlocked and unattended. LVN A admitted to forgetting to lock the cart, which contained several medications. The ADON and Administrator confirmed the expectation for carts to be locked when not in use.
The facility failed to maintain a safe, functional, sanitary, and comfortable environment, as grey water and soiled toilet tissue were observed streaming from a drain clean out and pooling in the parking lot. Despite efforts to address the issue, the problem persisted, posing a hazard to residents, staff, and the public.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, as evidenced by multiple observations of unclean and poorly maintained areas. On the date of the survey, Hall B was found with floors covered in trash, food particles, and candy wrappers between the handrail and wall. Resident rooms in Hall B had brown dry stains on the floor, overflowing trashcans, trash under beds, broken window blinds, and broken floor tiles. The dining room floor was also observed to have trash, food, and cups scattered throughout, despite breakfast having been served hours earlier. Similar unsanitary conditions were noted in Hall A, with floors covered in trash and food particles. Interviews revealed that the floor technician was late on the day of the observation, which contributed to the lack of cleanliness. The administrator acknowledged that staff are responsible for emptying trashcans and cleaning floors as needed, and stated that all staff had been in-serviced regarding their responsibility to maintain cleanliness. However, the administrator was unable to provide a policy on maintaining a homelike environment during the exit conference. No specific residents were identified as being directly affected in the report, and no medical history or conditions were mentioned.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific residents, staff, or events are provided in the report.
Failure to Prepare Palatable and Safe Food Due to Lack of Training and Recipe Use
Penalty
Summary
The facility failed to ensure that food was prepared in a safe, palatable, and attractive manner, particularly in the preparation of pureed food items. Observations revealed that a Dietary Aide (DA) did not follow puree recipes, did not measure liquids or thickeners, and was not trained on the correct procedures for preparing pureed foods. The DA relied on personal judgment to determine the amount and type of liquid to add, and was unaware of the existence of recipes or the importance of consistency in food texture, which could affect resident safety. The DA also did not take temperatures of the pureed foods before serving. The Dietary Manager (DM) confirmed that none of the Dietary Aides had received training on preparing purees and acknowledged that staff often filled in for positions without proper training. Multiple residents interviewed expressed dissatisfaction with the quality, temperature, and taste of the food, describing it as unappetizing and not good. Observations of a lunch test tray showed the food was unappetizing in appearance, with dried-out meat and overly peppered gravy, and the meat was difficult to cut. The Registered Dietician indicated that the DM was instructed to provide menus and recipes to staff, but there was no evidence that this had been done. The DM also stated there was no specific policy related to food palatability. Record review showed no significant weight loss among residents at the time of the survey.
Failure to Maintain Clean and Sanitary Resident Smoking Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in three designated resident smoking areas. Observations revealed that in smoking area 1, the grass and weeds were approximately 24 inches high, and the area was littered with trash such as used gloves, paper, cans, food wrappers, and numerous cigarette butts. This area is shared by the men's locked units E and F. In smoking area 2, located in the women's locked unit from hall C, there was scattered litter including paper, cans, cups, food wrappers, and cigarette butts, with the trash can overflowing and weeds/grass up to 1 foot tall. Smoking area 3, shared by halls A, B, and D, was observed to have trash, used gloves, paper, cans, food wrappers, and cigarette butts throughout. Additionally, this area contained a cat food bowl, a bag of cat food, and two cat houses, one of which had a blanket covered in cigarette butts, grass, and trash. Interviews and record reviews indicated that maintenance staff are responsible for cleaning the outside grounds, including smoking areas, every Monday, Wednesday, and Friday, while mowing is performed by a contractor who does not address the smoking areas unless specifically requested. The most recent maintenance log check-off for smoking area cleaning was dated several days prior to the observations. The administrator confirmed that mowing was not completed as scheduled due to mechanical issues with the contractor, and that the facility's expectation is to maintain a clean and sanitary environment. The facility's policy for a clean sanitary environment was not provided at the time of exit.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse for 2 out of 3 dumpsters, as observed during a survey. Specifically, the lids on two dumpsters were left open despite the dumpsters not being full, and trash, including a trash bag, a toilet, and wooden items, was found outside the dumpsters. The area surrounding the dumpsters was not free of garbage and debris. During an interview, the Administrator confirmed that the expectation was for dumpster lids to remain closed and the area to be free of trash or debris. The maintenance director was reported to conduct rounds outside the facility three times a week. No policy on garbage and refuse disposal was provided by the time of the survey exit. No specific residents or staff were directly involved in the observed deficiency, and no medical history or condition of residents was mentioned in relation to this event.
Failure to Maintain Resident Dignity and Prohibit Personal Cell Phone Use During Care
Penalty
Summary
Staff failed to treat residents with respect and dignity, as evidenced by multiple observations and interviews. One resident with severe cognitive impairment and incontinence was told by a CNA to urinate in her brief instead of being assisted to the bathroom, despite her request and care plan interventions that included prompted toileting and peri-care. The resident was observed crying out for help, and the CNA dismissed her request, instructing her to use her brief because it was dry. Additionally, several residents reported that staff frequently used their cell phones while providing direct care, including during wound care and medication administration. Residents described staff watching television shows or texting friends on their phones, which made them feel uncomfortable and neglected. One resident noted that a staff member did not change gloves after using their phone during wound care. Observations confirmed that a nurse was scrolling on social media while sitting next to a resident in the dining room. Interviews with facility leadership confirmed that personal cell phone use was not permitted during resident care, except for specific business-related reasons. Both the DON and Administrator acknowledged that telling residents to urinate in their briefs was not acceptable and not in line with facility policy. Facility policies reviewed emphasized the importance of treating residents with dignity and promptly responding to toileting needs, as well as prohibiting personal cell phone use while working on the floor or in resident rooms.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure that drug records were accurately maintained and that an account of all controlled drugs was kept for multiple residents. During an inspection of a medication cart, discrepancies were found between the number of controlled medication pills documented on individual medication records and the actual number of pills present in the blister packs for eight residents. These discrepancies were observed for various controlled substances, including phenytoin, acetaminophen-codeine, clonazepam, pregabalin, alprazolam, tramadol, and lorazepam. The medication aide responsible for administering these medications did not document the administration of controlled substances on the individual controlled medication records immediately after giving the medication. Instead, the aide reported typically signing out the controlled medication sheets during the shift count with oncoming staff, rather than at the time of administration. This practice resulted in mismatches between the recorded and actual pill counts for several residents with diagnoses such as epilepsy, chronic pain syndrome, anxiety disorder, fibromyalgia, and joint pain. Interviews with facility leadership, including the DON and the Administrator, confirmed that the expectation was for staff to sign out controlled medications immediately after administration, as outlined in the facility's policy. The policy requires that controlled substance inventory sheets be accurately maintained and that a log is used to track controlled substances from delivery to disposition, in accordance with federal and state regulations. The failure to follow these procedures led to the observed discrepancies in medication records.
Failure to Secure Smoking Materials for Independent Smoker
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards and that adequate supervision was provided to prevent accidents for a resident who smoked independently. Observation revealed that a lighter was left unattended on the resident's bedside table, contrary to the facility's policy and the resident's care plan, which required all lighters and smoking materials to be kept with facility staff for safety. The resident was cognitively intact and assessed as safe to smoke unsupervised, but the care plan specifically stated that smoking materials must be returned to the nurse's station after use and not kept on the resident's person. The facility's smoking policy required that incendiary devices and smoking materials be stored by staff and not be in the possession of residents. Despite this, the resident was found with a lighter in his room, and the DON acknowledged the oversight, noting that the resident often went out on pass alone and was considered an independent smoker. The failure to follow established procedures for the storage of smoking materials created a situation where the resident environment was not as free from accident hazards as possible.
Failure to Document Resident's Emergency Room Visit and Return Assessment
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one resident who was sent to the emergency room. The resident, an older adult with multiple diagnoses including diabetes, atrial fibrillation, COPD, and bipolar disorder, left the facility and was taken to the emergency room after being locked out and seeking help at a nearby restaurant. Upon her return, a head-to-toe assessment was performed by an LVN, but no documentation of the emergency room visit, the circumstances leading to it, or the assessment upon return was entered into the medical record. Interviews with facility staff revealed that the LVN did not document the assessment or complete an incident report because she was instructed not to by the Regional Compliance RN. The DON disagreed with this directive and believed documentation should have occurred. Other nursing staff, the administrator, nurse practitioners, and the medical director all stated that documentation of the emergency room visit and the resident's return assessment was expected and should have been completed. The Regional Compliance RN later stated that documentation was required and could not recall instructing staff otherwise. A review of facility policies indicated that accidents or incidents involving residents should be investigated and reported, and that nurses are required to complete descriptive documentation based on resident assessments. However, the facility did not have a specific policy addressing documentation requirements for residents returning from the hospital or emergency room. The lack of documentation in this case resulted in incomplete medical records for the resident involved.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Documentation
Penalty
Summary
A deficiency occurred when a male resident with severe cognitive impairment and a high risk for elopement, as documented in his care plan and elopement assessment, was able to leave the secured unit and exit the facility without staff detection. The resident, who had dementia with behavioral disturbance and a history of wandering, followed a contract worker out of the secured unit during a period of construction and subsequently exited the building. Staff interviews and record reviews revealed that the door to the secured unit was not properly monitored, and there was no staff member specifically assigned to watch the door during the construction activities, despite the increased risk. The incident was further compounded by a lack of proper documentation and communication among staff. There was no incident or accident report for the elopement in the electronic record, and nurse's notes for the day of the incident were missing. Staff interviews indicated confusion about the timeline and responsibilities, with some staff unaware of the resident's absence until after he had left the facility. The Director of Nursing (DON) and Administrator acknowledged failures in documentation and investigation, including not taking statements from all relevant staff and not maintaining head count forms as required by facility policy. The facility's investigation confirmed that the resident was missing for approximately two hours before being found by police nearly a mile away. The lack of supervision at the secured unit door, inadequate staff training or understanding regarding door security during construction, and insufficient documentation and follow-up all contributed to the resident's ability to elope. These failures resulted in the identification of an Immediate Jeopardy situation due to the potential for serious harm.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of dementia, behavioral disturbances, and high elopement risk. Despite the resident's documented severe cognitive impairment and previous elopement incidents, the care plan was not updated to address new elopement events. The care plan in place focused on general wandering and safety within the secured unit but did not include specific, measurable objectives or interventions following the resident's actual elopements. There was also no incident or accident report completed for a documented elopement, and the care plan was not revised to reflect this significant event. Interviews with facility staff, including the Administrator, DON, Regional RN Consultant, and MDS Coordinator, revealed a lack of awareness and follow-through regarding the need to update the care plan after elopement incidents. The MDS Coordinator acknowledged that care plans should be updated after such events but did not do so, believing the existing at-risk care plan was sufficient. The facility's policy required care plans to be revised after significant changes in a resident's condition, but this was not followed in the case of the resident's elopement.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to conduct weekly skin assessments for a resident from mid-July to late September, as required by their policy. The resident, who was cognitively intact and had a history of paranoid schizophrenia and Type II Diabetes Mellitus with Diabetic Peripheral Angiopathy, was at risk for developing pressure ulcers. Despite this risk, the resident's skin was not assessed weekly because he often left the facility on his scheduled assessment day. This oversight was confirmed during an interview with the wound care nurse, who admitted that the resident's skin was not assessed upon his return from being out of the facility. On September 23, the resident was observed with pitting edema and seeping serosanguinous fluid on his lower legs, yet there were no physician orders for treatment or assessment of this condition. The Director of Nursing acknowledged that the resident should have been evaluated upon returning to the facility if absent on the scheduled assessment day. The facility's policy on skin management, which mandates documentation of skin assessments every seven days, was not adhered to, leading to a lack of treatment for the resident's skin issues.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for residents, staff, and the public, as observed in six hallways, the dining room, and the kitchen. On two separate occasions, surveyors noted dirt and food crumbs along the walls at the baseboards in these areas. The observations were made on 09/19/2024 and 09/24/2024, indicating a persistent issue with cleanliness in the facility. Interviews with the Administrator revealed that there was an expectation for the floors to be cleaned, and it was acknowledged that the facility had a new housekeeping director and staff who were working on improving the situation. The Administrator also recognized the potential negative outcomes of not maintaining clean floors, such as fall hazards, infection control issues, and attracting pests. A review of the facility's policy on floor maintenance, last revised in December 2009, stated that all floors should be mopped, cleaned, or vacuumed daily according to established procedures.
Failure to Maintain Accurate Resident Sign-In/Out Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who was reviewed for signing themselves in and out of the facility. The resident, who was diagnosed with Paranoid Schizophrenia and Type II Diabetes Mellitus with Diabetic Peripheral Angiopathy, was cognitively intact and had a physician's order allowing them to go out on therapeutic pass with medications. However, the resident did not consistently sign out or back into the facility on multiple occasions in August and September 2024. Interviews with the facility's Medical Director and Administrator revealed that the resident was competent and frequently left the facility on their own accord. The Administrator acknowledged that it was the resident's responsibility to sign in and out, with staff reminding them to do so. Despite this, the resident admitted to not always signing out or back in. The facility's Admission Agreement emphasized the importance of informing staff and signing in and out when leaving and returning to the premises, but this procedure was not consistently followed, leading to incomplete and inaccurate documentation of the resident's whereabouts.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A and Hospitality Aid B during incontinence care for a resident. The resident, a male with a history of cerebral infarction and requiring total assistance for toileting, was observed receiving care where the staff members did not perform hand hygiene between glove changes. This oversight occurred despite the staff having recently passed a competency check and completed an in-service on hand hygiene. During the care, CNA A and Hospitality Aid B removed the resident's soiled brief, cleaned the resident, and changed gloves without performing hand hygiene in between. Both staff members acknowledged their mistake, attributing it to nervousness. The Director of Nursing confirmed that the facility's policy required hand hygiene after every glove change and recognized that the failure to adhere to this policy could lead to infection.
Failure to Implement Comprehensive Care Plans with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, which included measurable objectives and time frames to meet their highest practicable physical, mental, and psychosocial well-being. Resident #2 did not have a care plan addressing enhanced barrier precautions (EBP) for his pressure ulcers or catheter. His care plan focused on pressure ulcer management but lacked specific interventions for EBP, which are crucial for preventing infections. Resident #3 also lacked a care plan addressing EBP for his catheter, feeding tube, or pressure ulcer. Despite having severe cognitive impairment and being dependent on a feeding tube for nutrition, his care plan did not include EBP interventions. The absence of these precautions increased the risk of infection and cross-contamination, as noted by the MDS Coordinator during the interview. Similarly, Resident #4's care plan did not include EBP for his catheter and pressure injury. Although his care plan addressed pressure injury and catheter management, it failed to incorporate EBP, which is essential for infection prevention. The MDS Coordinator acknowledged the oversight, stating that EBP should have been care planned for residents at particular risk for infection, but it was not done due to a lack of understanding of its importance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in implementing Enhanced Barrier Precautions (EBP) for three residents with chronic wounds and indwelling medical devices. Resident #2, a cognitively intact male with multiple pressure ulcers and an indwelling catheter, did not have EBP measures documented in his care plan or orders. Observations revealed no signage or PPE availability indicating EBP status, increasing the risk of cross-contamination and infection spread. Resident #3, with severe cognitive impairment, a feeding tube, and a stage III pressure ulcer, also lacked EBP documentation in his care plan. Observations showed no EBP signage or PPE at his bedside, and staff interviews indicated a lack of awareness and training on EBP protocols. Similarly, Resident #4, with severe cognitive impairment, an indwelling catheter, and a stage III pressure ulcer, had no EBP measures documented or implemented, as evidenced by the absence of signage and PPE. Interviews with facility staff, including the DON, ADON, and various nursing staff, revealed inconsistencies in understanding and implementing EBP. The ADON, responsible for infection control, admitted to not having posted necessary signage and acknowledged gaps in staff education. Staff members expressed confusion and lack of training regarding EBP, with some unaware of its existence or purpose, highlighting a systemic failure in the facility's infection control practices.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide adequate post-dialysis care for a resident who required dialysis services. The resident, a male with severe cognitive impairment and end-stage renal disease, was admitted with a history of kidney failure and was dependent on dialysis. Despite having a care plan that included monitoring for symptoms of kidney failure and ensuring the resident attended dialysis sessions, the facility did not complete post-dialysis assessments on multiple occasions. These assessments were crucial for checking vital signs and the condition of the resident's AV shunt, which were not documented in the resident's records. Interviews with facility staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed a lack of follow-up on post-dialysis assessments. The DON acknowledged that the resident often refused dialysis sessions and that the dialysis information was kept in a notebook before being entered into the electronic medical record. The Administrator confirmed that while pre-dialysis assessments were completed, post-dialysis assessments were consistently missing. The ADON admitted that they were responsible for ensuring chart documentation was complete but were not present when the resident returned from dialysis. The absence of a dialysis policy and the failure to complete post-dialysis assessments could lead to unrecognized changes in the resident's condition. The ADON highlighted the importance of these assessments in identifying potential issues such as infection or malfunction of the dialysis access site. Despite the facility's acknowledgment of the deficiency, no policy on dialysis was provided to the surveyor.
Failure to Post Required State Agency Contact Information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups in a manner accessible and understandable to residents and their representatives. This list should include the State Survey Agency, the State licensure office, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. During an observation and interview, the Assistant Director of Nursing (ADON) was unable to locate the required postings in any of the facility's public areas, including the dining room and lobby. The ADON admitted to not knowing where the information was posted and had to search unsuccessfully for it. Further interviews revealed that the Director of Nursing (DON) was also unaware of the current location of the postings, acknowledging that they had been removed during a repainting of the facility and had not been replaced. The Administrator confirmed awareness of the requirement for these postings but did not know why they were missing. The Administrator mentioned that a new poster with the necessary information was supposed to be provided by the Corporate President but had not yet arrived. In the meantime, a temporary 1-800 number was posted. The facility's policy on Resident Rights and Abuse emphasizes the importance of maintaining these postings to ensure residents can communicate with outside agencies regarding any concerns.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents, leading to deficiencies in their care. Resident #33, a male with congestive heart failure, type 2 diabetes, and prostate hypertrophy, did not have a care plan in place for his urinary catheter despite physician orders for Foley catheter care. Similarly, Resident #72, who also had an indwelling catheter, lacked a care plan addressing his catheter care needs. Resident #37, a female with severe cognitive impairment and dysphagia, did not have a care plan for her PEG tube, despite multiple physician orders detailing the care required for her feeding tube. Additionally, Resident #79, who experienced significant unplanned weight loss, did not have a care plan addressing her nutritional needs and weight management. This resident had a severe cognitive impairment and required moderate assistance with most ADLs. Resident #137, a female with psychosis and generalized anxiety disorder, was receiving psychotropic medications without a corresponding care plan. The facility's CRC acknowledged the oversight and stated that care plans were mostly left to him, leading to missed updates. The DON confirmed that care plans should automatically include critical aspects like catheters and psychotropic medications but admitted that the facility had inconsistencies in care plan documentation and weight management.
Failure to Ensure Secure Unit Exit Doors Had Alarms
Penalty
Summary
The facility failed to ensure that the secure units' exit doors at the end of each hall had alarms to indicate and alert staff that residents were going outside to the secure unit patios. This deficiency was observed from 04/09/24 through 04/11/24, during which several residents were seen going in and out of the secure unit patios without proper supervision. Staff were observed monitoring residents inside the units but not necessarily those outside on the patios. Interviews with multiple CNAs revealed that they were unaware of any alarms on the exit doors and monitored residents by physically checking the patios periodically. The Maintenance Supervisor, who had been with the facility for almost two years, also confirmed the absence of alarms and was unaware that the secure unit doors required them. The Administrator acknowledged the lack of alarms and stated that staff were supposed to monitor residents in the patios, but did not consider the need for alarms as the patios were secure areas. During observations, it was noted that the male secure unit's exterior doors did not have an alarm to alert staff when residents went outside, and the exterior door on E hall did not have a latch to close properly. Interviews with CNAs indicated that they relied on visual checks and physical rounds to monitor residents in the patios. None of the CNAs reported any incidents of residents falling outside, but they all confirmed the absence of door alarms. The facility did not provide or have a specific policy regarding secured doors in the secure unit, which contributed to the lack of adequate supervision and potential accident hazards for the residents.
Failure to Maintain Clean Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean kitchen and ensure proper food storage, preparation, and distribution in accordance with professional standards. Observations revealed pooled water in front of the three-compartment sink, an opened and spilling bag of dry gravy in the dry pantry, brown grime along the walls and under storage shelves, and a buildup of grime on equipment. Additionally, stainless steel freezer doors, handles, rolling carts, and kitchen floors were visibly dirty, and the wall behind the dishwasher was covered in black grime. The freezer contained two opened, unlabeled, and undated bags of frozen white nuggets. Interviews with the Director of Food and Nutrition Services (DM) and the Administrator confirmed awareness of the kitchen's condition. The DM acknowledged that the kitchen was not up to cleanliness standards and mentioned ongoing efforts to clean and retrain staff. The Administrator was aware of the grime issue and stated that efforts to scrape it off the wall were unsuccessful, leading to plans for wall replacement. Review of the facility's policies and cleaning schedules indicated that the kitchen should be cleaned daily, but these standards were not met.
Rodent Infestation in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents. During a group interview with nine residents, it was revealed that while the new pest control company had successfully reduced the number of insects, there was still a significant issue with mice. Two residents even mentioned having pet mice in their rooms, which they fed and allowed on their beds. A dead rat was also observed in an air vent in a supply closet containing medical supplies. The Regional Maintenance Director, on his first day, was unaware of the dead rat, and the Administrator acknowledged the ongoing rodent issue despite weekly treatments by the new pest control vendor. The Director of Nursing (DON) and the Administrator noted that some residents were feeding the mice, complicating efforts to eradicate them. Despite multiple discussions with residents about the health risks posed by the rodents, the problem persisted. The facility's Infection Control Policy aimed to maintain a safe and sanitary environment, but the presence of rodents indicated a failure to meet these objectives.
Failure to Ensure Privacy for Residents with Urinary Catheters
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents, Resident #33 and Resident #72, by not covering their urinary catheter drainage bags with privacy bags. Observations on multiple occasions revealed that the urine content of the bags was visible to other residents, visitors, and facility employees. Both residents were seen in the dining room without privacy bags on their catheter drainage bags. Resident #33, an elderly male with diagnoses including congestive heart failure and prostate hypertrophy, and Resident #72, an elderly male with acute kidney failure and major depression disorder, were both affected by this deficiency. Additionally, neither resident had a comprehensive care plan in place for their urinary catheters, further indicating a lapse in care planning and execution. Interviews with facility staff, including the CRC, RN, and DON, confirmed that the facility's policy required all catheter bags to be covered with privacy bags when residents were outside their rooms. However, it was noted that the privacy bags often fell off, and in some cases, residents removed them out of frustration. The facility's policy on catheter care, dated April 2021, also stipulated the use of privacy covers to preserve resident dignity, which was not adhered to in these instances.
Expired Insulin Pens Found in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate administering of all drugs to meet the needs of the residents. During an inspection of the medication cart for halls A, B, and C, two insulin pens were found with an open date of 03/06/24, which had expired according to the manufacturer's recommendations. The pens were only good for 28 days after being opened. LVN A, who was present during the inspection, admitted that she had not noticed the pens had expired and would have replaced them if she had. The ADON confirmed that it was each nurse's responsibility to check and dispose of expired insulin pens, and acknowledged that administering expired insulin could lead to reduced medication effectiveness. The Administrator also stated that there was no specific person assigned to check the carts for expired medications, and the failure occurred because staff did not pay attention to the dates on the insulin pens. The facility's policy, dated August 2020, indicated that medications should be administered in a safe and effective manner, and this guideline applied to all medications. The manufacturer's instructions for the insulin pens stated that opened pens and vials kept at room temperature or refrigerated would last for 28 days. The failure to adhere to these guidelines and policies resulted in the presence of expired insulin pens in the medication cart, potentially compromising the effectiveness of the medication administered to residents.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. Specifically, the medication cart for halls A, B, and C was observed to be unlocked, unattended, and unsupervised by staff on 04/09/24 at 11:24 AM. LVN A admitted to stepping away and forgetting to lock the cart, which contained several over-the-counter and prescription medications. This lapse in protocol was confirmed during an interview with the ADON, who acknowledged that it was each nurse's responsibility to ensure their carts were locked when not in use. The Administrator was also interviewed and confirmed that the expectation was for medication carts to be locked if staff were not present. The facility's policy, dated August 2020, indicated that all medication storage areas should be locked at all times unless in use and under direct observation. The failure to lock the medication cart was attributed to the nurse getting distracted and forgetting to secure it when stepping away.
Facility Failed to Maintain Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations on two consecutive days revealed grey colored water streaming from a drain clean out located at the end of A Hall, with soiled toilet tissue next to the drain clean out. The grey water ran from the clean out location to the end of the parking lot, pooling in areas next to the exit on A Hall. Despite efforts by the Maintenance Director to address the issue, grey water continued to pool and flow from the drain clean out, creating a hazardous environment. Interviews with the Regional Maintenance Director and the Administrator revealed that the facility was aware of plumbing issues due to the age of the building but was not aware of the active sewage leak. The Regional Maintenance Director confirmed that the wastewater drainage included bodily solids, bodily waste, and paper solids, and acknowledged the hazard it posed to residents and the potential for sickness and groundwater contamination. The facility's Infection Control Policy emphasized maintaining a safe, sanitary, and comfortable environment, which was not upheld in this instance.
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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