Focused Care At Odessa
Inspection history, citations, penalties and survey trends for this long-term care facility in Odessa, Texas.
- Location
- 2443 W 16th St, Odessa, Texas 79763
- CMS Provider Number
- 675751
- Inspections on file
- 28
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Focused Care At Odessa during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, Parkinson’s disease, schizophrenia, and significant mobility limitations, dependent on staff for transfers and using a wheelchair/Broda chair, was allegedly pulled up by the shirt in an abusive manner by an LVN, as documented in a CNA’s written note. The note was found under the SW designee’s office door and given to the Administrator, who, along with the SW designee, interviewed the resident; the resident reported sliding down in the chair and being pulled up by the shirt, and other residents reported feeling scared of the LVN. Despite the facility’s abuse policy requiring immediate (within 2 hours) reporting of all abuse allegations to the State Agency, the Administrator did not report this allegation, stating it was because the resident said the LVN had only pulled him up by his shirt.
The facility did not ensure that staff received adequate and consistent training on bomb threat preparedness, as evidenced by multiple staff members' inability to describe appropriate procedures and inconsistent responses to a resident's bomb threat. Despite some in-services and policy documents, staff were unclear on key steps such as information gathering, notification, and evacuation, resulting in a deficiency in emergency preparedness training.
Six residents receiving oxygen therapy did not have required 'No Smoking' or oxygen signs posted outside their rooms, despite facility policy mandating such signage. These residents, with diagnoses including heart failure, COPD, and respiratory failure, were observed using oxygen without appropriate door signage. Facility leadership interviews revealed no designated staff responsible for posting signs and a lack of awareness of the policy requirement.
A resident with multiple fall risk factors and a history of falls did not have a floor mat at the bedside as required by the care plan, resulting in a fall with head injury. Staff interviews confirmed the absence of the mat at the time of the incident, despite established protocols and policies for fall prevention.
A resident with profound intellectual disabilities and multiple complex medical conditions did not have PASRR recommendations fully incorporated into their assessment and care plan. The facility failed to submit a complete and accurate NFSS request in the required online portal within the mandated timeframe, resulting in delays in obtaining specialized services and equipment identified as necessary for the resident's care.
A resident with a history of seizures, poor coordination, aphasia, and psychiatric conditions was placed in isolation for shingles, but the facility failed to post required isolation signage on the door. Although PPE was available outside the room and staff were aware of the contact precautions, the absence of signage was observed and confirmed by staff interviews, indicating a lapse in the infection prevention and control program.
A resident with a history of mental health diagnoses reported feeling abused when a nurse withheld medication after a hospital return. The incident was communicated to facility leadership, and the nurse was reassigned, but the administrator did not report the allegation to state authorities as required by policy, citing a lack of corroboration and misunderstanding. This failure to report the abuse allegation constituted a deficiency.
A resident with profound intellectual disabilities, physical impairments, and limited mobility was repeatedly observed lying in bed without any individualized or in-room activities, despite care plan requirements. Staff interviews revealed a lack of awareness and implementation of activity provision, and the activities staff had not supplied engagement items or entertainment, resulting in unmet psychosocial and physical needs.
A resident receiving continuous tube feeding was not consistently maintained with the head of bed elevated as required by physician orders and the care plan. Observations showed the resident lying flat despite ongoing feeding, and staff interviews revealed inconsistent understanding and implementation of proper positioning. The facility's policy did not specify required bed elevation, and staff reported a lack of recent training on G-tube monitoring and positioning.
A resident with multiple medical conditions returned from the hospital after a fall, but the assigned LVN did not document the return, including time, new orders, or vital signs. Staff interviews confirmed that required documentation was not completed, and facility leadership acknowledged the deficiency.
The facility's kitchen failed to meet food safety standards, with issues such as rotting food, improper storage, and inadequate staff training on sanitizer use and handwashing. The Dietary Manager acknowledged these problems, noting lapses in staff responsibilities and training.
The facility failed to uphold resident dignity and respect, as staff were observed using cell phones in residents' presence, causing feelings of disrespect and neglect. Residents reported delays in care due to staff phone use, and assigned seating in the dining room was enforced without resident consent. Clothing was labeled in large print, further impacting resident dignity. Interviews with staff, including the DON, confirmed these practices and acknowledged the ongoing issue of cell phone use during care.
A facility failed to provide adequate supervision and safe transfer practices for three residents. One resident had his leg improperly secured to a wheelchair with a gait belt, leading to skin tears. Another resident, with severe mobility impairment, was transferred unsafely by a CNA without assistance or a gait belt. Two CNAs used an improper technique to transfer a resident on hospice care. The facility's policies on safe lifting and movement were not followed, resulting in potential harm.
The facility failed to maintain an effective infection prevention and control program during incontinent care for three residents. CNAs did not change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. Despite competency checks, the CNAs did not adhere to the facility's infection control policies.
A facility failed to implement a comprehensive care plan for a resident's ankle enabler. The resident, with severe cognitive impairment and physical limitations, was observed with his leg secured to a wheelchair using a gait belt, which was not documented in his care plan. The physical therapist and MDS Coordinator were unaware of this practice, indicating a lack of communication and adherence to the facility's policy for individualized care plans.
The facility failed to ensure proper documentation of oxygen orders for two residents who occasionally used oxygen therapy. Despite the presence of oxygen concentrators in their rooms, there were no formal orders or care plans in place, as confirmed by the DON.
The facility failed to date and initial wound dressings for a resident with skin tears on bilateral elbows and shoulders, as required by facility policy. This oversight was confirmed by the DON, who acknowledged that the failure could lead to not knowing when the dressings were last changed and who changed them.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Survey Agency immediately, and no later than two hours after the allegation was made. A resident with Parkinson’s disease, schizophrenia, muscle wasting, and atrophy, who was severely cognitively impaired (BIMS score of 5) and dependent on staff for transfers and bed mobility, was the subject of the allegation. The resident used a wheelchair/Broda chair for mobility and required extensive to total assistance, including a two-person assist with a Hoyer lift. An undated written note by a CNA stated that the CNA observed an LVN grab the resident and pull him up by his shirt in what the CNA described as an abusive manner while the resident was in a chair. The CNA documented that the resident said he thought his leg was broken and that the CNA cried because she believed what she saw was very wrong. This note was later found on the floor under the social worker designee’s office door. The social worker designee reported finding the note on a Friday morning and handing it to the Administrator. The DON reported that the incident involving the LVN aggressively pulling the resident up in his Broda chair occurred on or about late December and that the note was found on a Friday in early January. The Administrator stated that she and the social worker designee interviewed the resident, who reported that he had been sliding down in his chair and that the LVN had pulled him up by his shirt. The Administrator also stated that some residents reported being scared of the LVN because he was intimidating. Despite this allegation of abuse and the facility’s own abuse policy requiring that all events involving an allegation of abuse be reported immediately or no later than two hours after the alleged violation, the Administrator acknowledged that she did not report the allegation to the State Survey Agency because the resident said the LVN had only pulled him up by his shirt.
Failure to Provide Adequate Bomb Threat Preparedness Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff regarding emergency preparedness, specifically related to bomb threats. Interviews and record reviews revealed that five staff members, including CNAs and LVNs, were inadequately trained on how to respond to bomb threats. Staff members provided inconsistent and incomplete responses when asked about their actions in the event of a bomb threat, with some stating they would simply notify a nurse or administration, while others admitted they would not know what to do or had never received specific disaster training for bomb threats. The facility's disaster preparedness training was primarily focused on fire drills, and staff could not recall receiving comprehensive or regular training on bomb threat procedures. A specific incident involved a resident with a history of behavioral issues, including low frustration tolerance and potential for verbal aggression, who made a threatening statement about bombing the facility. Staff responses to this threat varied, with some reporting the incident to administration and others expressing uncertainty about the appropriate steps to take. Interviews indicated that staff were unclear about procedures such as keeping a caller on the line, gathering information, and notifying authorities, as outlined in the facility's emergency procedures. Some staff referenced prior training or town hall meetings, but these were described as brief and lacking in detail regarding bomb threat response. Review of facility documentation showed that while in-services on disaster preparedness and bomb threats were conducted, the content and frequency were insufficient to ensure staff competency. The facility's emergency procedure for bomb threats included specific steps and a telephone checklist, but staff interviews demonstrated a lack of familiarity with these protocols. The absence of a provided checklist and inconsistent staff knowledge contributed to the deficiency in emergency preparedness training.
Failure to Post Required Oxygen Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure that residents requiring oxygen therapy had appropriate oxygen signage posted outside their rooms, as required by the facility's own policy. Observations, interviews, and record reviews revealed that six residents who were receiving oxygen therapy did not have 'No Smoking' or oxygen signs posted on their room doors. Each of these residents had physician orders and care plans specifying the use of oxygen via nasal cannula at various flow rates to maintain adequate blood oxygen saturation levels. During observations, all six residents were noted to be receiving oxygen therapy in their rooms without the required signage present. The residents involved had significant medical histories, including diagnoses such as heart failure, respiratory failure, COPD, pulmonary fibrosis, and nicotine dependence. Their cognitive statuses ranged from severely impaired to relatively intact, as indicated by their BIMS scores. Despite the presence of oxygen equipment in use, there was no visual indication on the room doors to alert staff or visitors to the presence of oxygen, which is a standard precaution outlined in the facility's oxygen therapy policy. Interviews with facility leadership revealed a lack of clarity and accountability regarding the responsibility for posting oxygen signs. The DON acknowledged that there was no designated staff member assigned to ensure the signs were placed, and the administrator was unaware that the facility policy required signage on individual resident doors, mistakenly believing that a sign at the front entrance was sufficient. Review of the facility's oxygen therapy policy confirmed the requirement to post 'No Smoking' signs on the outside of doors to rooms where residents are receiving oxygen.
Failure to Provide Required Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, a resident with a significant history of falls and multiple risk factors—including cerebrovascular disease, seizures, psychotic disorder, muscle weakness, lack of coordination, and cognitive impairment—did not have a floor mat at the bedside as required by his care plan. The care plan, updated prior to the incident, explicitly included interventions such as keeping the bed in a low position and placing a fall mat at the bedside when the resident was in bed. On the day of the incident, the resident was found to have fallen out of bed, sustaining a laceration and hematoma to the left forehead. Staff interviews revealed that the resident had recently been moved to a new room, and the floor mat was not present at the bedside at the time of the fall. CNAs and nursing staff acknowledged that the resident was a known fall risk and that the absence of the floor mat was contrary to established fall prevention protocols. The incident was unwitnessed, and the resident was later sent to the hospital for evaluation, where imaging confirmed a subcutaneous hematoma but no acute intracranial injury. Multiple staff, including CNAs, LVNs, the ADCO, and the DCO, confirmed that fall prevention measures such as floor mats, low beds, and accessible call lights were standard practice for residents at risk of falls. The failure to have the floor mat in place was recognized by staff and administration as a lapse in following the resident's care plan and facility policy. The facility's own policy required that fall prevention programs be implemented and reviewed after any fall, and that interventions be documented and updated in the plan of care.
Failure to Incorporate PASRR Recommendations and Timely Submit NFSS Request
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into the assessment, care planning, and transition of care for a resident identified as needing specialized services. The resident, a male with multiple complex diagnoses including profound intellectual disabilities, cerebral palsy, epilepsy, hemiplegia, and significant mobility limitations, was admitted with a positive PASRR Level 1 screening for intellectual disability and was determined to require specialized services. Despite this, the facility did not ensure that the PASRR recommendations were fully integrated into the resident's care plan and assessment process. Record reviews showed that the resident's quarterly MDS assessment did not include a BIMS score and was marked as moderately impaired for cognitive skills. The PASRR evaluation confirmed the need for specialized services, and an IDT meeting was held to identify necessary services such as durable medical equipment. However, the facility failed to submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the required LTC online portal within 20 days after the IDT meeting, as mandated by state policy. The initial NFSS submission was declined due to missing required assessments, and the resubmission was still pending at the time of the survey. Interviews with facility staff revealed gaps in communication and understanding of the PASRR process, with staff members unaware of the current status of equipment requests and the specific needs of the resident. The delay in submitting the NFSS form and the lack of integration of PASRR recommendations into the care plan resulted in the resident not receiving timely access to the specialized services identified as necessary for his care.
Failure to Post Isolation Signage for Resident with Shingles
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was placed in isolation due to shingles. Although the resident was moved to isolation and had personal protective equipment (PPE) available outside her room, there was no signage posted on the door to alert visitors and staff that the resident was under isolation precautions. Multiple staff interviews confirmed that the resident was on contact precautions for shingles, but the required signage was missing. Staff members acknowledged noticing the absence of signage but did not report it, and responsibility for ensuring signage was posted was attributed to nursing administration and the infection preventionist nurse. Record reviews indicated that the resident had a history of seizures, poor coordination, aphasia, anxiety, psychosis, and schizoaffective disorder, and was cognitively severely impaired. The care plan and physician orders documented the need for isolation and antiviral treatment for shingles. Despite these documented precautions, the lack of isolation signage was observed during the survey, and staff interviews confirmed that this omission could result in visitors or staff entering the room without appropriate PPE, increasing the risk of cross-contamination.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident who reported that a nurse withheld medication after the resident returned from the hospital and missed a scheduled dose. The resident, who had diagnoses of generalized anxiety, schizophrenia, and bipolar disorder and was assessed as cognitively intact, stated that he felt abused when the nurse did not administer his inhaler as requested. The resident reported the incident to the facility administrator, expressing that he felt the nurse's actions constituted abuse. Interviews with staff revealed that the nurse in question was reassigned from the resident's care following the complaint, and a disciplinary action was documented for speaking loudly and harshly to another resident. The Director of Clinical Operations and other staff confirmed that the incident was communicated internally, and the nurse was removed from the resident's care. However, the administrator determined that the incident did not constitute abuse and did not report it to the state survey agency or other required authorities, as required by the facility's abuse policy. The facility's abuse policy mandates that all events involving allegations of abuse or suspicious injuries of unknown origin must be reported immediately or within two hours of the alleged violation. Despite this policy, the administrator did not report the resident's allegation to the appropriate authorities, citing a lack of corroboration and a belief that the incident was a misunderstanding. This failure to report the allegation as required by policy and state law constituted the deficiency.
Failure to Provide Individualized Activities for Resident with Complex Needs
Penalty
Summary
The facility failed to provide regular, individualized activities to a resident with significant physical and cognitive impairments. The resident, a male with multiple diagnoses including contractures, muscle weakness, scoliosis, reduced mobility, encephalopathy, profound intellectual disabilities, epilepsy, cerebral palsy, and hemiplegia, was observed multiple times over the course of a day lying in bed, nonverbal, and without any form of engagement or stimulation. The care plan indicated a need for in-room activities as needed and required, but there was no evidence that such activities were being provided. Interviews with staff revealed a lack of awareness and implementation regarding the resident's activity needs. A CNA stated she was not aware of any in-room activities provided to the resident and had only seen him in bed without engagement items. The Activities Director confirmed that no in-room activities or entertainment, such as a radio, were provided and was unable to explain why. The Activities Director also expressed unfamiliarity with the resident's cognitive level and the risks of limited stimulation. Although the Administrator stated the resident participated in some facility events and received bedside engagement, there was no documentation or observation supporting regular, individualized activity provision as required by the facility's guidelines.
Failure to Maintain Proper Head of Bed Elevation During Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident receiving continuous enteral feeding was not maintained with the head of bed (HOB) elevated as required by physician orders and the resident's care plan. The resident, a female with multiple diagnoses including seizures, poor coordination, aphasia, anxiety, psychosis, and schizoaffective disorder, was observed in bed with the HOB at 30 degrees, but her torso and upper body were lying flat halfway down the mattress while tube feeding was ongoing. Staff interviews revealed inconsistent understanding and implementation of the required HOB elevation, with some staff believing a lower elevation was sufficient and others acknowledging the need for a 45-degree angle. The resident was nonverbal and unable to self-advocate for proper positioning. Record reviews showed that both the care plan and physician orders specified maintaining the HOB at a minimum of 30 degrees, preferably 45 degrees, during and after tube feeding to reduce aspiration risk. However, staff interviews indicated a lack of recent training on G-tube monitoring and positioning, and the facility's policy did not directly address required bed elevation during enteral feeding. The resident's tendency to slide down in bed was noted, but regular repositioning to maintain proper alignment was not consistently performed, leading to the deficiency.
Failure to Document Resident's Return from Hospital
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who returned from the hospital. Specifically, there was no documentation by the assigned LVN regarding the resident's return, including the time of return, new orders, or vital signs. The expectation was for staff to document these elements upon a resident's return from the hospital, but this was not completed. The LVN responsible acknowledged that the readmission assessment was not performed, citing a busy shift and communication issues as contributing factors. The resident involved was an older male with multiple complex medical diagnoses, including cerebrovascular disease, seizures, psychotic disorder, substance dependence in remission, generalized anxiety disorder, major depressive disorder, lack of coordination, muscle weakness, rhabdomyolysis, mild cognitive impairment, and a history of stroke. He had recently experienced a fall in the facility, resulting in a laceration and hematoma to his left forehead, and was sent to the hospital for evaluation. Upon his return, there was no documentation in the medical record to reflect his condition, any new orders, or interventions performed at the hospital. Interviews with facility staff confirmed that documentation was not completed as required. The ADCO and DCO both stated that staff are expected to document upon a resident's return from the hospital, including any new orders and interventions, and that failure to do so could impact continuity of care. The facility did not have a specific policy on accuracy of documentation, but training was provided to staff on documentation expectations. The lack of documentation was identified during the survey process and acknowledged by facility leadership.
Deficiencies in Food Safety and Staff Training
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The deficiencies included the presence of rotting food, such as discolored bananas and slimy potatoes, which were not discarded. Additionally, food items were not dated according to the facility's policy, and some were stored improperly, such as canned goods on the floor and food debris under shelves in both the dry storage and walk-in freezer. The Dietary Manager (DM) acknowledged these issues, noting that the night shift was responsible for certain tasks like putting up cans and cleaning under shelves, but these tasks were not consistently completed. Further deficiencies were noted in staff training and practices. Staff members were not adequately trained on checking the sanitizer level in the dishwasher, as evidenced by an employee using incorrect test strips. Handwashing practices were also inadequate, with an employee observed turning off the faucet with bare hands after washing. The DM admitted to not regularly checking the walk-in freezer and assumed that staff had been trained on certain procedures at other facilities. The facility's policies on food preparation and storage were not followed, contributing to the risk of foodborne illness and cross-contamination for residents receiving meals from the kitchen.
Deficiency in Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by several observations and interviews. Staff were observed using cell phones in the presence of residents, which made the residents feel disrespected and ignored. During a confidential resident council meeting, residents unanimously agreed that staff were frequently on personal calls, causing delays in care, such as a resident waiting 40 minutes for assistance, resulting in a rash. Additionally, staff were seen moving residents to different tables in the dining room without their consent, and residents were subjected to assigned seating, which was likened to being on house arrest. Furthermore, residents' clothing was labeled in large print, which was confirmed by a laundry aide and the Director of Nursing (DON), who acknowledged the labeling practice. Interviews with staff, including Licensed Vocational Nurses (LVNs) and the DON, revealed that cell phone use by aides was a known issue, with some aides being more frequent offenders than others. The DON admitted that staff cell phone use was a constant battle and that aides were observed using phones in resident rooms and during smoke breaks. The DON and Assistant Director of Nursing (ADON) also discussed the practice of assigned seating in the dining room, which was primarily for residents needing assistance with eating. The DON expressed that she would feel uncomfortable receiving care from someone on the phone, indicating awareness of the issue's impact on resident dignity.
Inadequate Supervision and Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents. Resident #17, who had severe cognitive impairment and hemiplegia, was found with his right leg secured to his wheelchair with a gait belt, which was not ordered or documented in his care plan. The nursing staff and the resident's doctor were unaware of this practice, which was initiated by the therapy department for transport purposes but continued by aides without proper assessment or instruction. This unauthorized use of the gait belt led to skin tears and discomfort for the resident. Resident #18, diagnosed with dementia and severe mobility impairment, was transferred by a CNA from his bed to his wheelchair without assistance or a gait belt, despite being dependent on staff for transfers. The CNA admitted that the transfer method was unsafe and acknowledged the risk of injury to both the resident and herself. The facility's Kardex did not specify the number of staff required for transfers, leading to confusion and improper handling of the resident. Resident #51, who was on hospice care and required moderate assistance for transfers, was moved by two CNAs using an improper technique. They lifted him by his arms and the waistband of his pants, which was not in line with safe transfer practices. The CNAs claimed they were trained to perform transfers this way, indicating a lack of proper training and understanding of safe transfer protocols. The facility's policy on safe lifting and movement of residents was not adhered to, resulting in potential harm to the residents involved.
Infection Control Deficiency in Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs during incontinent care for three residents. CNA A did not change her gloves after they became contaminated and failed to wash or sanitize her hands between glove changes while assisting a resident with severe cognitive impairment and frequent incontinence. This resident was at risk for skin breakdown, and the care plan required monitoring and prompt changing of incontinence products. CNA B also failed to change gloves after they became contaminated while providing care to two other residents. One resident, who was cognitively intact, required assistance due to limited mobility and frequent bowel incontinence. CNA B did not change gloves after removing soiled items and before handling clean items. Similarly, while assisting another resident with frequent incontinence, CNA B did not change gloves after applying barrier cream and before handling clean briefs and clothing. Interviews with the CNAs revealed a lack of adherence to proper infection control procedures, with CNA A acknowledging her mistake and CNA B unaware of the facility's policy. The facility's policies on hand hygiene and infection control were reviewed, indicating that hand hygiene should be performed before and after glove use, and that all personnel should be trained on these practices. Despite competency checks, the CNAs did not follow the established procedures, leading to potential cross-contamination and infection risks.
Failure to Implement Comprehensive Care Plan for Resident's Ankle Enabler
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, specifically regarding the use of an ankle enabler. The resident, a male with severe cognitive impairment and physical limitations due to a stroke and hemiplegia, was observed multiple times with his right leg secured to his wheelchair using a gait belt. This practice was not documented in his care plan, and there was no order for such an enabler. The resident's care plan, initiated months prior, addressed his mobility issues but did not include any interventions related to the use of a gait belt for his leg. Interviews revealed that the physical therapist was unaware that the gait belt was being used outside of therapy sessions and had not assessed the resident for its use. The MDS Coordinator also stated they were not informed about the use of the gait belt and only care planned it after being made aware. The facility's policy requires an individualized interdisciplinary care plan, but this was not adhered to in the case of this resident, leading to a deficiency in providing individualized care and services.
Failure to Document Oxygen Orders for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during a survey. Resident #41, a cognitively intact female with diagnoses including end-stage renal disease and heart failure, occasionally used oxygen when experiencing shortness of breath. However, there were no documented orders for oxygen in her medical records, despite the presence of an oxygen concentrator in her room. Similarly, Resident #20, also cognitively intact and diagnosed with conditions such as obstructive sleep apnea and morbid obesity, used oxygen as needed but lacked a formal order for oxygen therapy in her records. The Director of Nursing (DON) acknowledged awareness of the residents' use of oxygen but was uncertain why there were no official orders or care plans in place. The absence of documented orders for oxygen therapy for these residents indicates a failure to adhere to professional standards of practice, potentially compromising the residents' respiratory care needs.
Failure to Date and Initial Wound Dressings
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and services consistent with professional standards of practice to promote wound healing, prevent infection, and prevent new ulcers from developing. Specifically, the facility did not date and initial the wound dressings for a resident with skin tears on bilateral elbows and shoulders, as required by facility policy. This was observed during a skin assessment, where the resident's bandages were found to be undated and uninitialed. The resident was not interviewable at the time of the assessment. The Director of Nursing (DON) confirmed that the wound dressings should have been dated and initialed by the nurse performing the wound care, per facility policy. The DON acknowledged that the failure to date and initial the dressings could lead to not knowing when the dressings were last changed and who changed them. The facility's policy on skin management, effective since 11/01/19, mandates that wound care dressings be dated and initialed to ensure proper treatment and monitoring.
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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