Focused Care At Sherman
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman, Texas.
- Location
- 817 W Center, Sherman, Texas 75090
- CMS Provider Number
- 675089
- Inspections on file
- 45
- Latest survey
- January 31, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Focused Care At Sherman during CMS and state inspections, most recent first.
Surveyors found that several shared rooms lacked proper privacy curtains for one of the bed spaces, including one room with no curtain or ceiling track, another where the curtain was used to cover an uncovered window leaving the bed end exposed, and a third with a track but no curtain installed. Staff including an LVN, CNAs, an RN, and the Activity Director all acknowledged that privacy and dignity are important for residents’ self-esteem and comfort, and CNAs reported that repair and installation needs were to be entered in a maintenance logbook, but the missing or misused curtains remained unaddressed, leaving affected residents without full visual privacy during care.
Two residents with cognitive impairment and ADL self-care deficits were observed in public areas without adequate protection of their privacy and dignity: a female resident was seated in the lobby and later in the dining room without clothing from the waist down, with her brief and leg exposed up to the hip, and a male resident with an indwelling urinary catheter was in the dining room with his urine collection bag hanging from his wheelchair without a privacy cover. Staff interviews confirmed awareness of the importance of dignity and privacy, and facility policy required residents to be treated with respect and dignity.
The facility failed to ensure timely response to resident call lights, as multiple residents who were alert, oriented, and dependent on assistance due to conditions such as muscle weakness, lack of coordination, blindness, stroke history, and wheelchair use reported waiting from 15 minutes to over an hour for staff to respond. Surveyors repeatedly observed active call lights on the panel while staff, including RNs, LVNs, CNAs, and other personnel, remained at the nurse’s station or in the dining room without attempting to answer them, and test activations of call lights by residents remained unanswered for extended periods. Staff interviews confirmed that everyone was expected to answer call lights, yet no one was specifically assigned during meals, and leadership acknowledged there was no policy or procedure governing response to active call lights or assistance with activities of daily living, resulting in prolonged unmet needs for several residents.
A resident with dementia and other psychiatric diagnoses experienced increased confusion and distress, repeatedly expressing fear and discomfort about her male roommate, whom she no longer recognized. Staff failed to recognize these concerns as possible abuse or neglect, did not investigate or intervene, and lacked a care plan or policy addressing resident relationships and consent. The situation persisted without appropriate action until identified as Immediate Jeopardy by surveyors.
Two residents experienced serious incidents due to inadequate supervision and failure to control environmental hazards. One resident with moderate cognitive impairment eloped from the facility in a wheelchair after being let out by a visitor who had access to the door code, while another resident with limited mobility and impaired hand function sustained a second-degree burn after spilling overheated coffee on herself when left unattended in a reclined position.
Surveyors identified multiple deficiencies in food storage, preparation, and service, including unlabeled and improperly sealed food items, lack of facial hair coverings by dietary staff, failure to clean the grease trap as required, improper storage of broken tiles near open food, and failure to record food temperatures before serving. These actions were confirmed through staff interviews and direct observation.
A resident with dementia and other psychiatric diagnoses repeatedly expressed discomfort and lack of safety sharing a room with a male roommate, whom she no longer recognized. Despite her statements and behaviors indicating distress, staff continued to redirect her back to the shared room without reassessing her safety or updating her care plan, and the facility did not address her capacity to consent to the living arrangement.
Several residents' care plans did not address important aspects such as resident relationships and contracture management, despite staff and family awareness and existing therapy orders. Staff interviews revealed confusion about care planning responsibilities, and documentation showed that care plans were not updated to reflect current needs or physician orders, resulting in incomplete guidance for individualized resident care.
Surveyors found that a resident's insulin pen and a vial of TB PPD were not dated when opened, and multiple vials of flu vaccine and TB PPD were stored in an unsecured office refrigerator. Staff interviews confirmed that opened medications should be dated and securely stored, but these procedures were not followed, in violation of facility policy.
Staff failed to follow infection prevention protocols, including hand hygiene and proper glove use, during blood sugar checks and incontinence care for three residents with diabetes and Alzheimer's. An LVN did not sanitize hands or equipment properly and placed a soiled glucometer on a dining table, while a CNA handled clean briefs with soiled gloves and left a resident's room without hand hygiene. These actions were contrary to facility policy and acknowledged by staff during interviews.
A facility failed to maintain an effective pest control program, resulting in gnats being observed in a resident's room, the kitchen, a hallway, and the nurses' station. Staff and department heads confirmed ongoing issues with gnats, particularly in areas where food was present or consumed. Pest control logs and service records showed repeated reports and treatments for gnats, but the problem persisted across multiple areas of the facility.
The facility did not properly coordinate PASARR assessments or make necessary referrals after a resident was diagnosed with a serious mental illness. Despite documentation of a new schizoaffective disorder diagnosis, required follow-up screenings and reviews were not completed, leading to missed opportunities for appropriate mental health services.
A baseline care plan was not completed within 48 hours of admission for a resident with multiple complex medical needs, including COPD, heart failure, and continuous oxygen use. Only the Social Services section was initiated, and staff interviews revealed confusion about responsibility and lack of training regarding the care plan process. Facility policy required an RN to initiate the plan and for it to address immediate needs through an interdisciplinary approach, which was not followed.
A resident with a history of stroke, arthritis, and left-hand contracture did not receive consistent interventions to maintain or improve range of motion. Despite orders for a hand brace and documentation of the contracture, the care plan lacked appropriate interventions, and the brace order was discontinued without proper interdisciplinary communication. Staff were unclear about the resident's need for a splint, and the required restorative program was not implemented after therapy discharge.
Nursing staff failed to prime insulin pens before administering insulin to two residents with diabetes, contrary to manufacturer instructions and facility policy. One nurse was unaware of the priming requirement, while another forgot to perform the step, resulting in both residents potentially not receiving the full prescribed insulin dose.
A resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors was able to leave the facility unsupervised during a busy event. Staff failed to complete an elopement risk assessment upon admission and did not consistently recognize or communicate the resident's exit-seeking behaviors, resulting in the resident being found several blocks away by a bystander before being returned to the facility.
The facility did not follow its abuse prevention and reporting policy when a resident was witnessed hitting another resident. The incident was not documented in the facility's incident reports, and staff, including the DON and Administrator, were unaware of the event. Although staff are trained on reporting protocols, the required notification to the abuse coordinator and state agency was not made.
The facility failed to secure controlled medications in two medication carts, with broken seals found on bubble packaging cards of Tramadol, Alprazolam, and Lorazepam. Despite appropriate narcotic log counts, the compromised seals posed a risk of drug diversion. Staff interviews revealed that the broken seals were not noticed during routine counts, and the facility's policy for handling such issues was not followed.
A resident with severe cognitive impairment and chronic pain did not receive their scheduled Fentanyl patch due to misappropriation by an RN, who used the patch for personal recreational use. The RN, with a history of substance abuse, was found unresponsive due to an overdose, leading to emergency intervention. The facility's policy against medication diversion was violated.
A resident with severe cognitive impairment and frequent incontinence developed a pressure ulcer on the lower back, which was not treated in a timely manner due to communication and documentation failures. Despite weekly skin assessments indicating the presence of a wound, the WCN was not informed until several days later, delaying treatment. The facility's protocols for wound care and skin management were not effectively followed, leading to a deficiency in care.
Failure to Provide Privacy Curtains for Multiple Bed Spaces
Penalty
Summary
The deficiency involves the facility’s failure to ensure full visual privacy for residents in three of twelve rooms reviewed, specifically the B beds in rooms identified in the report. Surveyor observations showed that one room lacked a privacy curtain for Bed B and did not even have a ceiling track installed to allow a curtain to be hung. In another room, the privacy curtain for Bed B had been repositioned over the window because the window did not have its own curtain, leaving the end of Bed B exposed. A third room had a ceiling track installed for a privacy curtain for Bed B, but no curtain was present. The report states that this failure placed residents at risk for no visual privacy during care, which could cause decreased feelings of self-worth. Multiple staff interviews confirmed that privacy and dignity were recognized as important aspects of resident care. The Activity Director, LVN, CNAs, and RN all stated that residents had a right to privacy, that the facility was the residents’ home, and that protecting privacy was important for dignity, self-esteem, comfort, and helping residents feel safe and valued. CNAs reported that requests for repairs, including hanging curtains, were placed in a maintenance logbook, and one CNA stated she had not noticed the lack of curtains on the 100 Hall and that maintenance was responsible for hanging curtains. An attempted interview with the Director of Plant Operations was unsuccessful. Review of the facility’s “Quality of Life – Homelike Environment” policy from May 2017 reflected that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Protect Resident Dignity and Privacy in Public Areas
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity by allowing two residents to remain exposed in public areas. One resident, an elderly female with dementia, severe cognitive impairment (BIMS score of 7), wheelchair use, and total dependence on staff for ADLs including lower body dressing, was observed in the main lobby in a reclining chair with a blanket moved to the side and no clothing from the waist down, leaving her brief exposed. When asked if she wanted to cover up or wear pants, she declined. Later the same day, she was observed in the dining room eating her noon meal in the same reclining chair with her left leg exposed up to her hip and her brief visible, while other residents were in the immediate area. Her care plan documented an ADL self-care deficit and bowel and bladder incontinence. A second resident, an elderly male with kidney failure, complications of an indwelling urinary catheter, Parkinson’s disease, moderate cognitive impairment (BIMS score of 9), and dependence on staff for most ADLs, was observed eating his noon meal in the main dining room with his urine collection bag hanging from his wheelchair without a privacy cover. His care plan documented bladder incontinence, an indwelling catheter, and an ADL self-care deficit. Multiple staff interviews, including with the Activity Director, LVN, CNAs, RN, and ADON, confirmed their understanding that residents’ privacy, dignity, and self-esteem should be protected, that residents should not be exposed to others, and that the facility is the residents’ home. The ADON stated she was not aware that the male resident had been out without a privacy cover on his urine collection bag or that the female resident had exposed herself by pulling off her blanket, and stated the female resident should have been fully dressed. The facility’s Resident Rights policy required employees to treat all residents with kindness, respect, and dignity and affirmed residents’ rights to a dignified existence and to be treated with respect, kindness, and dignity.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident call lights were answered within a reasonable time, affecting three residents who relied on the call system for assistance. During initial rounds, surveyors observed two active call lights on the panel at the nurse’s station while three staff members sat at the station typing on computers without attempting to respond. One resident, who used a wheelchair and had diagnoses including muscle weakness, unsteadiness, lack of coordination, hyperlipidemia, and erosive osteoarthritis, reported that call light response times usually ranged from 15–30 minutes and sometimes up to an hour. At his request, his call light was activated and remained unanswered for approximately 23 minutes while staff, including an RN and the Facility Administrator, were present and made no attempt to respond. A floor technician reported that while working in laundry and housekeeping, he frequently observed residents waiting 30 minutes to an hour or longer for call lights to be answered, and that residents sometimes asked him to get a nurse because their call lights had been on for an hour without response. On the same day, staffing records showed four CNAs on duty for the morning shift, all of whom were observed in the dining room passing trays at noon, with no staff member observed as assigned to answer call lights during the meal. Multiple staff, including an RN, a CMA, and a CNA, stated that everyone could answer call lights and that there was no reason for licensed nurses not to respond, and one CMA stated her expectation that call lights should be answered within ten minutes. However, surveyors repeatedly observed active call lights on the panel with no attempts by available staff, including RNs and LVNs, to answer them. Two additional residents, both alert and oriented with BIMS scores of 15, reported prolonged call light response times. One resident, with a history of stroke, unsteadiness, lack of coordination, and wheelchair use, stated that call lights were answered anywhere from 15 minutes to one and one-half hours and activated his call light during the interview; another resident, who was blind with multiple diagnoses including repeated falls, myocardial infarction, anxiety disorder, muscle weakness, lack of coordination, cancer, hypertension, and polyneuropathy, stated that it took too long for call lights to be answered and that her family member sometimes had to help her lift her legs into bed. Both residents’ call lights remained unanswered at the end of a 45-minute interview. Later observations again showed two room call lights active while an RN, an LVN, and a CNA sat at the nurse’s station typing on computers without responding. In an interview with leadership staff, it was confirmed that the facility had no policy or procedure for any staff member regarding answering active call lights and assisting residents with needs and activities of daily living.
Failure to Prevent and Address Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to implement and follow written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for a resident with moderate to severe cognitive impairment. The resident, who had diagnoses including dementia, anxiety disorder, major depressive disorder, bipolar disorder, and schizophrenia, experienced increased confusion and no longer recognized her male roommate, with whom she previously had a relationship. Despite repeated expressions of fear and discomfort about her roommate, staff did not recognize these as possible allegations of abuse or neglect, nor did they investigate or intervene appropriately. The resident was observed repeatedly asking to leave, expressing fear of the roommate, and refusing to be in the same room or sit with him, yet staff continued to redirect her without addressing her underlying concerns or reassessing the appropriateness of the cohabitation arrangement. Progress notes and staff interviews revealed that the resident's confusion and distress persisted over several days, with staff documenting her statements about a 'creepy man' in her room and her refusal to be left alone with him. Despite these clear indications of psychosocial harm and potential neglect, there was no care plan addressing the cohabitation or relationship, and no assessment of the resident's capacity to consent to the relationship. Staff, including LVNs, the ADON, and the DON, failed to recognize the situation as a possible allegation of abuse or neglect, and did not report or protect the resident from further psychosocial harm. The facility also lacked a policy regarding resident capacity or consent for relationships and did not have procedures in place to assess or document consent when a resident's cognitive status changed. Interviews with staff and leadership confirmed that concerns about the resident's safety and consent were not escalated or addressed in a timely manner. The DON and Executive Director were unaware of the specific language used in progress notes indicating fear and discomfort, and there was no investigation or intervention until the situation was identified as Immediate Jeopardy by surveyors. The facility's failure to identify, report, and intervene placed the resident at risk for continued psychosocial harm and did not ensure her right to be free from abuse, neglect, and exploitation.
Failure to Prevent Elopement and Hot Liquid Burn Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who was moderately cognitively impaired and assessed at medium risk for elopement, was able to leave the facility in his wheelchair without staff knowledge. The resident was found outside the facility at a nearby intersection, having been let out by a family member of another resident who had access to the door code. The door alarm did not sound, and staff were unaware of the resident's absence until he was returned by a nurse who happened to see him outside. The resident had no prior history of exit-seeking behavior, and the care plan required supervision while smoking but did not anticipate this type of elopement. Another resident, also moderately cognitively impaired and with limited mobility, sustained a second-degree burn after spilling hot coffee on herself. The resident had requested her coffee be reheated, and a CNA used the microwave to heat the beverage before returning it to the resident, who was lying with her bed head lowered. The CNA placed the coffee on the overbed table and left the room after warning the resident that it was hot. The resident attempted to drink the coffee without raising her head, resulting in the spill and subsequent burn to her chin and chest. The resident had difficulty grasping the cup due to weakness in her left hand and was right-handed but wore a wrist splint on her right wrist. In both cases, the facility did not implement or enforce adequate supervision or safety measures to prevent the incidents. The first resident was able to exit the building due to a lack of control over access codes and insufficient monitoring of visitors' actions. The second resident was given a hot beverage without proper assessment of her ability to safely consume it in her current position, and the staff member did not ensure the resident was sitting up before leaving the coffee within reach.
Food Storage, Preparation, and Service Deficiencies Identified
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in its only kitchen. Observations revealed multiple food items in the facility's refrigerators and freezers that were not labeled or dated, including opened bags of bacon, lettuce, onions, tomatoes, and other items. Some food items were not properly sealed, and containers of liquids such as tea and water were found without covers or labels. Additionally, opened and unsealed bags of vegetables and other foods were stored inappropriately, and broken kitchen tiles were stored on shelves near open food items. Dietary staff were observed preparing and serving food without wearing required facial hair coverings. The staff acknowledged the availability of facial hair coverings but did not use them, stating that the coverings were ineffective and that they were awaiting new ones. The grease trap on the cooking griddle was found to be dirty, with a significant buildup of grime and liquid, and was not emptied or cleaned after each use as required. The staff admitted to emptying the trap only once daily, contrary to expectations, and could not recall when it was last cleaned. Meal temperature logs showed that food temperatures were not taken or recorded for certain meals, and staff admitted to forgetting to check temperatures before serving food. During meal service, food was served without verifying that it had reached safe temperatures. Facility policies required all food to be labeled, sealed, and stored properly, and for staff to wear appropriate uniforms, including facial hair coverings, while preparing and serving food. These deficiencies were confirmed through interviews with dietary staff and the Director of Food Services, who acknowledged the lapses in following established procedures.
Failure to Protect Resident from Emotional Distress Due to Unaddressed Roommate Concerns
Penalty
Summary
The facility failed to protect a female resident's right to be free from abuse and neglect when she expressed discomfort and a lack of safety sharing a room with a male resident. Despite the resident's repeated statements that she did not know her roommate, did not want to be in the same room with him, and described him as 'creepy' and 'weird,' the facility did not address her concerns or take action to separate them. The resident, who had a history of dementia, anxiety, depression, bipolar disorder, schizophrenia, and a BIMS score indicating moderate to severe cognitive impairment, exhibited increased confusion, exit-seeking behaviors, and distress related to her roommate. Progress notes documented her confusion, refusal to return to her room, and requests for help to leave the situation, yet staff continued to redirect her back to the same environment without reassessing her safety or consent to the living arrangement. The care plans for both residents did not address their cohabitation or relationship, and there was no assessment of the female resident's capacity to consent to the relationship after her cognitive decline. Staff interviews revealed that although the residents had previously been considered companions, the female resident's cognitive status had changed significantly, leading her to no longer recognize her roommate or recall their relationship. Multiple staff members noted her discomfort and confusion, but the facility did not implement interventions to ensure her safety or dignity, nor did they update her care plan to reflect her wishes or current condition. Facility policy required immediate protection of residents suspected of being abused or neglected, including assessment and intervention to prevent further harm. However, the facility did not follow these procedures when the resident's statements and behaviors indicated distress and a lack of consent to her living situation. The deficiency was identified through observation, interviews, and record review, and it was determined that the facility's failure to act placed the resident at risk for emotional harm and mental anguish.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, specifically neglecting to address resident relationships and a contracture management need. For multiple residents who were in consensual, non-sexual relationships or cohabitating, the care plans did not include any mention of these relationships, despite staff and family awareness. Interviews with staff, including the DON, ADON, and Executive Director, revealed uncertainty or lack of clarity about whether such relationships should be care planned, even though the Regional MDS Coordinator and other staff acknowledged the importance of including these aspects to ensure resident rights, privacy, and safety. In the case of a resident with a left-hand contracture, the care plan did not reflect the need for or use of a splint or brace, despite therapy orders and documentation in the facility's contracture management logs. Observations showed the resident without the prescribed splint, and interviews with staff indicated a lack of awareness or follow-through regarding the order and its inclusion in the care plan. The Director of Rehabilitation confirmed that the splint was necessary and should have been care planned, but noted that the order had been discontinued without his knowledge and that the care plan was not updated accordingly. Record reviews and staff interviews consistently demonstrated that care plans were not updated to reflect all current physician orders, therapy recommendations, and resident needs, particularly in the areas of psychosocial relationships and contracture management. The facility's own policy required the interdisciplinary team to review practitioner notes and orders and implement a comprehensive care plan, but this was not done for the residents in question. As a result, staff may not have been fully informed of or able to address the individualized needs of these residents.
Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. An insulin pen used for a resident was not dated when opened, and the nurse administering the medication was unable to determine how long the pen had been in use. The nurse acknowledged that insulin pens are required to be dated upon opening and that failure to do so could result in the use of expired medication. The Director of Nursing confirmed that the pen should have been dated and that not doing so could lead to ineffective treatment. Additionally, an open vial of Tuberculin Purified Protein Derivative (TB PPD) was found in a refrigerator located in an unlocked office, along with several unopened vials of flu vaccine and TB PPD. The treatment nurse stated that opened vials must be dated and that the current storage location was not secure, as the office was accessible during the day. The Director of Nursing was unaware that these medications were stored outside the medication room and confirmed that they should be kept in a secured medication room refrigerator. Facility policies reviewed by surveyors required dating of opened medications and secure storage, which was not followed in these instances.
Failure to Maintain Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not performing required hand hygiene during resident care. In one case, a male resident with type 2 diabetes had his blood sugar checked by an LVN who did not perform hand hygiene before or after the procedure, nor after cleaning the glucometer. The LVN changed gloves multiple times without sanitizing her hands and handled the glucometer and medication cart without proper infection control practices. Another incident involved a male resident with type 2 diabetes whose blood sugar was checked by the same LVN in the dining room. The LVN did not perform hand hygiene before or after the procedure, placed the soiled glucometer on the dining room table, and changed gloves without sanitizing her hands. The LVN acknowledged she was aware of the required protocols but did not have hand sanitizer on her cart and admitted to the risk of cross-contamination by her actions. The resident stated he would have complied with being moved for the procedure if asked. A third incident involved a female resident with Alzheimer's who received peri-care from a CNA who did not perform hand hygiene before or after care, and handled clean briefs with soiled gloves. The CNA also left the resident's room without sanitizing her hands. The CNA stated she believed wearing gloves kept her hands clean and was unaware of the need to change gloves and perform hand hygiene between glove changes. The facility's policy required hand hygiene before and after care, after glove removal, and after contact with potentially contaminated surfaces.
Failure to Maintain Effective Pest Control Program Resulting in Gnat Infestation
Penalty
Summary
The facility failed to implement and maintain an effective pest control program, resulting in the presence of gnats in multiple areas, including a resident's room, the kitchen, a hallway, and the nurses' station. Observations revealed that a resident was found in bed with food crumbs on the linens and floor, and several gnats flying around and landing on her bed and bedside table. The resident reported that the gnats had been present for some time and were bothersome, though she had become accustomed to them. Housekeeping staff confirmed that the room was cleaned regularly and that gnats were noted, particularly due to food being consumed in the room. The Director of Environmental Services acknowledged that food spills and delayed meal tray pickups contributed to the gnat problem in the resident's room. In the kitchen, multiple observations during meal service documented gnats flying around and landing on bread rolls. The Director of Food Services was aware of the issue and attributed it to gnats coming from the drains, noting that bleach was used in the drains and monthly fumigation was performed. Despite these efforts, gnats continued to be observed in the kitchen, posing a risk of food contamination. Additional observations found gnats in a hallway and at the nurses' station, with staff interviews confirming that gnats had been seen in these areas and that sightings were recorded in the pest control log. Review of pest control service agreements and logs showed that pest control services were performed monthly, with additional treatments as needed when issues were reported. However, pest logs indicated repeated reports of gnats in various locations over several months. Invoices from the pest control company documented treatments for gnats, but also noted occasions when gnats were not addressed. The facility's pest control policy was requested but not provided during the survey.
Failure to Coordinate PASARR Assessments and Referrals for Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program, resulting in missed referrals and duplicative efforts for residents with mental health diagnoses. Specifically, for one resident, the facility did not refer for a Level II PASARR screening or complete a Mental Illness Resident Review after a new diagnosis of schizoaffective disorder was added by the primary care provider. The initial PASARR Level I screening did not indicate mental illness, but subsequent documentation showed the onset of a serious mental illness, which was not followed by the required referral or updated assessment. Interview with the Regional MDS Coordinator confirmed that the process for monitoring new diagnoses and making appropriate referrals was not followed, as the order for the new mental health diagnosis was uploaded but not communicated effectively. The facility's policy required timely and accurate completion of PASARRs and coordination with state authorities for any changes in resident status, but this was not adhered to in this case, resulting in the resident not being properly assessed for needed mental health services.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by policy. Specifically, the baseline care plan for a moderately cognitively impaired female resident with chronic obstructive pulmonary disease, heart failure, and continuous oxygen needs was not completed. Only the Social Services section of the care plan was initiated, and no further interdisciplinary input was documented. Interviews with nursing staff, including RNs and LVNs, revealed a lack of clarity and training regarding responsibility for completing the baseline care plan. Several staff members assumed that either the DON or the MDS nurse was responsible, while the DON stated that the admitting nurse should initiate the plan and that it did not have to be an RN. The Corporate MDS Nurse confirmed that the baseline care plan was missing and described the intended interdisciplinary process, which was not followed in this case. Review of facility policies indicated that a baseline care plan must be completed within 48 hours of admission, initiated by an RN, and should address immediate needs based on admission orders, including physician, dietary, therapy, and social services input. The lack of a completed baseline care plan for the resident meant that her immediate needs, such as oxygen therapy, Foley catheter care, and infection management, were not formally addressed in a person-centered, interdisciplinary manner as required.
Failure to Provide Consistent Contracture Management for Resident with Limited ROM
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, arthritis, non-Alzheimer's dementia, and left-hand contracture did not receive appropriate interventions to maintain or improve range of motion. The resident was dependent on staff for most activities of daily living and had documented orders for a left-hand brace to prevent further contracture. However, the care plan did not include interventions for the contracture or the use of a brace, and the brace order was discontinued without proper interdisciplinary communication or documentation of medical necessity. Observations revealed the resident was not wearing a splint or brace, and staff interviews indicated confusion regarding the status of the order and the location of the brace. Some staff were unaware of the resident's need for a splint, while others reported the resident had previously used one but was not currently wearing it. The Director of Rehabilitation confirmed the resident required a splint and that the order had been discontinued without his input. The ADON stated the order was discontinued at the request of the resident's family due to poor fit, but could not recall if therapy was consulted before discontinuation. Record reviews showed the resident was listed on the facility's contracture management logs as needing a splint, but the occupational therapy discharge summary did not mention the contracture or splint. The facility's policy required therapy to develop and implement a restorative program upon discharge from therapy, but there was no evidence this was done for the resident. As a result, the resident did not receive consistent or appropriate interventions to address her contracture, as required by her condition and physician orders.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
The facility failed to ensure that nursing staff followed manufacturer instructions for priming insulin pens prior to administering insulin to two residents with Type 2 diabetes. In the first instance, a nurse performed a fingerstick blood sugar test for a female resident, determined the required insulin dose per sliding scale, and administered the insulin using an Insulin Aspart pen without priming it. The nurse later stated she was unaware of the need to prime the pen before each dose and had not been instructed on this step during her training. In the second instance, another nurse administered Lyumjev insulin to a male resident after receiving a physician's order for a specific dose, again without priming the insulin pen. This nurse acknowledged awareness of the priming requirement but stated she forgot to perform the step. The Director of Nursing confirmed that insulin pens are to be primed before each injection and that failure to do so could result in residents not receiving the prescribed amount of insulin. Facility policy and manufacturer instructions both require priming of insulin pens before each use.
Failure to Prevent Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision or implement necessary interventions to prevent an elopement incident involving a resident with significant cognitive impairment. The resident, who had diagnoses including dementia, Alzheimer's disease, and a history of wandering and exit-seeking behaviors, was admitted from another skilled nursing facility with documentation indicating a need for redirection and a secure unit placement if necessary. Despite this, an elopement risk assessment was not completed upon admission, and staff were not consistently aware of or acting upon the resident's exit-seeking behaviors, which were documented in progress notes and observed by staff. On the day of the incident, the resident was last seen at a facility event with many visitors present. The resident was able to leave the facility unnoticed, and staff were unaware of the elopement until notified by an external party. The resident was found several blocks away in a residential area by a bystander, who contacted the resident's responsible party using the resident's cell phone. The responsible party then returned the resident to the facility. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, incomplete communication about the resident's behaviors, and failure to follow facility policy requiring elopement risk assessment upon admission and when exit-seeking behaviors are observed. Documentation and interviews confirmed that the baseline care plan identified the resident as an elopement risk, but this information was not effectively communicated or acted upon by the admitting nurse or other staff. The responsible party was not involved in care planning discussions regarding the resident's risk or the need for secure unit placement prior to the incident. The facility's failure to assess, monitor, and implement appropriate interventions for a resident with known risk factors for elopement resulted in the resident leaving the facility unsupervised and unrecognized by staff.
Failure to Report Resident-to-Resident Altercation per Abuse Policy
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse for two residents, as evidenced by an unreported resident-to-resident altercation. According to the facility's abuse policy, any event involving an allegation of abuse or suspicious injury must be reported immediately or within two hours. However, a review of incident reports over a three-month period did not reveal any documentation of an altercation that occurred between two residents, despite nurse's notes indicating that one resident was witnessed hitting another. The nurse intervened and educated the resident but did not assess the resident or report the incident as required by policy. Interviews with staff, including the RN, CNA, DON, and Administrator, revealed that none were aware of the incident, and all confirmed knowledge of the facility's abuse reporting protocols. The DON and Administrator both stated that the incident should have been reported according to policy and that staff are trained on these procedures. The failure to report the incident as outlined in the facility's policy represents a deficiency in the implementation of abuse prevention and reporting protocols.
Failure to Secure Controlled Medications in Medication Carts
Penalty
Summary
The facility failed to ensure the security and proper storage of controlled medications in two medication carts, leading to potential risks for residents. During an observation of Medication Cart #1, it was found that a pill bubble packaging card containing Tramadol 50 mg tablets had seals that were not intact and were covered with tape. Additionally, a full pill bubble packaging card of Alprazolam 0.25 mg had one seal that was not intact. Despite the narcotic log count sheet reflecting the appropriate count, the compromised seals indicated a failure in maintaining the security of these controlled substances. Similarly, Medication Cart #2 was found to have a pill bubble packaging card of Lorazepam 0.5 mg with one seal not intact. The narcotic log count sheet again reflected the appropriate count, but the broken seal posed a risk of drug diversion. Interviews with staff revealed that controlled medications were counted at the beginning and end of shifts, but the broken seals were not noticed during these counts. The Director of Nursing (DON) confirmed that nurses were responsible for following medication rights and should notify the DON and discard any compromised pills with a second nurse. The facility's policy required that drug containers with missing or incorrect labels be returned to the pharmacy, but this protocol was not followed in these instances.
Misappropriation of Resident's Fentanyl Patch by RN
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their prescribed medication, specifically a Fentanyl patch, by a registered nurse (RN A). The resident, an elderly female with severe cognitive impairment and chronic pain conditions, was under a scheduled pain medication regimen that included the application of a Fentanyl transdermal patch every 72 hours. On the day of the incident, RN A attempted to replace the resident's Fentanyl patch but reported that the resident refused the procedure. Despite this, RN A had already signed off on the narcotic sheet indicating the patch had been administered. RN A subsequently misappropriated the Fentanyl patch for personal use, shredding the narcotic count sheet to conceal the missing patch. Later that day, RN A was found unresponsive in the staff bathroom, exhibiting signs of opioid overdose. A Fentanyl patch was discovered on the bathroom floor, and it was revealed that RN A had a history of substance abuse and had relapsed, using the resident's medication for recreational purposes. This incident resulted in the resident not receiving their scheduled pain management, potentially affecting their quality of life. The facility's Director of Nursing (DON) and other staff members discovered RN A in a compromised state, leading to emergency medical intervention. The DON initiated an investigation and suspended RN A, who was later terminated. The facility's policy on abuse, neglect, and exploitation explicitly prohibits the misappropriation of resident property, including medication diversion for staff use, which was violated in this case.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. The resident, a female with severe cognitive impairment and frequent incontinence, had a history of pressure ulcers and skin integrity issues. Despite documentation of a pressure ulcer on the resident's lower back in weekly skin assessments, the wound care nurse (WCN) was not notified until several days later, resulting in a lack of treatment for the wound until it was assessed on June 6th. The resident's care plan included interventions for monitoring and treating skin injuries, but these were not consistently followed. Weekly skin assessments were documented by LVN A, but they lacked specific details about the wound's location and type. The WCN was unaware of the wound until informed by a resident care provider (RCP) on June 6th, who discovered the open area during routine care. The WCN then assessed the wound, notified the primary care physician, and initiated treatment. However, the wound care was not documented as performed on June 12th, and there were discrepancies in the records regarding the completion of weekly skin assessments. Interviews with staff revealed a breakdown in communication and documentation processes. The WCN relied on nurses to report any skin breakdowns observed during assessments, while the RCPs were expected to report skin issues to the charge nurse. LVN A claimed to have informed the WCN about the wound, but this was not documented. The facility's protocols for wound care and skin management were not effectively implemented, leading to the deficiency in providing timely and appropriate care for the resident's pressure ulcer.
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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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