Ganado Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ganado, Texas.
- Location
- 107 E Rogers, Ganado, Texas 77962
- CMS Provider Number
- 676242
- Inspections on file
- 28
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Ganado Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide an ongoing activities program consistent with residents’ assessments, care plans, and the posted calendar. Weekend days had no scheduled activities, and on multiple weekdays, listed activities such as bingo, "pretty nails," and "appetizer hour" did not occur. Two residents with dementia, depression, and mobility limitations, whose MDS assessments and care plans emphasized the importance of group and favorite activities, reported that scheduled activities were not held and that there were no weekend activities. Resident Council minutes repeatedly documented that bingo was residents’ favorite activity and that they wanted more of it, yet bingo was inconsistently provided. The ADM and Activity Director acknowledged that the Activity Director had been absent due to physical issues, did not work weekends, had no assistant or formal backup plan, and was unaware that activities were not being held, despite facility policy requiring an ongoing, week-long activity program tailored to residents’ interests and needs.
Surveyors found that the facility failed to ensure breakfast menus reflected resident preferences and input, resulting in the same breakfast being served every day over an extended period. Observations showed a repetitive meal of eggs, sausage or bacon, toast, gravy, and cereal, while the written menu also listed the same core items daily. Several residents with moderate cognitive impairment and conditions such as dementia, severe protein-calorie malnutrition, and renal disease reported boredom with the unchanging breakfast and a desire for more options, despite care plans directing staff to determine and honor food preferences. Resident Council notes documented concerns about breakfast variety, and the Dietary Manager acknowledged receiving complaints but stated cooks had to follow the existing menu and that she had not consulted the dietitian about adjusting it. The report notes this practice could result in psychosocial harm and/or weight loss.
Staff failed to follow infection prevention and control practices during incontinent care and eye drop administration for several residents. CNAs did not fully sanitize their hands, including between fingers, while providing pericare to residents who were bowel incontinent and in some cases had indwelling catheters. In one instance, a CNA handled a soiled brief and then applied a clean brief without changing gloves or performing hand hygiene. Another CNA touched a bed remote with gloved hands and then proceeded with care without changing gloves or sanitizing hands, and did not sanitize between glove changes. A medication aide touched the med cart, keys, bedside table, and bed remote with gloved hands and then administered eye drops to a resident’s face without changing gloves or performing hand hygiene, contrary to facility policies and infection control expectations.
A resident with dementia, urinary incontinence, and obstructive/reflux uropathy was observed receiving incontinent care that did not follow the facility’s perineal care policy. During care, a CNA used a back-and-forth wiping motion with multiple passes over the same area instead of the required front-to-back technique from the urethral to rectal area. The resident’s care plan called for monitoring for s/sx of UTI, and the facility’s policy specified wiping from clean to dirty areas, but the observed practice did not comply with these standards.
A resident with severe cognitive impairment and mental health diagnoses was receiving Depakote 125 mg twice daily for mood stabilization without a documented associated diagnosis, and the medication was not addressed in the resident’s care plan, which focused on adverse medication effects and behavior monitoring. Review of records and staff interview showed that the Depakote order lacked an indicated diagnosis despite a facility policy requiring residents to remain free from unnecessary medications, including those used without adequate indications.
The facility did not ensure that meals were served at safe and appetizing temperatures, as several residents with moderate cognitive impairment and various medical conditions reported that their food was consistently cold. One resident on a renal diet who ate in a room at the end of the hall stated that meals delivered to the room were cold, while another resident on a regular diet who usually ate in the dining room also reported cold food. A third resident with neurologic conditions and an ADL self-care deficit, who always ate in her room, stated that all three daily meals were served cold and therefore unpalatable. The Dietary Manager reported that no residents had informed her of cold meals, despite a written policy stating that food would be served at a safe temperature.
Surveyors found that an opened jar of marmalade labeled to be refrigerated after opening was stored in a dry goods pantry instead of under refrigeration. A dietary staff member and the Dietary Manager both confirmed the jar had been opened, partially consumed, and improperly stored despite the label instructions. Review of the facility’s food storage policy indicated storage areas must preserve the condition of food and supplies, but this standard was not followed for the marmalade, potentially affecting all residents receiving meals and snacks.
A resident with severe cognitive impairment and multiple neurological and psychiatric diagnoses was able to exit the facility unsupervised through an unsecured sliding door with a malfunctioning alarm. The resident, who had no prior history of elopement or wandering, was found outside by another resident and returned to the facility. The deficiency was attributed to the failure to maintain a secure environment and provide adequate supervision.
The facility failed to secure medications properly, as observed during medication administration for two residents. A medication aide left a cart unlocked and out of sight, while another left blister packs unsecured on top of a cart. Both aides acknowledged their mistakes, citing forgetfulness and nervousness. Facility policies require medication carts to be locked and in view during administration.
The facility failed to maintain a safe environment in a spa/shower room, where a toilet was found to be loosely affixed to the floor, moving approximately two inches to the side. This was confirmed by the Administrator, who acknowledged the risk of injury. The facility's Preventive Maintenance Policy was not effectively implemented.
A resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was found invalid due to missing witness signatures, despite being signed by the resident and physician. This oversight was confirmed by the Regional Compliance RN and DON, indicating a failure to adhere to the facility's policy requiring two witness signatures for validity.
A facility failed to ensure proper pharmaceutical services by storing an expired medication, Lorazepam, in the Narcotics refrigerator. The ADON acknowledged the medication was expired and should have been discarded. Facility policy requires expired drugs to be removed, and a pharmacist's review recommended pulling expiration dates 2-3 months in advance.
A medical assistant failed to sanitize blood pressure cuffs and a stethoscope between use on two residents, despite knowing the protocol and having received recent infection control training. The facility's policy requires such equipment to be cleaned between uses to prevent cross-contamination, as confirmed by the Registered Clinical Nurse.
The facility failed to discard an expired food item in the kitchen's reach-in refrigerator, as observed during a survey. A container of pineapple was found with a use-by date that had passed, and the kitchen staff did not perceive a concern since it had not been served. This oversight contradicts the facility's policy and FDA guidelines, which require perishable items to be used within seven days.
The facility failed to post daily nurse staffing information for two days due to confusion over responsibilities and lack of a clear policy. The MDS Nurse and ADON were responsible for updating the information, but delays occurred due to scheduling issues and other duties. The RCN noted no company-wide requirement for posting responsibilities, and the facility relied on a checklist for postings.
Failure to Provide Ongoing, Scheduled Activities Program Based on Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing activities program that followed the posted calendar and met residents’ assessed interests and care plan goals. The February activity calendar showed no activities scheduled on weekends, and surveyor observations on a Sunday afternoon found no activities occurring. On subsequent weekdays, activities listed on the calendar, such as bingo and other group events, were not provided as scheduled, with no alternative or backup activities implemented when the Activity Director was absent. Two residents with moderate cognitive impairment and depression, both care planned to benefit from and be encouraged to attend group and individual activities, reported that scheduled activities were not occurring. One resident, with diagnoses including dementia, major depressive disorder, and mobility limitations, had an MDS indicating that doing favorite activities and participating in groups were very important, and her care plan called for out-of-room social, spiritual, and stimulating activities at least twice weekly. She stated there was no bingo on a day it was scheduled and that there were no weekend activities, noting the Activity Director had not worked for several days. Another resident, with Alzheimer’s disease, dementia, major depressive disorder, and mobility issues, had an MDS indicating that keeping up with the news, doing things with groups, doing favorite activities, and going outside were very important, and his care plan directed encouragement to participate in exercise and activity programs. He reported that “pretty nails” and “appetizer hour” did not occur as scheduled and that there had been no activities all week or on weekends. Interviews with the ADM and the Activity Director confirmed that the Activity Director had been physically unable to work during the survey week and did not work weekends, and that there was no assistant or formal backup plan to ensure activities occurred when she was absent. The ADM stated he would get staff together to ensure residents received scheduled activities if the Activity Director could not work, but observations showed that scheduled activities such as bingo were not consistently provided. The Activity Director stated she was unaware that activities were not being held, that one-to-one activity notes were not kept at the facility, and that she did not have a backup plan for her absence, despite facility policy requiring an ongoing activity program based on residents’ interests and needs, including programming throughout the entire week and for residents unable to participate in groups. Resident Council minutes from several months documented that residents’ favorite activity was bingo and that they wanted more bingo, including twice weekly, yet bingo and other posted activities were not reliably provided as scheduled.
Failure to Provide Breakfast Variety and Honor Resident Food Preferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure menus reflected the needs and preferences of the resident population, particularly regarding breakfast variety, despite policy stating that every attempt would be made to honor resident food preferences. Facility menus in effect from November 2025 through May 2026 listed the same breakfast each day: choice of juice, hot or cold cereal, fresh pasteurized eggs, bacon or sausage, breakfast bread, margarine, jelly, and whole milk. Observations on three separate mornings showed that residents were consistently served scrambled eggs, toast, sausage patties, bacon, gravy, and cereal, indicating that the same breakfast meal pattern was being followed daily. The Dietary Manager confirmed that the current menu had been in effect for a couple of months and that cooks were required to follow the menu as written. Multiple residents with moderate cognitive impairment and various medical conditions reported dissatisfaction with the lack of breakfast variety. One resident with Alzheimer’s disease, dementia, major depressive disorder, and a care plan identifying potential risk for malnutrition stated she had the same breakfast every day, found it boring, and said dietary staff had not asked for her preferences, despite her dietary profile noting she liked breakfast and her care plan calling for updating food preferences as needed. Another resident with degenerative disease of the basal ganglia and altered mental status reported being served sausage and eggs every day since admission and expressed a desire for more options, even though her care plan required staff to anticipate and meet her ADL self-care needs. Additional residents with diagnoses including severe protein calorie malnutrition, atrial fibrillation, renal osteodystrophy, pleural effusion, and emphysema also reported being tired of the same breakfast of eggs and sausage every morning and wanting variety, despite care plans directing staff to determine and provide food preferences within dietary limitations. Resident Council meeting notes for February 2026 documented a concern under Nutrition Services regarding breakfast variety, and the resident who had reported boredom with breakfast was in attendance at that meeting. The Dietary Manager acknowledged that a few residents had complained about having the same breakfast every day and stated she had not discussed any deviation from the set menu with the consultant dietitian, resulting in menus that did not incorporate resident input or provide variety as requested. The report states this practice could affect residents who consume breakfast and could result in psychosocial harm and/or weight loss.
Inadequate Hand Hygiene and Glove Use During Care and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during personal care and medication administration for multiple residents. For one resident with epilepsy, Down syndrome, Alzheimer’s disease, type 2 diabetes mellitus, hypothyroidism, and hyperlipidemia, who was severely cognitively impaired, dependent on staff for care, and always incontinent of bowel with an indwelling catheter, two CNAs provided incontinent care without fully sanitizing their hands. During care, both CNAs used hand sanitizer but did not sanitize between their fingers, contrary to the facility’s infection control policy, which requires covering all surfaces of the hands and fingers when performing hand hygiene. Another deficiency occurred during incontinent care for a cognitively intact resident with type 2 diabetes mellitus, hypertension, chronic kidney disease, hypothyroidism, and hyperlipidemia, who was dependent on staff for toileting hygiene, had an indwelling catheter, and was always incontinent of bowel. While removing a soiled brief, a CNA touched the soiled brief and then, without changing gloves or performing hand hygiene, handled and applied a clean brief to the resident. This action conflicted with the facility’s infection control policy, which requires hand hygiene after handling soiled items such as linens and catheter-related supplies. A third incident involved a resident with convulsions, hypothyroidism, hyperlipidemia, dementia, hypertension, and obstructive and reflux uropathy, who was severely cognitively impaired and always incontinent of bowel and bladder. During incontinent care, a CNA washed her hands and donned gloves, then used the gloved hand to touch the bed remote to adjust the bed, which she later acknowledged was considered dirty. She did not change gloves or sanitize her hands before proceeding with care and did not sanitize her hands between glove changes, despite facility policy requiring hand hygiene after removing gloves and after handling soiled or used items in the resident’s environment. The final deficiency involved medication administration for a resident with hemiplegia, type 2 diabetes mellitus, hyperlipidemia, hypertension, and dementia, who required extensive to total assistance with activities of daily living. While administering eye drops, a medication aide wore gloves and used the same gloved hand to touch the medication cart key, the medication cart, the resident’s side table, and the bed remote, all of which she later identified as dirty or contaminated surfaces. She did not change gloves or sanitize her hands before touching the resident’s face and administering the eye drops. This sequence of actions occurred despite the facility’s eye ointment administration policy requiring handwashing and donning gloves in connection with medication administration and the broader infection control expectations described by the DON.
Improper Perineal Care Technique During Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the provision of incontinent care and catheter-related infection prevention for one resident. The resident had multiple diagnoses including convulsions, hypothyroidism, hyperlipidemia, dementia, hypertension, and obstructive and reflux uropathy, and was documented on the quarterly MDS as severely cognitively impaired with always incontinent bowel and bladder. The resident’s care plan included a problem of bladder incontinence with an intervention to monitor and document for signs and symptoms of UTI, such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul-smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. During an observation of incontinent care, a CNA was seen using a back-and-forth wiping motion instead of a front-to-back motion while cleaning the resident’s perineal area. The CNA later stated she should have wiped front to back instead of using a back-and-forth motion and performing multiple passes on the same area. The DON stated that staff should not use a back-and-forth motion during incontinent care and should perform a front-to-back pass with a wipe and change wipes before another pass to prevent fecal matter from entering the urinary tract. Review of the facility’s perineal care policy showed it directed staff to gently perform perineal care by wiping from the clean urethral area to the dirty rectal area. Despite this policy and documented annual training and proficiency checks, the observed care did not follow the required front-to-back technique.
Depakote Administered Without Documented Indication or Care Plan Inclusion
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medication by administering Depakote without an associated diagnosis or adequate indication for its use. A resident admitted with diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood, Generalized Anxiety Disorder, and Insomnia had a quarterly MDS showing a BIMS score of 0, indicating severe cognitive impairment. The resident’s care plan, initiated for adverse medication effects and behavior monitoring, did not address that the resident was receiving Depakote. The medication order for Depakote Sprinkles 125 mg, to be given orally twice daily for mood stabilization, lacked an associated diagnosis. During interview, the DON acknowledged that the Depakote order should have had an associated diagnosis and that it did not, despite the facility’s Unnecessary Medications policy stating that each resident must remain free of unnecessary medications, including drugs used without adequate indications for their use. This deficient practice was identified for one resident reviewed for unnecessary medications and had the potential to affect all residents receiving prescription medications, as it demonstrated a failure to ensure that prescribed drugs had documented, adequate indications in accordance with facility policy.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for multiple residents. One resident with end stage renal disease, anxiety disorder, and heart failure, who was on a renal diet with regular texture and large portions and was independent with eating, reported that he ate in his room at the end of the hall and that his food was cold. Another resident with major depressive disorder, dementia, and anemia, who was on a regular diet with regular texture and typically ate in the dining room, stated that her food was cold. Both residents had moderately impaired cognition per their BIMS scores and no documented weight loss, and their care plans and dietary profiles reflected regular or renal diets with regular textures and preferences for meals. A third resident with degenerative disease of the basal ganglia, altered mental status, and a history of transient cerebral ischemic attack, who had moderate cognitive impairment and an ADL self-care performance deficit, was ordered a regular diet with regular texture and consistency and reported always eating in her room. She stated that all three of her daily meals were served cold and that receiving cold food made the meals unpalatable, despite generally enjoying their taste. During an interview, the Dietary Manager stated that no residents had informed her that meals were served cold. The facility’s policy on Daily Food Temperature Control, dated 2012, stated that the facility would assure that food is served at a safe temperature, but resident interviews indicated that this was not consistently achieved.
Improper Storage of Opened Refrigerated Food Item in Dry Goods Pantry
Penalty
Summary
Surveyors identified a deficiency in food storage practices when an eighteen-ounce jar of marmalade labeled "refrigerate after opening" was found stored in a non-refrigerated dry goods pantry after it had been opened and partially consumed. During observation in the kitchen, the opened jar remained in the dry storage area instead of being placed under refrigeration as required by the product label. In interviews, a dietary staff member confirmed the marmalade had been improperly stored and acknowledged it should have been refrigerated but could not explain why it had not been. The Dietary Manager also confirmed that the opened marmalade, which required refrigeration after opening, was stored in the dry goods pantry instead of being refrigerated. Review of the facility’s 2012 "Food Storage and Supplies" policy showed that all facility storage areas were to be maintained in an orderly manner that preserves the condition of food and supplies. This deficient practice was determined to have the potential to affect all residents who consume meals and/or snacks provided by the facility, as it involved improper storage of a food item used in resident meal service.
Resident Elopement Due to Unsecured Exit and Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinsonism, dementia, osteoarthritis, dystonia, dysphagia, psychosis, and major depressive disorder, was assessed with a BIMS score of 3, indicating severe cognitive impairment. Prior to the incident, the resident had no documented history of wandering or elopement risk, and the care plan did not include interventions for elopement prevention. On the day of the incident, the resident was able to exit the facility through an unlocked sliding door at the end of a hallway. This door was typically secured with a keypad lock, but on the day in question, it was found to be unlocked, and the alarm system was not functioning. The facility could not determine the exact cause of the malfunction but suspected it was related to weather conditions. The resident was found outside the facility by another resident and was returned to the building within approximately ten minutes of last being seen by staff. The incident was identified as non-compliance and Immediate Jeopardy, as the failure to secure the door and supervise the resident allowed the elopement to occur. The deficiency was based on direct observation, interviews, and record review, which confirmed that the resident was able to leave the facility unsupervised due to the malfunctioning door alarm and lack of adequate supervision.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled according to professional principles. During medication administration for a resident, a medication aide left the medication cart unlocked outside the resident's room and out of sight. The cart contained medication blister packs, bottles, and vials for residents on the hall. The medication aide admitted to forgetting to lock the cart, acknowledging the risk of medications being accessed by unauthorized individuals. The facility's policy requires medication carts to be locked when not in direct use and in full view of the nurse during administration. In another instance, a medication aide prepared medications for a resident and left blister packs unsecured on top of the medication cart while administering the medications inside the resident's room. The aide acknowledged the mistake, attributing it to nervousness during the surveyor's presence. The facility's policy and a pharmacist's review emphasize the importance of securing medications and removing expired or discontinued drugs. The Registered Nurse Coordinator confirmed that medications should always be secured inside the locked cart.
Unsafe Toilet in Spa/Shower Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of the three spa/shower rooms reviewed. Specifically, the toilet in the spa/shower room on the 200 hallway was observed to be loosely affixed to the floor, allowing it to move approximately two inches to the side. This condition was confirmed by the Administrator during an interview, who acknowledged the potential risk of injury to anyone attempting to use the toilet. The facility's Preventive Maintenance Policy, dated 2003, emphasizes the importance of regular inspections and maintenance to prevent equipment failures, but this policy was not effectively implemented in this instance.
Invalid DNR Order Due to Missing Witness Signatures
Penalty
Summary
The facility failed to ensure the validity of a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order, which was not signed by two witnesses as required. This oversight was identified during a review of the resident's records, which included a face sheet indicating the resident's DNR status, a comprehensive care plan, and an order summary report. Despite the resident and their physician having signed the OOH DNR form, the absence of the required witness signatures rendered the document invalid. Interviews with the Regional Compliance RN and the Director of Nursing (DON) confirmed the deficiency, acknowledging that the missing witness signatures meant the resident would receive CPR in the event of cardiac arrest, contrary to their documented wishes. The facility's policy on DNR orders clearly states that two witness signatures are necessary for the form to be valid, highlighting a failure in adhering to established procedures.
Expired Medication Found in Storage
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident by storing an expired medication, Lorazepam, in the Narcotics refrigerator within the main medication storage room. During an observation, it was found that the medication had an expiration date of March 12, 2024, but was still present in the storage room on November 13, 2024. The Assistant Director of Nursing (ADON) acknowledged that the medication was expired and should have been discarded according to the pharmacy expiration date. The ADON explained that expired or discontinued medications should be removed by nurses or medication aides during their medication cart checks, and the Supply Nurse and Director of Nursing (DON) should dispose of any expired medications during re-supply. The facility's policy, as part of the Pharmacy Policy & Procedure Manual, states that drugs should not be kept after their expiration date. A review of the Pharmacist's Monthly Medication Review for October 2024 indicated that medications should be pulled from carts or the med room on the same day they are discontinued or expired, with a recommendation to pull expiration dates 2-3 months in advance to prevent expired administration.
Failure to Sanitize Equipment Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA) who did not sanitize blood pressure cuffs and a stethoscope between use on different residents. During an observation, the MA was seen taking the blood pressure of one resident using both a wrist and manual blood pressure cuff, and then proceeded to use the same equipment on another resident without sanitizing them in between. This practice was acknowledged by the MA, who admitted to forgetting to sanitize the equipment despite being aware of the protocol and having received infection control training within the year. The Registered Clinical Nurse (RCN) confirmed that the MA should have sanitized the equipment between uses to prevent cross-contamination. The facility's policy, updated in March 2023, requires non-invasive resident care equipment to be cleaned daily or as needed between uses. The RCN also mentioned that infection control training is provided to staff annually and as needed, with competency checks in place. This incident highlights a lapse in adherence to the facility's infection control protocols, potentially placing residents at risk for infection.
Expired Food Item Not Discarded in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not discarding an expired food item in the reach-in refrigerator. During an observation, a plastic container labeled as pineapple was found with a use-by date that had passed. The kitchen staff member, identified as [NAME] A, acknowledged that all kitchen staff were responsible for removing expired items but did not see a concern since the pineapple had not been served. This oversight in food safety practices was noted during an interview with the RCN, who also did not perceive an impact from the expired item remaining in the refrigerator. The facility's policy on food storage, dated 2012, requires perishable items to be dated once opened and used within seven days. This policy aligns with the Food and Drug Administration Food Code, which mandates that refrigerated, ready-to-eat, time/temperature control for safety food must be clearly marked and consumed or discarded within seven days. The failure to comply with these standards could potentially affect residents receiving meals from the facility's kitchen, as they may be at risk of consuming expired food items.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information for two consecutive days, from October 15 to October 16, 2024. During an observation on October 17, 2024, it was noted that the posted document was outdated, showing information from October 14, 2024. The MDS Nurse, responsible for updating the daily census and nurse staffing document, stated that the document was not updated due to the unavailability of the scheduling book on the morning of October 17, 2024. The MDS Nurse and the ADON shared the responsibility of posting the information, but there was confusion about who was the backup for this task, leading to the oversight. Interviews with the RCN and ADON revealed that the facility lacked a clear policy on staffing postings, relying instead on a checklist for required postings. The ADON admitted to being late on October 15, 2024, and being occupied with medication administration on the mornings of October 16 and 17, 2024, which contributed to the delay or omission of the postings. The RCN mentioned that there was no company-wide requirement for who should post the daily census and nurse staffing information, and she did not perceive any impact from the postings being late or missed, as staff used a sign-in sheet for assignments.
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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