Golden Estates Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 130 Spencer Ln, San Antonio, Texas 78201
- CMS Provider Number
- 675690
- Inspections on file
- 31
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Golden Estates Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was administered Alprazolam for anxiety without prior consent from the responsible party, despite clear orders and facility policy requiring notification and consent before administration. Staff interviews and record review confirmed that the responsible party was not informed of the risks or side effects, and the medication was given before the consent form was signed.
A resident with multiple diagnoses, including Schizophrenia, did not have all relevant conditions and medications accurately coded on the MDS assessment. The MDS omitted the psychiatric diagnosis, use of a lidocaine patch for pain, and recent antibiotic administration, despite documentation in the medical record and MAR. The MDS Nurse acknowledged these omissions and confirmed that the required look-back periods and coding procedures were not properly followed.
A resident admitted for hospice respite care with severe cognitive impairment had a hospice order requiring notification of her responsible party prior to administration of Alprazolam. This instruction was not transcribed into the resident's physician orders or MAR, resulting in the medication being administered without the required notification. Staff interviews confirmed the omission and acknowledged the importance of accurate order transcription.
The facility did not post the required daily nurse staffing information for two days, leaving an outdated staffing poster in the front lobby despite having scheduled nursing staff. Both the MA and DON, who were responsible for posting, acknowledged the lapse and confirmed the importance of this regulatory requirement.
Surveyors found loose medication pills in two medication carts, with four loose pills in one cart and one in another. LVNs confirmed the findings, and interviews with the ADON and Administrator indicated that medication carts are supposed to be checked daily and that all drugs should be stored in their original packaging, as per facility policy.
A beauty shop was found unlocked and unattended, containing hazardous bleach wipes, hair color products with safety warnings, and plastic razors, all accessible to residents, staff, and the public. The Regional Nurse confirmed these items should not have been accessible, and facility policy requires storage areas to be maintained safely.
A resident with multiple medical conditions was admitted without an accurate assessment of her dental status. The MDS assessment failed to document missing teeth or dental issues, despite physical signs and staff knowledge of her partial edentulism. The MDS LVN reported confusion during coding, resulting in an incorrect assessment.
Surveyors found that a container of shredded cheese and a case of breakfast sausage in the kitchen's reach-in cooler were not properly sealed, leaving both items exposed to air. The Dietary Manager confirmed that staff are responsible for ensuring food is properly sealed, and facility policy requires all food to be covered to prevent contamination.
A resident with severe cognitive impairment and a history of wandering was able to exit the facility undetected and was found outside near a busy road. The facility failed to complete a care plan addressing wandering risk, did not ensure consistent monitoring of exit doors, and did not document or report the elopement incident as required by policy. Staff interviews revealed lapses in supervision and unclear responsibilities for monitoring the front entrance.
A resident with severe cognitive impairment and a history of wandering was found missing, and facility staff failed to notify the resident's physician and representative as required. Staff interviews revealed confusion about notification responsibilities, and documentation did not show that appropriate notifications were made. The family was informed by hospice, not the facility, and the physician was not notified at all.
A resident admitted for respite care with multiple medical and psychiatric diagnoses did not have a baseline care plan developed or implemented within 48 hours of admission. Key sections of the admission documentation were left blank, and staff interviews revealed confusion about responsibility and procedures for care plan completion, resulting in incomplete care planning and documentation.
A medication cart was found unlocked and unattended in a main pathway near several residents in wheelchairs. The cart, assigned to a medication aide, was supposed to be locked according to facility policy. Staff interviews confirmed that medication carts must remain locked when not in use to prevent unauthorized access.
The facility failed to maintain a safe and comfortable environment due to inadequate heating, leaving residents in cold conditions. The heating issues were known but not addressed, resulting in indoor temperatures as low as 51°F. Residents wore multiple layers and used several blankets to keep warm, with some refusing showers and therapy due to the cold. Family members expressed concern, and one family removed their relative from the facility. The situation led to an Immediate Jeopardy designation.
The facility failed to report a malfunctioning heating system to the State Survey Agency within the required timeframe, leaving residents in cold conditions during low temperatures. Despite known issues with the heating system, including clogged lines and broken valves, the facility did not consider it a reportable incident. Residents and staff experienced discomfort, with room temperatures dropping significantly, yet the Administrator did not report the issue, believing it did not constitute a total outage.
A resident was left unattended in a sling attached to a mechanical lift, despite requiring assistance from two staff members for transfers. The resident, who was cognitively intact and had multiple diagnoses, reported being left in the sling for about 10 minutes, causing feelings of helplessness. The CNA involved had not received training on mechanical lifts from the facility, and the DON confirmed that leaving a resident unattended in a lift is a safety hazard.
A resident with multiple health issues experienced a significant change in condition, including pain, vomiting, diarrhea, and low oxygenation, but the facility failed to immediately notify the physician. The resident's condition deteriorated, leading to CPR and eventual death. The nurse on duty was new and lacked contact information for other staff, contributing to the delay in medical intervention.
A resident with a Full Code status was found unresponsive, and the LVN on duty failed to provide continuous CPR, stopping once to obtain an AED. The resident, who had a complex medical history, was admitted with conditions like encephalopathy and acute kidney failure. Despite having physician orders for CPR, the LVN's actions led to a lapse in emergency protocol, contributing to the resident's death.
A resident with a gastrostomy tube experienced a significant change in condition, including pain, decreased oxygenation, and multiple episodes of emesis, which were not appropriately recognized or responded to by the facility staff. The order for enteral feeding was incomplete, lacking details such as formula type, total volume, time of administration, or contraindications. Communication and procedural gaps, such as the LVN not knowing the phone numbers to other stations and using a personal phone to call the DON and 911, contributed to the deficiency.
The facility failed to comply with food safety standards, including not using beard restraints, improperly labeling refrigerated foods, and inadequate temperature monitoring. A staff member did not wear a beard guard, and refrigerated items lacked prepared and discard dates. Additionally, food temperatures were not consistently recorded, with one staff member failing to take temperatures for certain protein consistencies and another relying on refrigerator readings for cold items.
The facility failed to update care plans for four residents, leading to discrepancies in fall interventions and transfer methods. A resident's care plan lacked new fall interventions after major falls, while another's did not document transfer needs. Two residents' care plans inaccurately required a two-person Hoyer lift, despite staff using one-person transfers. These deficiencies could risk resident safety.
A resident with severe cognitive impairment and anxiety disorder was prescribed Citalopram Hydrobromide for depression without a documented diagnosis of depression. The facility's policy requires medication orders to include the clinical condition, but the resident's clinical record lacked this documentation. The DON noted the diagnosis was only in the doctor's notes, and the prescribing physician was on vacation.
A medication cart in a common area was found unlocked and unattended, containing prescription drugs and sharps. LVN A, responsible for the cart, was in a nearby room and unable to monitor it. The DON confirmed that carts should be locked when not in use, as per facility policy.
A resident with severe cognitive impairment and dietary needs did not receive a vegetable side during a lunch meal, contrary to the facility's menu. The RD and CDM were unable to identify the meal contents initially and later confirmed the resident received pureed cornbread instead of the vegetable option. The facility's policy requires nutritional equivalence in menu changes, which was not followed.
The facility failed to provide food in the correct minced and moist texture for a resident's lunch meal, as the food particles were too large to fit between the prongs of a standard fork. The RD confirmed the need for finer chopping to prevent choking, and the CDM acknowledged the lack of tools to ensure proper texture. Facility records and manuals outlined the required food texture, which was not followed.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents of improper hand hygiene by staff. A CNA did not wash or sanitize her hands between glove changes during incontinent care for a resident with epilepsy and dementia. An RN failed to perform hand hygiene before donning gloves during medication administration for a resident with Parkinson's disease and dementia, only doing so after intervention by the VP RN. Both staff members were aware of the facility's hand hygiene policy, which was reinforced during training.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, lacking specific fall prevention interventions despite identifying them as fall risks. Interviews and record reviews revealed that care plans did not include individualized measures, only general fall protocols.
Failure to Obtain Consent Prior to Administration of Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's responsible party was informed in advance of the risks and benefits of a proposed anti-anxiety medication, Alprazolam, and did not obtain proper consent prior to administration. The resident, an elderly female with severe cognitive impairment, dementia, depression, and anxiety, was admitted for hospice respite care. Her medical records indicated that she required partial to moderate assistance with activities of daily living and had a physician's order for Alprazolam to be given as needed for anxiety, with a specific instruction that the responsible party must be notified before administration. Despite these orders, Alprazolam was administered to the resident before consent was obtained from the responsible party. The medication consent form, which included information about potential side effects, was signed by the responsible party after the medication had already been given. Interviews with facility staff revealed that nurses were aware that consent should be obtained prior to administering anti-anxiety medications, and the facility's policy required written or verbal consent before starting such medications. However, the nurse who administered the medication was not aware of the requirement to notify the responsible party prior to administration and did not confirm that consent had been obtained. The responsible party reported not being educated on the risks or side effects of Alprazolam by the facility and explicitly stated that she did not give consent for its administration. She also noted that she had observed the hospice orders, which required notification before administration, and that both hospice and facility staff were aware of this requirement. The failure to obtain consent and notify the responsible party prior to administering the medication was confirmed through interviews and record review.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's current status. Specifically, a male resident with diagnoses including Schizophrenia, Cerebral Palsy, and Dementia was not properly coded on his quarterly MDS assessment. The assessment omitted the diagnosis of Schizophrenia in the active diagnoses section, did not indicate the use of a lidocaine patch for pain management, and failed to record the administration of an antibiotic, Cipro, which the resident received during the look-back period. These omissions were identified through interviews and a review of the resident's medical records, including the Medication Administration Record (MAR) and the electronic medical record (EMR). The MDS Nurse, who was responsible for completing the assessment, acknowledged during an interview that the resident's Schizophrenia diagnosis, use of a lidocaine patch, and antibiotic administration should have been coded on the MDS. The nurse confirmed that information for the MDS is obtained through record review and that the look-back periods for diagnoses and medications were not properly followed in this case. The facility's policy requires all personnel completing any portion of the MDS to certify its accuracy, but this was not adhered to for this resident's assessment.
Failure to Accurately Transcribe Hospice Medication Orders and Notification Instructions
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident who was admitted for hospice respite care. The resident, an elderly female with diagnoses including dementia, depression, and anxiety, had a hospice order upon admission specifying that her responsible party must be notified prior to the administration of Alprazolam .5mg as needed for anxiety. This instruction was documented in the hospice orders and discussed between the hospice RN and the admitting LVN, but it was not transcribed into the resident's physician orders or Medication Administration Record (MAR). As a result, the MAR only reflected an order for Alprazolam .5mg every 4 hours as needed for anxiety, without the requirement to notify the responsible party before administration. The medication was subsequently administered to the resident without prior notification to the responsible party, as confirmed by interviews with nursing staff and the responsible party. The responsible party became aware of the administration after observing the resident's drowsiness and inquiring with staff, at which point it was confirmed that the medication had been given without her knowledge or consent. Interviews with facility staff, including the LVN who completed the admission and the DON, revealed that the omission occurred because the responsible party notification instruction was not entered into the electronic medical record system or the MAR. The staff acknowledged the importance of accurately transcribing all hospice orders, including special instructions, to ensure that all care directives are followed as intended.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information on two consecutive days. Observations on the morning of the second day revealed that the staffing poster displayed in the front lobby was outdated, showing information from the previous day. Record reviews confirmed that the facility had scheduled various nursing staff, including CNAs, MAs, DON, ADON, MDS Nurse, Treatment Nurse, and LVN/RNs for both days in question, but the current staffing information was not posted as required. Interviews with staff clarified that the responsibility for posting the daily staffing numbers alternated between a medication aide (MA) and the DON, depending on their schedules. Both the MA and the DON acknowledged their roles in posting the information and confirmed that the posting had not occurred on the specified days. The DON admitted to not posting the staffing numbers when required, and both staff members recognized the importance of this task as a regulatory requirement.
Loose Medication Pills Found in Medication Carts
Penalty
Summary
Surveyors observed that two out of three medication carts contained loose medication pills that were not stored in their original packaging or containers. Specifically, the medication aide cart for station 2 had four loose pills in one of its drawers, and the medication aide cart for station 1 had one loose pill in a drawer. These findings were confirmed by interviews with the respective LVNs responsible for each cart, who acknowledged the presence of the loose pills. Further interviews with the ADON and the Administrator revealed that medication carts are expected to be checked daily by medication aides and nurses, with additional weekly checks by pharmacy staff. Facility policy requires that drugs and biologicals be stored in the packaging or containers in which they are received, and that nursing staff are responsible for maintaining proper medication storage. The presence of loose pills in the medication carts was not in accordance with these requirements.
Unlocked Beauty Shop with Hazardous Items Accessible
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the beauty shop area. On observation, the beauty shop was found unlocked and unattended, with no staff present. Inside the room, there were several potentially unsafe items accessible, including a container of bleach wipes labeled as hazardous, four tubes of hair color with warnings to avoid contact with eyes and skin and to keep out of reach of children, and a package of plastic razors. The Regional Nurse confirmed that these items were potentially unsafe and that the room should have been locked to prevent access by residents, staff, or the public. Review of facility policy indicated that maintenance storage areas are required to be kept in a clean and safe manner.
Inaccurate Dental Status Assessment on Admission
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected her dental status. Record review showed that the resident, an elderly female with diagnoses including hypertensive heart disease, dementia, major depressive disorder, and legal blindness, was admitted on a specialized diet but had no care plan focus area addressing her dental status. The admission MDS assessment did not indicate that the resident was edentulous or had obvious dental issues, despite observations of sunken lips suggesting missing teeth. The quarterly MDS assessment also did not document dental concerns. During interviews, the Administrator confirmed the resident had some upper teeth but no lower teeth and sometimes did not use her dentures. The MDS LVN admitted to being confused when completing the MDS, as there was no problem with the resident's denture itself, and acknowledged that the assessment was coded incorrectly. The facility used the RAI manual as their policy for coding resident assessments.
Improper Sealing and Storage of Food Items in Kitchen Cooler
Penalty
Summary
Surveyors observed that the facility failed to properly store food items in the kitchen's reach-in cooler. Specifically, a container of shredded cheese was found with its plastic lid not fully sealed, leaving one corner open and exposing the cheese to the ambient air. Additionally, a cardboard case of breakfast sausage was discovered open, with the bag inside also unsealed, resulting in the sausage being exposed to the cooler's air. These observations were made during a routine inspection of the kitchen. During an interview, the Dietary Manager confirmed that both the cheese and sausage should have been sealed to prevent exposure, acknowledging that all staff responsible for storing food in the cooler are expected to ensure proper sealing. Review of the facility's Food Safety and Sanitation policy, as well as the 2022 FDA Food Code, confirmed that food must be stored in covered containers or wrappings to prevent contamination. The facility's failure to adhere to these standards was documented as a deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and assistance devices to prevent accidents, specifically failing to prevent an elopement by a resident with severe cognitive impairment. The resident, a male with unspecified dementia and no behavioral disturbances noted on his MDS, was admitted for respite care and was independent with mobility. Documentation revealed gaps in the resident's baseline care plan, with several sections left blank, including those related to mood, behavior, and care planning. There was no physician order for monitoring the resident, and the admission documentation did not indicate any assessment or plan for wandering risk. On the day of the incident, the resident was observed to have increased wandering behavior. Staff interviews and record reviews confirmed that the resident was able to leave the facility undetected and was found outside near an access road by the expressway. The front door was observed to be unlocked and unattended at the time, and although staff stated that door alarms were in place, the monitoring of the front entrance was inconsistent. Multiple staff members recalled the event, noting that the receptionist was sometimes away from the desk, and that the resident was able to exit quickly. There was no incident report completed regarding the resident's wandering or elopement, and the family was notified of the attempt to leave by the hospice company, not the facility. Facility policies required identification and supervision of residents at risk for unsafe wandering, as well as completion of incident reports and notification of appropriate parties in the event of an elopement. However, these procedures were not followed in this case. The lack of a completed care plan, insufficient monitoring of exit doors, and failure to document and report the incident contributed to the deficiency. Staff interviews revealed inconsistent understanding and implementation of monitoring responsibilities, and the facility did not have effective measures in place to prevent the resident's elopement.
Failure to Notify Physician and Representative After Resident Went Missing
Penalty
Summary
The facility failed to notify a resident's physician and representative when there was a significant change in the resident's status, specifically when the resident was found missing. The resident, a male with severe cognitive impairment due to unspecified dementia and other psychiatric diagnoses, was admitted for a respite stay and was noted to have increased wandering behavior. On the day of the incident, staff discovered the resident was missing, initiated a search, and found him after a short period. Documentation revealed no evidence that the resident's representative or physician was notified about the wandering or the missing event. Interviews with facility staff indicated confusion and lack of clarity regarding notification responsibilities. The ADON reported being informed by a nurse that the resident was missing and subsequently notified the Administrator, who was already present in the building. The Administrator stated she notified the hospice company but did not notify the physician and believed the hospice company would inform the family. Nursing staff believed that the Administrator and ADON would handle notifications, and the family representative confirmed that notification came from the hospice company, not the facility. Facility policy required documentation of changes in a resident's condition and notification of family, physician, or other staff. However, the records lacked documentation of such notifications for this incident. Staff interviews further confirmed that the physician and family representative were not directly notified by the facility, and the Administrator acknowledged that the physician should have been notified but was not.
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 a resident who was admitted for a respite stay and had multiple complex medical diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. The resident was noted to be severely cognitively impaired for daily decision-making but was independent with mobility and transfers. Upon review, the baseline care plan for this resident was found to be blank and undated, and several sections of the clinical admission documentation, including care planning and special care, were also incomplete or left blank. Interviews with facility staff revealed confusion and lack of clarity regarding the process and responsibility for completing baseline care plans. Licensed vocational nurses involved in the admission assessment believed that the MDS Coordinator was responsible for generating the care plan, while the MDS Coordinator stated that the baseline care plan should be started on admission and completed within 72 hours, but acknowledged that the resident's care plan was incomplete. Other nursing staff were unaware of the requirements or their roles in the development of the baseline care plan, and the ADON was unsure of the required timeframe for completion. The facility's documentation policy required that all services provided, progress toward care plan goals, and changes in the resident's condition be documented in the medical record to facilitate communication among the interdisciplinary team. However, the lack of a completed baseline care plan and incomplete documentation in the resident's record indicated that these requirements were not met for this admission, resulting in a deficiency related to the timely development and implementation of a person-centered care plan.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on Unit 1 was observed left unlocked and unattended in front of the nurse's station, facing a main pathway where six residents were present in wheelchairs. The cart was assigned to a medication aide, who stated she believed she had locked the cart, but the lock must have popped open. The aide acknowledged that the cart should not be left unlocked and unattended, as only facility staff should have access to it, and she was the only one with the key. The LVN present confirmed the cart was assigned to the medication aide, and the administrator also identified the cart as belonging to her. Interviews with the ADON and the RN Corporate Nurse confirmed that facility policy requires medication carts to be locked when unattended to prevent unauthorized access. Both staff members stated that leaving the cart unlocked could allow residents or others to access medications. A review of the facility's policy document titled 'Security of Medication Cart' indicated that medication carts must be securely locked at all times when out of the nurse's view and when not in use, they must be locked and parked at the nurse's station or inside the medication room.
Inadequate Heating System Leads to Cold Conditions for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the inadequate heating system that left residents in cold conditions. The heating issues were known to the facility, with the heater motor on the 300-hallway being out since January 22, 2025, and the 200-hallway heaters not functioning adequately. Additionally, the motor on the 100-hallway heater had not been operational for an unknown period. This resulted in indoor temperatures dropping as low as 51 degrees Fahrenheit during a period when outdoor temperatures were as low as 21 degrees Fahrenheit, affecting all three hallways, the common living room area, and all rooms on the 300-hallway. Multiple residents reported being cold, with some wearing multiple layers of clothing and using several blankets to keep warm. For instance, one resident on the 300-hallway stated that he wore a winter hat, sweatpants, socks, shoes, and a vest, yet his feet remained cold even with socks. Another resident reported hearing others crying out due to the cold, and one resident was found on the floor having removed her clothes because she was cold. Family members of residents also expressed concern, with one family removing their relative from the facility due to the cold conditions. The facility's failure to address the heating issues in a timely manner led to residents refusing showers and therapy due to the cold. Some residents were observed visibly shivering, and others had moved their beds closer to walls in an attempt to stay warm. The facility's inaction in repairing the heating system and ensuring adequate temperatures for residents resulted in an Immediate Jeopardy situation, highlighting the severity of the deficiency.
Failure to Report Heating System Malfunction
Penalty
Summary
The facility failed to report an incident involving the malfunction of its heating system to the State Survey Agency within the required 24-hour timeframe. The heating system on the 300-hallway was not operational since January 22, 2025, and when a resident complained about the lack of heat on the 200-hallway, the repair could not be completed immediately. This left the facility without adequate heating during a period when local temperatures dropped to 21 degrees Fahrenheit. Observations and interviews revealed that room temperatures in various parts of the facility were significantly below comfortable levels, with some rooms as low as 55 degrees Fahrenheit. The Maintenance Director acknowledged the issue and stated that the heater repairman had been called to address the problem. However, the repairman indicated that the facility's heating system had multiple issues, including clogged water lines and broken valves, which required manual intervention. Despite these known issues, the facility did not report the heating failure to the State Survey Agency, as the Administrator believed it did not constitute a total outage. Interviews with staff and residents indicated widespread awareness of the cold conditions within the facility. Residents, including one with moderate cognitive impairment, expressed discomfort due to the cold, and staff members reported wearing layered clothing to cope with the low temperatures. The facility's policy required immediate reporting of any allegations of neglect, but the Administrator did not consider the heating issue as meeting the criteria for reporting, despite the significant impact on residents' comfort and well-being.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment for Resident #17 by not providing adequate supervision during a mechanical lift transfer. The resident, who was cognitively intact and required assistance from two staff members for transfers, was left alone in a sling attached to a mechanical lift. This occurred when a CNA left the resident unattended in the sling to assist another resident, despite knowing the importance of not leaving a resident suspended in a sling. Resident #17, a female with multiple diagnoses including heart failure and diabetes, was observed by a surveyor in a sling attached to a mechanical lift, with no staff present in the room. The resident reported that staff often left her in the sling while they went to get help, and she had been left in the sling for approximately 10 minutes on this occasion. The resident expressed feelings of helplessness and anxiety about missing her scheduled activities due to being left in the sling. Interviews with staff revealed that CNA A had not received training on mechanical lifts from the facility, although she had been trained at a previous job. The Director of Nursing confirmed that two staff members should always be present during mechanical lift transfers and that leaving a resident unattended in a lift is a safety hazard. The facility's policy on safe lifting and movement of residents requires staff to be trained in the use of lifting devices, but CNA A was not included in the last in-service training for mechanical lifts.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately inform a resident's physician when there was a significant change in the resident's physical condition. This deficiency was identified for a resident who experienced a significant change in condition, including pain, vomiting, diarrhea, and low oxygenation, and subsequently died. The resident was a male with a primary diagnosis of encephalopathy, noninfective gastroenteritis and colitis, rhabdomyolysis, and acute kidney failure. The resident had been admitted from a short-term general hospital and had unclear speech, memory problems, and required partial assistance with eating. On the night of the incident, the resident was restless and experienced multiple episodes of vomiting and bowel movements. The resident's oxygen saturation dropped to 90%, prompting the nurse to administer supplemental oxygen, which increased the saturation to 97%. Despite these significant changes, the nurse did not immediately notify the physician. The nurse attempted to contact the physician after consulting with the DON, but the physician did not return the call. The resident's condition continued to deteriorate, and he was found unresponsive, leading to CPR being initiated and EMS being called. The resident was pronounced dead by EMS upon their arrival. Interviews with staff revealed that the nurse on duty was new to the facility and did not have contact information for other staff members. The nurse was working alone on a hallway with a low census and did not have CNA assistance. The DON stated that a resident requiring supplemental oxygen should have been reported as a change in condition, and the facility's policy required immediate notification of the physician and DON in such cases. The facility's failure to follow these protocols contributed to the delay in medical intervention for the resident.
Failure to Provide Continuous CPR to Resident with Full Code Status
Penalty
Summary
The deficiency involved a failure to provide basic life support, including CPR, to a resident who required emergency care. The resident, a male with a Full Code status, was found unresponsive with no pulse or respirations. Despite having physician orders for CPR, the LVN on duty did not provide continuous and uninterrupted CPR. The LVN stopped CPR once to obtain an AED, which was against professional standards of practice. This lapse in emergency protocol resulted in the resident's death. The resident had a complex medical history, including encephalopathy, noninfective gastroenteritis, colitis, rhabdomyolysis, and acute kidney failure. He was admitted to the facility from a short-term general hospital and had unclear speech, memory problems, and required modified independence for daily decision-making. The resident was on enteral feeding and had a Full Code order in place, indicating that CPR should be performed in the event of cardiac arrest. The LVN, who was on his first shift after completing new hire orientation, found the resident unresponsive and initiated CPR. However, he left the resident during CPR to retrieve the Crash Cart and AED, which interrupted the resuscitation efforts. The LVN also faced challenges in contacting other staff for assistance due to a lack of phone numbers and was the only nurse assigned to the hallway with no CNA support. The delay in continuous CPR and the miscommunication with emergency services contributed to the resident's death.
Failure to Provide Appropriate Enteral Feeding Care
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. The resident, a male with a primary diagnosis of encephalopathy, noninfective gastroenteritis and colitis, rhabdomyolysis, and acute kidney failure, was admitted to the facility with a gastrostomy tube. However, the order for enteral feeding was incomplete, lacking details such as formula type, total volume, time of administration, or contraindications. This oversight in the resident's care plan was a significant factor leading to the deficiency. The resident experienced a significant change in condition, including pain, decreased oxygenation, multiple episodes of emesis, and fecal incontinence, which were not appropriately recognized or responded to by the facility staff. Despite the resident's complaints of stomach discomfort and vomiting, the feeding was only turned off after the first emesis, and the DON was called. The LVN on duty did not receive a return call from the doctor and continued to manage the resident's symptoms without further medical intervention. The resident's condition deteriorated, leading to his death. Interviews with facility staff revealed communication and procedural gaps, such as the LVN not knowing the phone numbers to other stations and using a personal phone to call the DON and 911. The facility's policy required immediate notification of the MD and DON in case of a significant change in condition, which was not adhered to. The lack of adequate staffing and support on the 300-hallway, where the resident was located, further contributed to the deficiency, as the LVN was left to manage the situation without assistance.
Food Safety and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, distribution, and service, as observed during a survey. One staff member, identified as [NAME] Z, did not wear a beard restraint despite having facial hair, contrary to the facility's policy requiring personnel with facial hair to wear a beard guard. Additionally, the facility did not label refrigerated food items with prepared and discard dates, which is against their policy. The CDM admitted that the kitchen staff did not add discard dates to food products, relying instead on their knowledge to discard prepared foods after three days. Furthermore, the facility did not consistently monitor food temperatures. [NAME] AA failed to take temperatures for proteins with specific consistencies due to a lack of space on the temperature log. The CDM also did not check the temperatures of cold food products, such as milk, relying instead on the refrigerator's temperature reading. These practices were not in line with the facility's policy, which requires recording food temperatures at the start, end, and every 30 minutes during meal service. These deficiencies could potentially place residents at risk for foodborne illness.
Care Plan Deficiencies in Resident Transfers and Fall Interventions
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for four residents were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. For Resident #29, the care plan was not updated with new fall interventions after two major falls that resulted in hospitalization. Despite the resident being identified as a fall risk, the care plan lacked documentation of additional interventions that staff were implementing, such as following the resident to activities and frequent rounding. Resident #36's care plan did not document the resident's transfer needs, despite being totally dependent on staff for mobility. The MDS Coordinator acknowledged that the care plan should have included transfer documentation under ADLs or mobility for safety reasons. The absence of this information in the care plan could lead to unsafe transfer practices by staff. For Residents #35 and #50, the care plans inaccurately reflected the need for a two-person Hoyer lift transfer, while staff and the residents themselves indicated that one-person transfers were often sufficient. This discrepancy between the care plan and actual practice was confirmed by staff interviews, highlighting the need for care plan updates to ensure resident safety and appropriate care.
Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident, who had not been diagnosed with depression, was not given psychotropic medication unnecessarily. The resident, a female with severe cognitive impairment and a history of anxiety disorder, was prescribed Citalopram Hydrobromide, an antidepressant, for depression. However, there was no documented diagnosis of depression in her clinical record or comprehensive MDS assessment. The Director of Nursing (DON) acknowledged that the diagnosis was only mentioned in the doctor's notes and not formally documented in the resident's clinical record. The facility's policy requires that medication orders include the clinical condition or symptoms for which the medication is prescribed. Despite this, the resident was receiving the medication without a documented diagnosis of depression, which is a violation of the facility's policy and could lead to unnecessary medication administration. The prescribing physician was unavailable for clarification as they were on vacation at the time of the interview.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, the 300-hallway Nurses Medication Cart was found unlocked and unattended in a common area in front of the nurses' station. The cart contained prescription and over-the-counter medications, sharps for blood glucose monitoring, and other paraphernalia for administering drugs. At the time, there were staff, residents, and visitors in the area, posing a risk of medication misuse or drug diversion. LVN A, who was responsible for the medication cart, was observed discarding a cooler of ice in a nutrition room with his back turned to the common area, unable to see the cart. Despite LVN A's belief that he could monitor the cart while handling the cooler, the cart was left unattended and accessible. The Director of Nursing (DON) confirmed that the expectation was for medication carts to be locked when not in active use, and staff were trained on this principle during onboarding and annual refresher trainings. The facility's policy on the storage of medications also required that compartments containing drugs and biologicals be locked when not in use.
Failure to Provide Balanced Diet to Resident
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of a resident. Specifically, the facility did not ensure that a resident received a vegetable side during a lunch meal. The resident, who had severe cognitive impairment, muscle wasting, anorexia, and dysphagia, did not receive the vegetable option as per the facility's menu. The resident's care plan and doctor's orders did not contain pertinent information related to this deficiency. During the meal observation, the registered dietitian (RD) and certified dietary manager (CDM) were unable to identify the contents of the resident's meal tray and later confirmed that the resident received pureed cornbread instead of the vegetable option. The CDM eventually provided green beans with the appropriate texture. The facility's policy requires that menu changes based on resident preferences should ensure nutritional equivalence, but this was not adhered to, as the resident was not given a vegetable due to her dislike of the option provided.
Failure to Provide Correct Food Texture for Minced and Moist Diet
Penalty
Summary
The facility failed to ensure that residents received food and drink prepared in a form designed to meet individual needs, specifically for a minced and moist textured diet during a lunch meal. Observations and interviews revealed that the food particles, such as browned potatoes and carrots, were not chopped finely enough to fit between the prongs of a standard-sized metal fork, which is the required size for a minced and moist diet. The Registered Dietitian (RD) confirmed that the food should have been more finely chopped to prevent choking. Further investigation showed that the Certified Dietary Manager (CDM) acknowledged the lack of tools, such as pictures or rulers, in the kitchen to ensure the correct food texture. The CDM admitted that the potatoes could have been chopped more finely and that he had to manually adjust the texture. The facility's records, including therapeutic spreadsheets and recipes, indicated specific instructions for preparing minced and moist foods, which were not followed. The facility's Diet Manual and Policy and Procedure handbook also outlined the requirements for food texture, which were not adhered to during the meal preparation.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving improper hand hygiene practices by staff members. In the first incident, a Certified Nursing Assistant (CNA) failed to wash or sanitize her hands between glove changes while providing incontinent care to a resident. The resident, a male with a history of epilepsy and dementia, required moderate assistance for toileting and was at risk for skin breakdown. The CNA acknowledged her failure to perform hand hygiene, attributing it to nervousness and the absence of pump-style hand sanitizer bottles on the unit. In the second incident, a Registered Nurse (RN) did not wash or sanitize her hands before donning gloves during medication administration for another resident. This resident, an elderly female with Parkinson's disease and dementia, was observed by the Vice President of Nursing (VP RN) who intervened to ensure proper hand hygiene was performed. The RN admitted to knowing the requirement for hand hygiene but stated that nervousness led to her oversight. She also mentioned that hand sanitizer was readily available in the care areas. Both staff members involved in these incidents were aware of the facility's hand hygiene policy, which mandates hand washing or sanitizing before applying gloves. The Director of Nursing (DON) confirmed that the facility's policy was communicated during new hire orientation, in-service trainings, and annual competency assessments. The failure to adhere to these protocols could lead to cross-contamination and increased risk of infection among residents.
Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. The care plans for these residents did not include specific fall prevention interventions such as appropriate footwear, non-slip socks, and bed in low position, despite these residents being identified as fall risks. This deficiency was identified through interviews, observations, and record reviews conducted by the surveyors. Resident #1, a [AGE] year-old female with diagnoses including muscle wasting, difficulty walking, and muscle weakness, was found to have a care plan that lacked specific fall prevention interventions. Similarly, Resident #2, a [AGE] year-old female with dementia and muscle weakness, and Resident #3, a [AGE] year-old female with unspecified dementia and difficulty walking, also had care plans that did not list individual fall prevention measures. The care plans only mentioned following the facility's fall protocol without detailing specific interventions for each resident. Interviews with the Director of Nursing (DON), MDS Nurse, CNA, and LVN revealed that while the facility had a general fall prevention policy, the care plans did not reflect individualized interventions for each resident. The staff were aware of the fall risks and the general interventions, but these were not documented in the care plans. The facility's policy on falls indicated that interventions should be identified based on assessments, but this was not adequately reflected in the care plans of the residents reviewed.
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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