Golden Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlanta, Texas.
- Location
- 1104 S William St, Atlanta, Texas 75551
- CMS Provider Number
- 675490
- Inspections on file
- 41
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Golden Villa during CMS and state inspections, most recent first.
A resident with heart failure, heart disease, and hypertension was ordered carvedilol twice daily with specific BP and HR hold parameters and daily vital sign monitoring. The care plan required checking and documenting BP per MD order and holding the medication if values were below set parameters. Review of the MAR showed no BP or HR documentation for the evening carvedilol dose over an extended period, and the MAR lacked a designated area to record these vital signs for the second daily dose. The DON confirmed that untimed vital signs in nurses’ notes could not be linked to the medication administration, and a medication aide reported that although she checked BP and pulse before giving the evening dose, there was no place on the MAR to record them, resulting in incomplete clinical records contrary to facility policy.
A resident with severe cognitive impairment and dependence on staff for ADLs experienced a delay in incontinent care after a bowel movement, despite a care plan requiring assistance with toileting and hygiene every two hours and as needed. The resident was observed sitting in a wheelchair with stool-stained clothing and a noticeable odor, while a hospitality aide reported having notified a CNA about the need for changing approximately an hour earlier. The CNA went on break without informing an LVN of the resident’s need for care, and leadership later confirmed their expectation that incontinent care be completed before breaks and provided promptly, consistent with facility policy requiring necessary services to maintain grooming and personal hygiene.
The facility failed to ensure that nurse aides working more than four months were properly trained, competent, and certified within the required four-month timeframe. Two nurse aides were hired and worked full-time providing resident care, including incontinence care and bathing, before timely completion of the LTCR Nurse Aide Training and Competency Evaluation Program and without having taken or scheduled the CNA exam. The DON, Administrative Assistant, and Administrator each gave differing and incorrect timeframes for when aides must be certified, and the Administrative Assistant, who shared responsibility for tracking certification with the staffing coordinator, was unsure of the actual requirements. These practices conflicted with the facility’s written policy that prohibits using an aide for more than four months unless the aide has completed an approved training and competency evaluation program or has been deemed competent under federal regulations.
A resident with dementia and mobility issues was found to have a raised toilet seat missing an anti-slip rubber foot, causing instability. Staff interviews revealed there was no specific schedule or policy for checking the safety and function of equipment, and the issue had not been reported or documented.
A staff member was observed vaping between the nurse's station and a resident sitting area while residents were present, in violation of the facility's non-smoking policy. Interviews with staff and residents confirmed that the facility prohibits smoking and vaping inside, and that staff are only allowed to smoke in a designated outdoor area. The incident was directly observed by a surveyor, and the staff member involved denied remembering the event but acknowledged using vapes and cigarettes.
Staff, including LVNs and a medication aide, were found to have pre-popped medications from blister packs and placed them in cups labeled with resident names or left unlabeled, storing them in medication carts or leaving them in resident rooms. These actions were contrary to facility policy, which requires medications to be administered directly to residents without pre-preparation or unattended storage.
The facility failed to properly label and date food items in storage, did not ensure all staff wore required hair restraints while in the kitchen, and did not maintain cleanliness of kitchen equipment and surfaces. Observations revealed unmarked food in the cooler and freezer, staff entering the kitchen without hairnets or beard guards, and significant grease buildup on cooking equipment, with cleaning schedules not being followed or documented.
Multiple residents reported that meals were bland, repetitive, overcooked, and not served according to their preferences, with observations confirming issues such as mushy vegetables and soggy breading. Residents with various medical conditions, including cognitive impairment and malnutrition, expressed dissatisfaction with food quality and variety, and documentation showed ongoing complaints over several months. The Dietary Manager acknowledged the problems and lack of a food palatability policy, while meal observations by surveyors confirmed the deficiencies.
Two residents were placed at risk when one was found with a prohibited antimicrobial skin cleanser in her room, and another was transferred using a mechanical lift with the legs in the narrow position, contrary to facility policy and FDA best practices. Staff interviews revealed a lack of awareness regarding the proper procedures for both chemical storage and safe resident transfers.
Three residents requiring respiratory care did not have their oxygen cannulas or nebulizer masks properly covered when not in use, contrary to facility policy and professional standards. Two residents' nasal cannulas were left uncovered on oxygen concentrators, and another resident's nebulizer mask was left uncovered on a nightstand. Staff interviews confirmed responsibility for covering equipment and acknowledged infection control concerns.
A CNA failed to change gloves and perform hand hygiene during incontinent care for a resident with severe cognitive impairment and multiple chronic conditions. The CNA used the same gloved hands to handle both soiled and clean items, including the resident's clothing, bedding, and bed remote, contrary to facility policy and infection control standards. Staff interviews and policy review confirmed that proper procedures were not followed, resulting in a breach of infection prevention protocols.
A resident with severe cognitive impairment and chronic pain experienced pain after an LVN yanked her left arm during care, as witnessed by another resident. The resident reported the LVN was mean and abusive, and the incident was documented in facility records. Staff interviews provided conflicting accounts, but the facility's abuse prevention policy was not upheld in this instance.
A resident with a history of wandering was found outside the facility unsupervised, despite having a wander guard. The facility failed to investigate multiple elopements, did not document incidents, and did not notify the family or physician. Faulty alarm systems and inadequate staff response contributed to the deficiency, leading to an Immediate Jeopardy situation.
The facility failed to maintain an effective pest control program, resulting in a roach infestation affecting two residents. A resident with severe cognitive impairment reported seeing roaches in her living area, while another resident with moderate cognitive impairment found roaches in his clothing. Staff interviews revealed inadequate communication and housekeeping practices, contributing to the problem. The facility's pest control measures, including monthly exterminator visits, were insufficient to address the infestation.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks in their care. Errors included incorrect weight coding, missing documentation of wounds and treatments, and unrecorded diagnoses of anxiety, depression, and medication use. Interviews with staff emphasized the importance of accurate MDS coding for individualized care plans and appropriate staffing.
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. This included unaddressed weight loss, wound care, and medication management for residents with significant health issues.
The facility failed to provide palatable, attractive, and safe food for seven residents, leading to complaints about the taste, lack of seasoning, and improper cooking. Despite measures to address meal preferences, residents continued to express dissatisfaction with the food quality.
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies in catheter and incontinent care. Staff did not change gloves or sanitize hands appropriately, risking the spread of infections among residents with severe medical conditions.
The facility failed to provide a homelike environment by not replacing missing slats from a resident's window blinds, causing discomfort and difficulty napping. Despite repeated requests, the issue remained unresolved for months, and the maintenance log did not list the room as needing repairs.
The facility failed to update the care plans for two residents to reflect their current medication regimens, leading to potential risks in their care. One resident's care plan incorrectly listed Eliquis instead of Aspirin, and another resident's care plan was not updated to show the discontinuation of Eliquis.
A facility failed to ensure a safe transfer for a resident with severe cognitive impairment and physical limitations. Staff members did not use a gait belt as required by policy, instead lifting the resident under her arms, which could cause harm. The DON and ADM were unaware of this practice, and staff competencies lacked proper training for two-person transfers.
A resident with anxiety, depression, and dementia was prescribed Duloxetine and Lorazepam without adequate behavior and side effect monitoring. The facility's DON and ADM acknowledged the oversight, emphasizing the importance of monitoring due to potential major side effects in the elderly. The facility's policy mandates ongoing documentation and monitoring, which was not followed in this case.
Incomplete Documentation of Vital Signs for Antihypertensive Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident receiving antihypertensive medication with specific vital sign parameters. The resident, an older adult with diagnoses including heart failure, heart disease, and hypertension, had an admission MDS showing a BIMS score of 9, indicating moderate cognitive impairment, and required substantial staff assistance for most ADLs. The resident’s care plan identified hypertension with associated risks and included interventions to administer antihypertensive medications as ordered, check and document blood pressure per MD order, and hold medication and notify the MD per facility protocol if blood pressure was below ordered parameters. Physician orders and the Nursing MAR for the month showed an order for carvedilol 3.125 mg by mouth every 12 hours at 8 AM and 8 PM, with instructions to hold the medication for systolic blood pressure less than 105, diastolic blood pressure less than 60, and heart rate less than 60, and to monitor vital signs daily. However, review of the MAR from 3/01/26 through 3/19/26 revealed no documentation of blood pressure or heart rate for the 8 PM carvedilol dose. The DON acknowledged that there was no place on the MAR to document a second set of vital signs for the 8 PM dose and that, although some vital signs appeared in nurses’ notes, they were not timed, so it was not possible to determine their relationship to the medication administration. A medication aide who typically worked the 2 PM to 10 PM shift stated that when administering medications with blood pressure and pulse parameters, she documented those vital signs on the MAR and that, if a medication was ordered more than once daily, there should be a place to document vital signs with each administration. She confirmed that there was no place on this resident’s MAR to document blood pressure or pulse for the 8 PM carvedilol dose, even though she reported checking them before administration. She further stated that if blood pressure and pulse were not documented, it was as if they were not checked, and there would be no way to tell if the medication was given within the physician’s parameters. The facility’s medication administration policy required medications to be administered as prescribed and for vital signs to be checked and verified, if necessary, prior to administration, underscoring the incomplete documentation for this resident’s evening carvedilol doses.
Failure to Provide Timely Incontinent and ADL Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and assistance with activities of daily living (ADLs) to a dependent resident. The resident was an elderly female with Alzheimer’s disease, dementia, and anxiety disorder, with a Comprehensive MDS showing a severely impaired BIMS score of 5 and a need for substantial/maximal assistance with toileting, dressing, and personal hygiene. Her care plan required assistance from one staff member for toileting every two hours and as needed, with incontinent care after each episode. On the cited date, surveyors observed the resident sitting in her wheelchair with pajama pants stained brown from the crotch area and a noticeable stool odor; she was fidgeting and trying to grab clean clothes from her bed, and her verbalizations were incomprehensible. A hospitality aide present in the room stated the resident had a bowel movement and that she had informed a nursing assistant about an hour earlier that the resident needed to be changed. Further interviews revealed that the nursing assistant who had been caring for the resident was on break and had not informed the LVN that the resident required incontinent care before leaving. The LVN stated that the nursing assistant should have reported the need for care so that the LVN or another CNA could provide it, and acknowledged that residents not being provided incontinent care promptly could result in skin breakdown. The DON and the Administrator both stated their expectation that resident care, including incontinent care, be provided before staff go on break and that such care be provided promptly, with managers responsible for oversight. The facility’s policy on quality of life and ADL care for dependent residents required that residents unable to carry out ADLs receive necessary services to maintain grooming and personal hygiene. The resident’s family member also reported that they often observed the resident’s clothing soaked in urine, indicating ongoing concerns with timely incontinent care.
Failure to Ensure Nurse Aides Met Training and Certification Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides working more than four months were trained, competent, and certified within the required four-month timeframe, as required by OBRA and the facility’s own policy. Record review showed that NA D was hired on 01/03/2024 and completed the LTCR Nurse Aide Training and Competency Evaluation Program on 12/31/2024, indicating she worked full-time providing resident care such as incontinence care and bathing before timely completion of the program. NA B was hired on 11/12/2024 and completed the same training program on 02/16/2025, also working full-time and providing similar resident care during this period. Both aides reported they had not tested to become CNAs and did not have test dates scheduled. Interviews with facility leadership revealed confusion and incorrect understanding of the required certification timeframe. The DON stated that nurse aides had up to one year to get certified, while the Administrator stated that nurse aides had two years from completion of skills training to become certified. The Administrative Assistant, who along with the staffing coordinator was responsible for ensuring aides were certified within required timeframes, reported uncertainty about what those timeframes were and noted that the facility had been without a staffing coordinator until the day of the interview. These actions and inactions occurred despite a written facility policy stating that no individual would be used as a nurse aide for more than four months unless competent and having completed an approved training and competency evaluation program, or otherwise deemed competent under the federal requirements.
Failure to Maintain Safe Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition for one resident who used a raised toilet seat. Observation revealed that the raised toilet seat was missing an anti-slip rubber foot on one of its legs, causing the seat to rock when weight was applied. The resident, who had dementia, COPD, anxiety, and moderate cognitive impairment, required supervision for transfers and used a walker as her primary mode of mobility. The care plan identified her as being at risk for falls and included the use of a raised toilet seat as an intervention. Interviews with facility staff indicated there was no specific schedule for checking equipment for function and safety. The maintenance director relied on staff to report broken equipment via clipboards and checked these twice daily, but there was no record of the missing anti-slip foot. The DON stated that the maintenance director was responsible for monthly equipment checks and completing work orders, but the administrator confirmed there was no policy regarding the functioning of essential equipment.
Staff Member Vaped Indoors in Violation of Facility Non-Smoking Policy
Penalty
Summary
A staff member was observed vaping inside the facility, specifically between the nurse's station and the resident sitting area, while residents were present. The staff member, when questioned, denied remembering the incident but acknowledged using vapes and cigarettes, and stated that staff were not allowed to vape inside the facility. Multiple interviews with other staff members, including CNAs, LVNs, the DON, and the Regional Nurse, confirmed that the facility is a non-smoking environment and that staff are only permitted to smoke in a designated area outside the building. The facility's policy explicitly prohibits smoking, including electronic cigarette products, inside the building for both residents and visitors. Despite the facility's non-smoking policy, the incident of vaping occurred in a common area, exposing residents and staff to vape fumes. Interviews with residents and staff indicated no prior issues with vaping inside the facility, and staff expressed varying levels of awareness regarding the risks associated with vaping indoors. The event was directly observed by a surveyor, and the staff member involved was identified and questioned about the incident.
Improper Pre-Popping and Storage of Medications by Staff
Penalty
Summary
The facility failed to ensure proper pharmaceutical services were provided, specifically in the dispensing and administration of medications by staff. Multiple instances were observed where medications were pre-popped from blister packs and placed into medication cups, which were then either left unattended in resident rooms or stored in medication carts prior to administration. On one occasion, five clear medication cups containing different residents' medications were found in a resident's room, with the medications intended for administration but apparently forgotten. Further observations revealed that staff, including LVNs and a medication aide, had pre-popped medications for multiple residents and stored them in labeled or unlabeled cups within medication carts. One LVN had 15 cups with different resident names and medications, while another had two cups with resident names written on the bottom. The medication aide had three cups with medications but no resident names. Staff members acknowledged during interviews that they were aware pre-popping medications was not permitted and that medications should not be dispensed prior to the time of administration. Record reviews confirmed that the facility's policy required medications to be administered safely and timely, with verification of the right resident, medication, dosage, time, and route before administration. The policy also stated that medications should not be left at the bedside or pre-prepared for later administration. These practices were not followed, as evidenced by the observations and staff admissions.
Failure to Maintain Food Safety Standards in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as evidenced by multiple observations and interviews. In the walk-in cooler and freezer, numerous food items were found without proper labeling or dating, including foam bowls with unknown contents, plastic containers with unidentified meats, and bags of various unmarked food items. The dietary manager acknowledged that the staff responsible for labeling and dating had been absent, and the replacement staff did not follow proper procedures. The lack of labeling and dating was confirmed by both observation and staff interviews, with the dietary manager stating that undated food could be served past its safe period and that all food should be labeled and dated according to policy. Additionally, the facility did not ensure that all staff entering the kitchen wore appropriate hair restraints. The Activity Director Assistant was observed entering the kitchen without a hairnet while food was being prepared and admitted to doing so daily, unaware of the requirement. Two male dietary aides were also observed assisting with meal service without facial hair coverings, despite having mustaches and chin hair. Both aides stated they did not wear facial hair coverings, with one citing discomfort and the other only wearing a mask when ill. The dietary manager confirmed that all staff, including non-dietary personnel, were expected to wear hairnets and beard guards in the kitchen, and that this had been communicated previously. The facility also failed to maintain cleanliness of kitchen equipment and surfaces. Observations revealed a significant greasy buildup on the oven doors, knobs, backsplash, and the shelf above the stove, with drops of grease hanging over areas where food was being prepared. The cleaning schedule, which required daily and weekly cleaning of kitchen equipment, was posted but showed no documentation of completed cleaning tasks for the observed period. The dietary manager confirmed that all equipment should be cleaned daily and that the lack of cleaning could result in contamination. These failures were corroborated by facility policies and training records, which outlined the requirements for food labeling, staff hygiene, and sanitation practices.
Failure to Provide Palatable and Attractive Food to Residents
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for the majority of residents reviewed. Multiple residents reported that the food was bland, mushy, overcooked, and repetitive, with some stating that their dislikes and preferences were not honored. Observations confirmed that vegetables were often overcooked and watery, and fried foods were tough or soggy. Residents also reported that the same foods, such as chicken, instant mashed potatoes, and green beans, were served repeatedly, and that meal variety and texture were lacking. Resident interviews revealed dissatisfaction with the quality and presentation of meals, with several residents stating that the food was not appealing or fit to eat. Some residents with moderate to severe cognitive impairment, as well as those with diagnoses such as dementia, stroke, heart failure, depression, and malnutrition, expressed that their dietary needs and preferences were not being met. Grievance logs and resident council minutes documented ongoing complaints about food quality, temperature, lack of variety, and failure to honor dislikes, with issues persisting over several months. During meal observations, surveyors and the Dietary Manager noted that food items such as country fried steak and Brussel sprouts were not prepared to an acceptable standard, with soggy breading and mushy vegetables. The Dietary Manager acknowledged awareness of the complaints and agreed with the observations but stated there was no food palatability policy in place. Despite in-service education and discussions with dietary staff, the issues with food quality and resident satisfaction remained unresolved at the time of the survey.
Failure to Prevent Accident Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents. In the first instance, a resident with moderate cognitive impairment and a diagnosis of dementia was found to have an antimicrobial antiseptic skin cleanser in her room on two separate observations. The resident was unaware of who placed the bottle in her room or its intended use. Interviews with staff, including an LVN, the Director of Nurses, and the Administrator, confirmed that such items are prohibited in resident rooms due to the risk of harm, especially for residents with cognitive impairment. Despite this, the item remained in the resident's room, and facility policies provided did not specifically address the prohibition of such chemicals in resident rooms. In the second instance, a resident with severe cognitive impairment, hemiplegia, and a history of falls required two-person assistance with mechanical lift transfers. During an observed transfer, CNA B and CNA C did not maintain the mechanical lift legs in the wide position while moving the resident from his wheelchair to the bed. CNA B was unsure of the purpose of spreading the lift legs and routinely moved the resident with the lift legs in the narrow position. CNA C and the DON both stated that the lift legs should be in the wide position for stability and safety, as per facility policy and FDA best practices. The Administrator also confirmed that the staff did not follow the correct procedure, which could have compromised the resident's safety. Record reviews showed that CNA B had previously demonstrated satisfactory performance in mechanical lift procedures, which included keeping the lift legs in the wide position during transfers. Facility policy and FDA guidance both require the lift base to be at its maximum open position to ensure stability and prevent accidents. Despite this, the observed transfer did not adhere to these protocols, and the staff involved were not fully aware of the safety rationale behind the procedure.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required such care, as evidenced by observations, interviews, and record reviews. Specifically, two residents who used oxygen concentrators did not have their nasal cannula tubing covered with a bag when not in use, and one resident's nebulizer face mask was left uncovered on a nightstand. These actions were inconsistent with professional standards of practice, the residents' care plans, and the facility's own policy on oxygen administration. For the two residents with oxygen concentrators, both had physician orders for oxygen therapy and required maximal assistance with activities of daily living. During observations, their nasal cannulas were found uncovered and, in one case, nearly touching the floor. Both residents were cognitively impaired and typically wore oxygen, but the unused cannulas on their concentrators were not protected as required. The third resident, who was cognitively intact and required supervision with activities of daily living, had a nebulizer and mask sitting on her nightstand without a protective bag. Staff interviews confirmed that nurses and aides were responsible for ensuring respiratory equipment was covered when not in use, and acknowledged that failure to do so could lead to infection control issues. The facility's policy required safe handling and storage of respiratory equipment, but this was not followed in these instances.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control practices during incontinent care for a resident with severe cognitive impairment, multiple chronic conditions, and total incontinence. The CNA, after performing perineal care, did not change gloves or perform hand hygiene before handling clean items such as the resident's clothing, clean brief, clean incontinent pad, bedding, and bed remote. This sequence of actions was observed directly and confirmed through interviews with staff, who acknowledged that the CNA did not adhere to established protocols for glove use and hand hygiene. The resident involved was an elderly individual with diagnoses including dementia, heart disease, diabetes, hemiplegia, and cerebrovascular disease, and was always incontinent of urine and bowel. The care plan identified a risk for skin breakdown due to incontinence. During the observed care episode, the CNA used the same gloved hands that had been in contact with soiled areas to touch the resident's shoulder, hip, clothing, bedding, and other clean items, and also failed to perform hand hygiene after removing soiled gloves and before donning new ones. Interviews with another CNA, the Director of Nursing (DON), and the Administrator confirmed that the expected practice was to change gloves and perform hand hygiene when moving from a dirty to a clean area, and before handling clean items. Facility policies reviewed also required hand hygiene and glove changes at appropriate points during resident care. The CNA's failure to follow these procedures was acknowledged by the staff involved and was documented as not meeting the facility's infection control standards.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when a licensed vocational nurse (LVN) yanked the resident's left arm during care. The resident, an elderly female with diagnoses including parkinsonism, dementia with severe cognitive impairment, osteoarthritis, and chronic pain, required maximal assistance with activities of daily living. The incident was reported to have caused pain in the resident's left arm, which was already affected by chronic conditions, and was witnessed by another resident who described the action as abusive. Interviews and record reviews confirmed that the resident expressed feeling hurt and described the LVN as being mean and abusive, specifically mentioning repeated yanking of her left arm. The witness corroborated the account, stating that the LVN yanked the resident's arm in an abusive manner while administering pain medication. The resident reported ongoing pain in her arm following the incident, although she acknowledged pre-existing pain in that area. The facility's documentation included an incident report and a subsequent x-ray, which did not reveal acute injury but did confirm severe osteoarthritis in the affected shoulder. Staff interviews revealed differing perspectives on the incident, with the LVN denying any intent to harm and stating she was careful due to the resident's known pain. Facility leadership acknowledged the resident's sensitivity to her shoulder and noted that the witness supported the resident's account. The facility's abuse prevention policy requires protection of residents from all forms of abuse, but the actions described in the report indicate a failure to uphold this standard for the resident involved.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with a history of wandering. The resident, who was severely cognitively impaired and required supervision for various activities, was found approximately 50 feet away from the facility entrance around 4:00 AM. Despite having a wander guard and being identified as an elopement risk, the facility did not prevent the resident from leaving unsupervised. The facility did not investigate the resident's three separate elopements that occurred over several months. There was no documentation of these incidents in the resident's chart, nor were the family or physician notified. Staff interviews revealed that the resident had been found outside the facility on multiple occasions, yet these incidents were not properly reported or documented. The facility's alarm systems were found to be faulty, with issues in the wander guard system and door alarms that could turn off prematurely. Despite these problems, the facility did not take appropriate actions to address the risks, and staff failed to follow protocols for documenting and reporting elopements. This lack of action and oversight led to the identification of an Immediate Jeopardy situation.
Removal Plan
- Regional Nurse provided in-service training to Administrator on identifying an elopement, the importance of training staff to document any elopements, notifications required when elopements occur, the importance of facility investigating each elopement and placing intervention to prevent reoccurrence, the importance of facility elopement screening and assessments being completed accurately to determine wanderguard placement or potential secure unit placement, how to report an elopement to HHSC.
- In-services to all staff were initiated. Training will be conducted by administrator, ADONS, and Regional nurses. Topics covered include facility revised elopement policy. Policy addresses required assessments, documentation to complete, and notifications employees should contact.
- All in servicing will be completed. No employee will be allowed to work until in servicing is completed.
- Elopement policy will be included in new hire training packets.
- All resident's elopement screens and care plans were updated to ensure accuracy. Facility will follow elopement screen assessment guidelines for identifying level of risk. Facility screening tool provides a risk level numerical value based on key questions. All high-risk residents will be placed on Wander guard System. Audit and updates were completed by unit managers and ADONS.
- All residents that are on wanderguard will be identified in a binder at the nurse's station, with resident demographics (face sheet) to identify each. Completed by Unit managers and ADONS.
- Resident #1 was assigned a designated sitter until secure unit placement can be arranged.
- Facility adopted a new Elopement policy. The updated policy clearly defines steps for employees to take during an elopement. The new policy directs staff on necessary notifications to make, and all documents to complete. Incident reports and medical record entry are covered as well.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the environment of two residents. Resident #1, a female with severe cognitive impairment and multiple health issues, reported seeing roaches in her bathroom and around her living area. Her roommate corroborated these sightings, noting frequent bug activity in their shared space. Similarly, Resident #2, a male with moderate cognitive impairment, expressed concerns about roaches in his clothing and room. Observations confirmed the presence of roaches in Resident #2's room, with numerous insects seen on the sink and walls. Interviews with staff revealed systemic issues in pest control management. CNA KKK, who had been with the facility for three months, noted occasional roach sightings and attributed some of the problem to inadequate housekeeping practices. The Maintenance Supervisor acknowledged receiving verbal reports of roaches but did not consistently communicate these issues to the Administrator. The Director of Housekeeping admitted to seeing roaches in various facility areas and relied on verbal communication with the Maintenance Supervisor rather than maintaining a log of sightings. The lack of a structured deep cleaning schedule further contributed to the problem. The facility's pest control measures were insufficient, as evidenced by the exterminator's monthly visits not addressing the infestation effectively. The exterminator recommended keeping areas clean but did not provide specific instructions for deep cleaning or furniture management. The Administrator was unaware of the roach problem, despite expectations for a clean environment. The facility's policy on pest control, dated 2020, outlined measures to eradicate pests, but these were not effectively implemented, leading to an unsanitary environment for residents.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks in their care and services. For Resident #61, the MDS was inaccurately coded with a weight of 262 pounds, despite a recorded weight of 255.4 pounds. Additionally, the MDS did not reflect the presence of a wound on the resident's left lower extremity, which was being treated as per physician orders. The care plans for Resident #61 also lacked documentation for the wound and weight loss, despite ongoing treatments and observations confirming these conditions. Resident #51's MDS was not coded to include diagnoses of anxiety and depression, despite these conditions being documented in the resident's medical records and care plans. Similarly, Resident #12's MDS did not reflect the use of the antidepressant Duloxetine, which was prescribed and administered regularly as per the physician's orders. The care plan for Resident #12 also failed to mention the use of this medication, despite its documented administration. For Resident #13, the MDS did not include active diagnoses of major depressive disorder and anxiety disorder, even though these conditions were documented in the resident's medical records and care plans. The resident was receiving medications for these conditions, but the MDS only reflected a diagnosis of bipolar disorder. Interviews with the MDS Coordinator, DON, and ADM highlighted the importance of accurate MDS coding for developing individualized care plans and ensuring appropriate staffing and care levels. The facility's policy on MDS accuracy emphasized the need for assessments to accurately reflect residents' statuses, as required by federal regulations.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #61, a 62-year-old male with diagnoses including wound infection, diabetes mellitus, and atrial fibrillation, did not have a care plan for his wound or weight loss despite significant weight reduction and specific wound care orders. Observations confirmed the presence of an open lesion on his left lower extremity, which was not addressed in his care plan. Resident #77, an elderly male with bladder cancer, diabetes mellitus, and obstructive uropathy, experienced weight loss that was not care planned. His quarterly MDS indicated moderate cognitive impairment and a need for supervision with eating, but no interventions were documented to address his weight loss. Similarly, Resident #12, an elderly female with depression and heart failure, had no care plan for her use of an antidepressant and diuretic, despite these medications being prescribed and administered regularly. Resident #30, an elderly female with hypothyroidism and heart failure, also lacked a care plan for her diagnoses and use of a diuretic. Her quarterly MDS indicated severe cognitive impairment and a need for maximal assistance with activities of daily living, yet her care plan did not reflect her medical conditions or medication regimen. Interviews with the MDS Coordinator, DON, and ADM revealed that care plans were not consistently updated or individualized, leading to potential risks for the residents involved.
Failure to Provide Palatable and Safe Food
Penalty
Summary
The facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature for seven residents. Multiple residents reported that the food tasted horrible, lacked flavor, and was sometimes improperly cooked. One resident mentioned that the chicken served was raw and bleeding, while another stated that the eggs were overcooked. Several residents expressed that they had to buy their own food due to the poor quality of the meals provided by the facility. The dietary manager acknowledged that the food needed more seasoning and flavoring, and residents had repeatedly requested different salt and seasoning mixes, which had not been provided by the facility. During a test tray sampling, the survey team and dietary manager found that the noodles were sticky and flavorless, the green beans were bland, and the chicken fried steak was soggy, although the gravy had good seasoning. The dietary manager confirmed the lack of seasoning in the food. Residents also reported that the food was often too soft and lacked variety, with some meals being mixed up, such as lunch and dinner. The facility's policies indicated that residents should be provided with nourishing, palatable, and well-balanced meals that meet their daily nutritional and special dietary needs, but these standards were not being met. Interviews with the Director of Nursing (DON) and the administrator revealed that they were aware of the food complaints but believed the food quality had improved. The DON mentioned that he had not received direct complaints from residents and that the facility monitored residents' weights to prevent weight loss. The administrator stated that a staff member inquired about residents' meal preferences daily and that alternate meals were available. Despite these measures, residents continued to express dissatisfaction with the food quality, indicating ongoing issues with the facility's meal services.
Infection Control Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies in the care provided to residents. Specifically, the treatment nurse did not change her gloves or sanitize her hands appropriately while providing catheter care to a resident with multiple diagnoses, including sepsis and cellulitis. This failure was observed during an interview and record review, where the nurse admitted to not following proper procedures, which could have led to further infections for the resident. Another incident involved a CNA who did not change her gloves or perform hand hygiene correctly while providing incontinent care to a resident with severe cognitive impairment and chronic obstructive pulmonary disease. The CNA acknowledged her mistake during an interview, stating that she realized she should have changed her gloves but did not do so until later in the procedure. This lapse in infection control practices was confirmed by the DON, who emphasized the importance of universal precautions in preventing the spread of infections. A third deficiency was observed when a CNA did not change her gloves or sanitize her hands after removing a foley catheter stabilizer device from a resident with chronic kidney disease and urinary retention. The CNA admitted to being nervous and not following proper procedures, which included putting a dirty towel back into clean water. This was corroborated by an LVN who assisted during the procedure and confirmed that such actions could lead to urinary tract infections. The facility's policies and skills check-offs did not adequately address the need for changing gloves during these procedures, contributing to the observed deficiencies.
Failure to Maintain Homelike Environment by Not Replacing Window Blinds
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident by not replacing missing slats from the window blinds. The resident, who is [AGE] years old and has severe cognitive impairment, expressed that the missing slats allowed sunlight to enter the room, making it difficult for her to nap and causing discomfort. Despite the resident's repeated requests for the blinds to be fixed, the issue remained unresolved for months. The Maintenance Supervisor confirmed that the maintenance log did not list the resident's room as needing blind slats replaced, although other rooms had their blinds fixed. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that facility policies require maintaining a homelike environment, which includes ensuring that window blinds are functional. The facility's policy on Quality of Life - Homelike Environment emphasizes the importance of providing a comfortable and personalized setting for residents.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plans for two residents were not updated to reflect their current medication regimens. Resident #12's care plan incorrectly indicated that she was prescribed Eliquis, while her records showed she was actually taking Aspirin. Similarly, Resident #13's care plan was not updated to reflect the discontinuation of Eliquis, which had been stopped on 04/08/24. Resident #12, an elderly female with a diagnosis of paroxysmal atrial fibrillation, had a care plan that indicated she was taking Eliquis, a blood thinner. However, her physician orders and medication administration records (MAR) showed that she was actually prescribed Aspirin. This discrepancy was not corrected in her care plan, which could lead to inappropriate care interventions. Resident #13, another elderly female with a history of gastrointestinal hemorrhage, had her Eliquis discontinued, but this change was not reflected in her care plan. Interviews with the MDS Coordinator, DON, and ADM revealed that they were aware of the importance of accurate and updated care plans for individualized resident care. They acknowledged that failing to update care plans could lead to residents not receiving appropriate care. The facility's policy on comprehensive person-centered care plans emphasized the need for ongoing assessments and timely updates, but this was not adhered to in these cases.
Improper Transfer Technique Used by Staff
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that two staff members, a CNA and an LVN, performed a safe two-person transfer for a resident with severe cognitive impairment and physical limitations. The resident, who required maximal assistance for transfers and was dependent on others for mobility, was transferred without the use of a gait belt, contrary to the facility's policy and the resident's care plan. Instead, the staff members lifted the resident from under her arms, a technique known as 'chicken winging,' which is not approved and could cause harm to the resident's arms and shoulders. The resident involved was an elderly female with diagnoses including dementia and age-related osteoporosis. Her care plan indicated that she required substantial assistance and was at risk for falls due to her medical conditions. Despite this, during an observed transfer, the staff did not use a gait belt and instead lifted her under her arms, which is against the facility's policy. The CNA involved stated that she believed using a gait belt was less safe for this resident, despite the policy requiring its use. The LVN also confirmed that the resident refused the mechanical lift, but did not authorize the omission of the gait belt. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of the improper transfer technique being used. Both confirmed that the facility's policy mandates the use of a gait belt for all transfers unless otherwise care planned. The DON emphasized that 'chicken winging' could cause damage to the resident's arms and shoulders, and the ADM acknowledged that improper transfers could lead to falls and injuries. The review of staff competencies showed that the CNA and LVN had not been checked off for two-person transfers, highlighting a gap in training and adherence to safety protocols.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that Resident #12's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Resident #12, an elderly female with diagnoses including anxiety disorder, depression, and dementia, was prescribed Duloxetine for depression and Lorazepam for anxiety. However, there were no orders for behavior or side effect monitoring for these medications, as confirmed by the resident's medical records and MAR. The care plan also did not indicate the use of an antidepressant, despite the prescription of Duloxetine. The Director of Nursing (DON) acknowledged the oversight and emphasized the importance of monitoring due to the potential major side effects of psychotropic medications on the elderly population. The Administrator (ADM) also confirmed that the nursing staff was responsible for ensuring medication and side effect monitoring, and that failure to do so could lead to unrecognized side effects and ineffective treatment outcomes. During interviews, both the DON and ADM highlighted the necessity of behavior and side effect monitoring to assess the efficacy of the medications and to report any adverse effects to the medical doctor (MD). The facility's Psychotic Medication policy from 2017 mandates ongoing documentation, including root cause analysis of behavioral indicators, monitoring for efficacy and adverse consequences, and documentation of target behaviors each shift. The lack of adherence to these protocols for Resident #12 indicates a significant lapse in the facility's medication management practices, potentially compromising the resident's therapeutic outcomes and safety.
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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