Gracy Woods Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 12021 Metric Blvd, Austin, Texas 78758
- CMS Provider Number
- 675918
- Inspections on file
- 45
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Gracy Woods Nursing Center during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment, visual loss, and dependence on staff for eating and personal hygiene was assisted with feeding in the dining room while fecal matter was present on both hands. The care plan required that the resident be kept clean, dry, and comfortable before meals and that substantial to maximal assistance be provided for eating and personal hygiene. A family member arriving during dinner detected a foul odor, observed fecal matter on the resident’s hands held at chest level, and became upset. The SW and an LVN both observed the resident being fed by a CNA while fecal matter remained on the resident’s hands; the CNA reported feeding the resident for about 10 minutes before the issue was pointed out and stated he had not noticed or smelled the fecal matter. Facility leadership acknowledged the resident’s known behavior of putting his hands in his pants, the expectation that residents be clean before meals, and that the incident involved dignity and infection control concerns, in contrast to the facility’s resident rights policy requiring treatment with respect and dignity.
A resident with dementia, moderate cognitive impairment, visual deficits, and multiple comorbidities who required substantial assistance with eating and personal hygiene was assisted with a meal in the dining room while fecal matter remained on both hands. The care plan called for ensuring the resident was clean before meals, yet a CNA fed the resident for several minutes before a family member noticed and reported the fecal matter. A social worker and an LVN also observed the resident being fed with fecal matter on his hands, despite the facility’s infection prevention and control policy requiring a safe, sanitary environment to prevent the transmission of infections.
The facility did not maintain required documentation showing that nurse aides had completed skill performance checklists after their training, as confirmed by record review and staff interviews. Although staff stated that skills were checked off, the binder containing this evidence could not be located, resulting in no proof that nurse aides were properly trained and competent according to facility policy and state requirements.
A resident with dementia and anxiety experienced a fall resulting in a nondisplaced right humerus fracture, confirmed by X-ray. Although pain management orders were implemented and the responsible party declined aggressive treatment, the care plan was not updated to address the fracture or specify related interventions. Staff interviews confirmed the care plan should have been revised to reflect this significant change, but no update was completed.
A resident with cognitive impairment and a complex medical history was not properly identified as an elopement risk, despite staff and family observations of confusion. The resident exited the facility through a window that was not adequately monitored and was missing for over a day before being found. Staff interviews revealed inconsistent assessment practices and lack of effective supervision, leading to the deficiency.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility failed to provide mandatory effective communication training for 16 staff members, including CNAs, LVNs, and RNs. Personnel records showed no evidence of such training, and interviews revealed that the HR Personnel only handled initial orientation, while the DON conducted weekly in-services without a set curriculum. This lack of structured training could risk residents being cared for by untrained staff.
The facility failed to provide mandatory training on the QAPI program to all staff, including CNAs, LVNs, and RNs. Personnel records showed no evidence of QAPI training, potentially placing residents at risk. The HR Personnel handled initial orientation, while the DON conducted weekly in-services without a set curriculum, leading to the deficiency.
The facility failed to provide compliance and ethics training to all 16 employees reviewed, as required. Personnel records showed that annual training in-services did not include the necessary compliance and ethics program's standards, policies, and procedures. Interviews revealed that the HR Personnel was only responsible for initial orientation, while the DON conducted weekly meetings without a set curriculum, leading to a lack of structured training.
The facility failed to provide mandatory annual training on abuse prevention to seven staff members, including LVNs, an RN, and a SW. Personnel records lacked evidence of such training, and interviews revealed that ongoing training was unstructured, with no set curriculum. This deficiency could place residents at risk of being cared for by untrained staff.
The facility failed to maintain a sanitary and comfortable environment for residents, with issues such as missing light strings, peeling wallpaper, and blocked bathrooms. Despite complaints, these issues remained unresolved, affecting residents' comfort and independence.
The facility failed to maintain accurate and comprehensive care plans for residents, leading to potential health risks. Several residents' care plans did not reflect their refusal of staff assistance with personal refrigerated items, resulting in unsanitary conditions. Another resident's care plan was outdated regarding dietary and medication needs, causing confusion during medication administration. Additionally, a resident's care plan inaccurately documented their code status and medical needs, highlighting a lack of communication and updates.
The facility failed to ensure proper labeling and secure storage of medications, with two medication carts left unlocked and medications unattended. Insulin pens lacked pharmacy labels, and two residents had unauthorized medications at their bedside. The DON acknowledged the safety risks and the need for proper labeling and storage.
The facility failed to ensure six dietary staff members had the required Texas Food Handler Certificate, as identified through record review and interviews. These staff members were responsible for washing dishes, and a staff member believed they did not need the certification. The facility's policy mandates that food and nutrition services staff be trained and certified, which was not followed.
The facility failed to maintain food safety standards, including improper handwashing supplies, food storage, and equipment cleanliness. A resident's lunch tray was left uncovered, and the ice machine lacked a cleaning log. These issues could risk foodborne illnesses.
The facility failed to implement a policy for the use and storage of foods brought by visitors, resulting in unsafe conditions. A resident's refrigerator contained spoiled food and lacked a temperature log, while another resident's fridge had expired food and an incomplete log. Staff inconsistently monitored these refrigerators, contrary to the facility's policy requiring regular checks and education on food safety.
The facility failed to maintain an effective infection prevention and control program. An LVN did not perform proper hand hygiene while administering medications to multiple residents. Another LVN failed to wear a gown and change gloves during medication administration for a resident with EBP orders. Additionally, a resident's urinary catheter bag was observed on the floor, contrary to infection control guidelines.
The facility failed to maintain essential laundry equipment, with only one washer and dryer operable, leading to service delays. Residents expressed concerns during a council meeting, and staff confirmed the issue had persisted for over a year. The Administrator and Maintenance Director were aware, but the facility lacked a policy for equipment maintenance.
The facility failed to provide required education on resident rights and facility responsibilities to nine staff members, including CNAs, LVNs, an RN, and a social worker. Personnel records lacked evidence of such training, and interviews revealed that ongoing training was conducted without a set curriculum, potentially leading to this oversight.
The facility failed to provide mandatory infection prevention and control training for seven staff members, as revealed by personnel record reviews and interviews. The HR Personnel was responsible only for initial orientation, while the DON conducted weekly in-services without a set curriculum, leading to the omission of essential training.
The facility failed to provide mandatory behavioral health training for 15 out of 16 staff members reviewed, including CNAs, MAs, LVNs, RNs, and a social worker. Personnel records showed no evidence of such training, and interviews revealed that ongoing training was conducted without a set curriculum or guidelines. This deficiency could place residents at risk of being cared for by untrained staff.
A resident reported missing personal items, including laptops and a wallet, after being temporarily relocated due to bed bugs. The facility failed to fully investigate the grievance or assist in replacing identification and bank cards. Staff interviews revealed a lack of proper documentation and skepticism about the resident's claims, leading to a deficiency in addressing grievances effectively.
A resident was forced to leave his room due to a bed bug infestation, and upon returning, found his wallet, DVDs, snacks, and two laptops missing. The facility failed to maintain an inventory of the resident's belongings and did not report the incident as misappropriation. The grievance report was incomplete, and the facility did not assist the resident in replacing his missing items.
A resident reported missing personal items, including laptops and a wallet, but the LTC facility failed to report the alleged misappropriation to the state agency. Staff interviews revealed inconsistencies in inventory management and grievance documentation. The facility's policy required reporting such incidents, but the Administrator did not believe it was necessary as the resident did not explicitly state the items were stolen.
The facility failed to ensure a safe environment for two residents. One resident, with diabetes and intact cognition, had an insulin needle left on her bedside table without proper assessment for self-administration. Another resident, with a history of falls and other health issues, had a power strip with a fan plugged into it in his room, contrary to facility policy. These oversights posed potential safety risks.
A facility failed to maintain proper communication and coordination with a dialysis center for a resident with chronic kidney disease. The resident's dialysis communication sheets were often incomplete or missing, and the facility lacked a policy to ensure their completion. Staff interviews revealed that the responsibility for managing these sheets was not consistently upheld, potentially impacting the resident's care.
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. A medication aide prepared medications for a resident, but an LVN administered them without verifying the medications. In another case, an LVN did not administer the full prescribed dose of an arginine-based powder mixture to a resident with a PEG tube, discarding part of the mixture. These actions violated facility policy and state regulations, potentially putting residents at risk for medication errors.
The facility failed to properly dispose of garbage and refuse, as Dumpster #1 was observed open with trash on the ground. Staff interviews revealed that the dumpster is shared, and sometimes left open, attracting animals. Maintenance is responsible for trash pickup, but any staff can assist.
The facility failed to maintain accurate medical records for two residents, leading to potential risks in their care. One resident's records were not updated to reflect changes in diet and medication administration, while another resident's DNR status was not accurately documented. The DON and MDS Coordinator acknowledged issues with updating care plans, which are crucial for guiding staff in providing appropriate care.
A resident in a LTC facility was found without a privacy curtain, compromising his visual privacy. The resident, who was primarily bedbound and required assistance for all ADLs, did not have a curtain due to it having fallen off and not being replaced. Staff interviews revealed a lack of awareness about the missing curtain until the survey, and the facility's policy emphasized the importance of privacy and dignity for residents.
Three CNAs at a facility failed to follow infection control protocols during peri care for two residents, using dirty gloves to handle clean items and not sanitizing hands. This breach in protocol was acknowledged by the DON, who noted the CNAs' limited understanding of proper practices.
A resident with a history of hypertension and shortness of breath had nasal cannulas and tubing improperly stored, hanging over a wheelchair handle instead of in a protective bag. Despite staff training on proper storage procedures, multiple staff members failed to notice the issue, potentially risking cross-contamination and illness.
A resident with malignant cancer experienced chronic pain due to the facility's failure to provide prescribed pain medications, methadone and hydromorphone, which were frequently unavailable. Despite the resident's severe pain and documented need for these medications, the facility did not ensure their availability, leading to significant distress and inadequate pain management.
A resident with malignant cancer did not receive prescribed pain medications for three months due to unavailability, resulting in unmanaged pain. Additionally, the facility failed to administer a chemotherapy medication, leading to missed doses. Staff interviews revealed issues with prescription fulfillment due to insurance and paperwork delays.
A facility failed to develop a comprehensive care plan for a resident, leaving their medical, nursing, and psychosocial needs unaddressed. The resident had multiple health issues, including impaired cognition, an ostomy, and a history of stroke, among others. Despite these needs, the care plan was blank, as confirmed by interviews with the Administrator and DON, who emphasized the importance of care plans for resident safety and care guidance.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with multiple food items in the refrigerator, freezer, and dry storage area found unsealed, unlabeled, and undated. Staff shortages and rushing were cited as reasons for the oversight.
The facility failed to serve meals simultaneously to two residents at the same table, leading to delays of 10 and 17 minutes. Staff interviews revealed poor communication between the kitchen and nursing staff, despite a policy requiring coordinated meal service.
The facility failed to ensure resident privacy for two residents. One resident was exposed when a CNA opened the door without informing another CNA who was providing care. Another resident was found lying in bed with no clothing from the waist down, with the door open and the privacy curtain not pulled closed. Staff interviews confirmed that privacy protocols were not followed.
Resident Fed in Dining Room With Fecal Matter on Hands, Violating Dignity and Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was clean and treated with dignity while being assisted with feeding in the dining room. The resident was an older male with moderate cognitive impairment, dementia, visual loss including left eye blindness, generalized weakness, poor endurance, impaired balance, and reduced range of motion in both shoulders. His MDS and care plan documented that he required substantial to maximal assistance with eating and personal hygiene, and that he needed maximum assistance for ADLs and mobility. The care plan also included an intervention to ensure the resident was clean, dry, and comfortable before mealtime and to provide assistance as needed for meal completion. On the evening in question, the resident’s family member arrived during dinner and went to the dining room, where the resident was being assisted with his meal. As the family member approached the table, he smelled a foul odor like bowel movement and then observed fecal matter on both of the resident’s hands, which were at chest level. The family member became extremely upset and demanded that the resident be cleaned. The social worker, who was present in the facility, went to the dining room and also observed fecal matter on both of the resident’s hands while the resident was being fed by a CNA. The social worker stated he was shocked and alarmed by what he saw and noted that the resident was known to scratch himself and put his hands in his pants. The CNA who was feeding the resident reported that he had not assisted the resident to the dining room and was unsure who had done so. He stated that after passing out meal trays, he sat down to assist the resident with feeding and had been feeding him for approximately 10 minutes before the family member arrived and alerted him to the fecal matter on the resident’s hands. The CNA stated he had not noticed the fecal matter because the resident did not use his hands during feeding and that he did not smell it, believing it had dried. A LVN in the dining room became aware of the situation when he heard the family member and saw the resident being fed with fecal matter on his hands. Both the CNA and LVN acknowledged that residents were expected to be groomed and cleaned prior to going to the dining room. Facility leadership, including the DON and administrator, confirmed that the resident had known behaviors of putting his hands in his briefs and that it was their expectation that residents be clean when fed. The facility’s resident rights policy stated that employees shall treat all residents with kindness, respect, and dignity, and that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity. Interviews indicated that the resident himself did not recall the event when interviewed later. The social worker stated that at the time of the incident the resident was calm, did not recognize he had fecal matter on his hands, and only responded to the family member’s upset reaction by asking why he was upset. The CNA reported that the resident told the family member to “shut up,” which the CNA believed was due to embarrassment. The social worker acknowledged that he did not complete a psychosocial evaluation related to the incident and stated that he "dropped the ball" in not asking psychosocial questions within 72 hours. The DON and administrator both acknowledged awareness of the incident and described it as an unfortunate situation involving infection control and dignity issues, occurring despite the resident’s known behavior of putting his hands in his pants and the care-planned need for assistance with personal hygiene and to ensure cleanliness before meals.
Failure to Ensure Hand Hygiene and Cleanliness Before Assisting Resident With Meal
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program when a resident with known behaviors and significant ADL dependence was assisted with eating while fecal matter remained on his hands. The resident was an older male with moderate cognitive impairment (BIMS score of 11) and active diagnoses including progressive neurological conditions, hypertension, viral hepatitis, diabetes mellitus, and non-Alzheimer’s dementia. His MDS and care plan documented that he required substantial/maximal assistance with eating and personal hygiene, had visual deficits including blindness in one eye, and needed maximum assistance for personal hygiene tasks. His care plan also included interventions to ensure he was clean, dry, and comfortable before mealtime and that he required substantial assistance for meal intake. On the evening in question, the resident’s family member arrived during dinner and, upon approaching the dining room table, smelled a foul odor like bowel movement and observed fecal matter on both of the resident’s hands, which were at chest level, while the resident was being assisted with his meal by a CNA. The family member reported being extremely upset that the resident was being fed without his hands being cleaned. The social worker, who was in the facility at the time, responded to the complaint, went to the dining room, and also observed fecal matter on both of the resident’s hands while the CNA was feeding him. The social worker stated the amount of fecal matter was enough to be noticed and that the resident was known to scratch himself and put his hands in his pants. The CNA who was feeding the resident reported that he had been assisting the resident with his meal for approximately 10 minutes before the family member alerted him to the fecal matter on the resident’s hands. He stated he had not noticed the fecal matter because the resident did not use his hands during feeding and that there was no smell, describing the fecal matter as appearing dried. An LVN working in the dining room as the nurse checking meal trays stated he became aware of the situation when he heard the family member bring attention to it and then saw the CNA feeding the resident while the resident had fecal matter on his hands. The DON and ADM both acknowledged that the resident had known behaviors of putting his hands in his briefs and that residents were expected to be clean when being fed. The facility’s Infection Prevention and Control policy required implementation of a program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, which was not followed in this instance.
Lack of Documentation for Nurse Aide Skill Competency
Penalty
Summary
The facility failed to ensure that nurse aides who had completed more than four months of employment were properly trained and deemed competent, and that those with less than four months of employment were enrolled in appropriate training. Record reviews for 13 nurse aides revealed that, although their training programs were reportedly completed, there was no documented proof of completion of the Nurse Aide Curriculum skill performance checklists in their employee records. This lack of documentation was consistent across all 13 nurse aides reviewed. Interviews with the Director of Nursing (DON), Administrator (ADM), and Staffing Coordinator confirmed that the skill performance checklists, which were supposed to be maintained in a binder, could not be located anywhere in the facility. All three staff members acknowledged that the binder was expected to be up to date and available for review, and that the absence of this documentation would appear as if the required skill checks had not been completed. The DON and Staffing Coordinator both stated that the skills had been checked off, but without the binder, there was no way to validate this claim. The facility's own Nurse Aide Qualification and training requirements specify that nurse aides must undergo a state-approved training program and complete a minimum of 16 hours of training in specific areas before having direct contact with residents. Despite these requirements, the facility was unable to provide evidence that the nurse aides had completed the necessary skill performance checklists, as required by both facility policy and state regulations.
Failure to Update Care Plan After Resident Fracture
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan to address a resident's newly diagnosed right humerus fracture following a fall. After the resident was found on the floor with a skin tear near her bed, an X-ray confirmed a nondisplaced fracture of the medial epicondyle of the right humerus. Despite this significant change in the resident's condition, the care plan was not updated to include the fracture, associated interventions, or measurable goals. The resident had a history of dementia with agitation, anxiety disorder, and required staff assistance with activities of daily living. She was also on hospice care, and her responsible party declined aggressive treatment for the fracture, opting for comfort measures. Orders for pain management were received and implemented, but the care plan continued to reflect only fall risk and did not address the new fracture or specify interventions related to the injury. Interviews with facility staff, including the DON and MDS nurse, confirmed awareness of the fracture and acknowledged that the care plan should have been updated to reflect this significant change. The facility's policy required care plans to be revised when there is a significant change in a resident's condition, but no acute or comprehensive care plan update was completed for the fracture. This omission resulted in a lack of documented guidance for staff on how to address the resident's new medical needs.
Failure to Prevent Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically failing to prevent the elopement of a cognitively impaired resident. The resident, who had a history of cerebral infarction, language disorder, heart failure, cardiomyopathies, aphasia, substance abuse, and confusion, was admitted to the facility and was noted by multiple staff members and family to be confused and cognitively impaired. Despite these observations, the resident's elopement risk assessment did not indicate cognitive impairment or identify the resident as an elopement risk. Staff interviews revealed inconsistent recognition of the resident's confusion and potential for elopement, with some staff considering the resident at risk and others not, based on the absence of exit-seeking behaviors at the time of admission. The resident was last seen in his room early in the morning and was discovered missing a few hours later. Upon searching, staff found a window open with the screen removed, indicating the resident had exited through the window. The facility did not have a plan in place for monitoring windows to ensure resident supervision and prevent such incidents. The lack of accurate assessment and monitoring contributed to the resident's ability to leave the facility undetected, and the resident was found 26 hours later at a family member's home, displaying agitation and confusion. Interviews with staff and family members highlighted gaps in communication, assessment, and supervision. Staff had received training on elopement assessments, but there was confusion about when to identify a resident as an elopement risk, particularly for new admissions with cognitive impairment but no immediate exit-seeking behavior. The facility's policy required identification and care planning for residents at risk of wandering or elopement, but this was not effectively implemented for the resident in question, resulting in the deficiency.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Facility Lacks Mandatory Effective Communication Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on effective communication for 16 employees, including CNAs, LVNs, RNs, and other staff members. The personnel records of these employees, with hire dates ranging from 2014 to 2023, showed that their annual training in-services did not include evidence of effective communication training. This omission was identified through interviews and record reviews, indicating a lack of structured training programs for effective communication. During interviews, the HR Personnel stated that she was only responsible for initial orientation training, while the Director of Nursing (DON) or Administrator handled all other training. The DON mentioned conducting weekly meetings or in-services based on issues that needed addressing, without following a set curriculum or guidelines. This lack of structured training could place residents at risk of being cared for by untrained staff.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff members, which included 16 employees such as CNAs, LVNs, RNs, and other personnel. The personnel records reviewed showed that none of these employees had evidence of receiving training on the QAPI program as part of their annual in-service training. This lack of training could potentially place residents at risk of being cared for by untrained staff. Interviews with the HR Personnel and the Director of Nursing (DON) revealed that the HR Personnel was only responsible for initial orientation training, while the DON or Administrator was responsible for all other training. The DON stated that she conducted meetings or in-services weekly based on issues that needed to be addressed, but there was no set curriculum or guidelines followed for these trainings. This lack of structured training on the QAPI program contributed to the deficiency identified by the surveyors.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to communicate the compliance and ethics program's standards, policies, and procedures through a training program or other practical manner for all 16 employees reviewed. This deficiency was identified through interviews and record reviews, which revealed that the facility did not provide evidence of training on the compliance and ethics program's standards, policies, and procedures as required. Personnel records for various staff members, including CNAs, LVNs, RNs, and other staff, showed that while annual training in-services were provided, they did not include the necessary compliance and ethics training. Interviews with the HR Personnel and the Director of Nursing (DON) further highlighted the deficiency. The HR Personnel indicated that she was only responsible for initial orientation training, while all other training was managed by the DON or Administrator. The DON stated that she conducted weekly meetings or in-services based on issues that needed addressing, but there was no set curriculum or guidelines followed for these trainings. This lack of structured training could place residents at risk of being cared for by untrained staff, as the facility did not ensure that all employees were adequately informed about the compliance and ethics program's requirements.
Failure to Provide Mandatory Abuse Prevention Training
Penalty
Summary
The facility failed to provide mandatory annual training to staff on the prevention of abuse, neglect, and exploitation of residents. This deficiency was identified for seven out of twenty-two staff members reviewed, including various licensed vocational nurses (LVNs), a registered nurse (RN), and a social worker (SW). Personnel records for these staff members showed no evidence of education on these critical topics, despite their hire dates ranging from 2014 to 2024. The lack of training was confirmed through interviews and record reviews, indicating a systemic issue in the facility's training program. During interviews, the HR Personnel stated that they were only responsible for initial orientation training, while ongoing training was managed by the Director of Nursing (DON) or the Administrator. The DON mentioned conducting weekly meetings or in-services based on issues that needed addressing, but there was no set curriculum or guidelines followed. This lack of structured training could potentially place residents at risk of being cared for by untrained staff, as the facility did not ensure that staff completed their mandatory abuse annual training.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for several residents, as observed during a survey. Resident #69's room had multiple maintenance issues, including a missing pull string for the overhead light, peeling wallpaper, a missing drawer cover, and a torn privacy curtain. Despite the resident's complaints to staff and the Maintenance Manager, these issues remained unresolved, affecting the resident's ability to independently control lighting and contributing to feelings of neglect. Resident #74's room also had significant deficiencies, including a missing light switch and plate cover for the bathroom, which was used as storage, blocking access. This situation was inconvenient for the resident's family during visits, and although the Maintenance Manager was aware of the issue, it had not been addressed. Additionally, room [ROOM NUMBER] had structural damage, including a broken baseboard, peeling wallpaper, and a missing toilet tank cover, which had not been inspected by the Maintenance Manager since his employment began. Other residents experienced similar issues, such as Resident #31, whose room had a stained privacy curtain, and Resident #12, who had broken blinds and a missing drawer. Resident #15's room had a large hole in the wall and a missing pull string for the overhead light, causing distress due to nightmares. Despite the facility's policy for maintaining a homelike environment, these deficiencies persisted, with staff and management failing to address them promptly, as evidenced by the Maintenance Log and interviews with staff and the Administrator.
Inaccurate and Incomplete Care Plans Lead to Potential Risks
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential confusion and improper care. For instance, the care plans for three residents did not reflect their refusal of staff assistance with personal refrigerated items, which resulted in unsanitary conditions and potential health risks. Observations revealed that these residents had expired and moldy food in their personal refrigerators, and staff interviews confirmed that the residents often refused assistance, which was not documented in their care plans. Another resident's care plan was not updated to reflect changes in dietary and medication needs. Despite a speech therapy discharge summary and physician's orders indicating the resident could consume a regular diet and whole medications, the care plan still required crushed medications and thickened liquids. This discrepancy led to confusion during medication administration, as observed when a medication aide attempted to administer crushed medications and thickened fluids, which the resident refused, stating they had been on a regular diet for a year. Additionally, a resident's care plan inaccurately documented their code status and medical needs. Although the resident and their family had decided on a DNR status, the care plan still listed them as full code. Furthermore, the care plan incorrectly included a colostomy, which the resident did not have. Interviews with staff revealed a lack of communication and updates to the care plans, contributing to these inaccuracies and potential risks to resident care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications, as observed in two medication carts and two residents' rooms. On the 200-unit, seven out of eleven insulin pens lacked pharmacy labels, and the medication cart was left unlocked with medications unattended. LVN A explained that insulin pens were delivered in a multi-count box with a label, but individual pens were not labeled, leading staff to write residents' names on the caps. MA D also left the cart unlocked with medications on top while washing hands, acknowledging the oversight. On the 400-unit, MA U left the medication cart unlocked and unattended with a bottle of medication on the counter. The DON confirmed that insulin pens were not individually labeled and acknowledged the safety benefits of having pharmacy labels on each pen. The facility's policy requires all drugs to be stored in locked compartments, and the failure to do so was recognized as a safety hazard. Resident #72, with mild cognitive impairment, was found with medicated ointment at his bedside, which he applied himself, despite not being assessed for self-administration. Similarly, Resident #84, who was cognitively intact but had impaired safety awareness, had a bottle of cough syrup at his bedside without a current order. The DON stated that residents should not have medications at their bedside without proper assessment, as it could lead to negative interactions with prescribed medications.
Deficiency in Food and Nutrition Service Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. Specifically, six dietary staff members, identified as DA K, DA L, DA M, DA N, DW P, and DA O, did not possess the required Texas Food Handler Certificate. This deficiency was identified through record review and interviews, where it was noted that the certificates for these staff members were not found among the facility's records. During an interview, a staff member stated that these individuals were only responsible for washing dishes and did not believe they needed a food handler certificate. The facility's policy requires that food and nutrition services staff be trained and possess the necessary certifications to perform their duties, which was not adhered to in this case.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas within the kitchen. During an observation, it was noted that the handwashing station in the kitchen was improperly equipped with hand sanitizer instead of hand soap, which is necessary for proper hand hygiene. This was acknowledged by the Dietary Supervisor (DS), who indicated that the sanitizer was mistakenly placed in the dispenser. Additionally, dish racks were found directly on the kitchen floor, and juice lines were observed resting on the floor, with fruit flies present in the area. The DS was unaware of the fruit flies and stated that the juice machine was not in use. Further observations revealed improper food storage practices. A crate of milk cartons was found on the floor of the walk-in cooler, and there were undated open packages of turkey and shredded cheese. The DS confirmed that food items should be dated upon opening. Additionally, a container of onions was undated, a rotten potato was found among other potatoes, and an open bag of grits was not properly sealed. A bottle of BBQ sauce, which required refrigeration after opening, was found expanded and not refrigerated. The DS acknowledged these issues and indicated that the sauce should have been discarded. The facility also failed to maintain cleanliness and proper procedures in other areas. A resident's lunch tray was observed uncovered on a hallway cart, which could affect the food's temperature and safety. The ice machine was found with black spots inside the cover, and there was no cleaning log available. The DS stated that the ice machine had been cleaned months ago and was recently repaired, but there was no record of its cleaning. These deficiencies in food storage, preparation, and equipment maintenance could potentially place residents at risk for foodborne illnesses.
Failure to Implement Food Storage Policy in Resident Rooms
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsafe and unsanitary conditions. Specifically, Resident #70's personal refrigerator contained spoiled food, including lunch meat with green spots, and lacked a temperature log. The resident reported that staff did not assist in discarding food items or checking the refrigerator. Similarly, Resident #31's refrigerator contained expired food, such as a hard sandwich and a meatball with green spots, and had an incomplete temperature log. The staff did not consistently monitor or document the refrigerator temperatures, as evidenced by the blank entries in the log. Interviews with staff revealed inconsistencies in the monitoring of personal refrigerators. A CNA mentioned that sometimes they checked the refrigerators, but residents occasionally refused assistance. An LVN stated that the night shift was responsible for checking the refrigerators but admitted to not verifying if this was done. The facility's policy, dated 2013, required staff to monitor food safety in personal refrigeration units and educate individuals on safe food handling. However, the policy was not effectively enacted, as demonstrated by the lack of regular checks and documentation, potentially placing residents at risk of foodborne illness.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies in hand hygiene and personal protective equipment (PPE) use. Licensed Vocational Nurse (LVN) A did not perform proper hand hygiene while administering medications to three residents. LVN A was observed preparing and administering insulin and obtaining blood samples without washing or sanitizing hands between residents, despite having received recent in-service training on infection control practices. Another deficiency was observed with LVN J, who failed to wear a gown while administering medication via a peg tube to a resident with enhanced barrier precautions (EBP) orders. LVN J also did not change gloves after handling medication supplies, which could lead to cross-contamination. LVN J admitted to being unsure about the resident's EBP status and acknowledged the importance of changing gloves to prevent infection. Additionally, the facility did not ensure that a resident's indwelling urinary catheter bag was kept off the floor, as required by infection control guidelines. The catheter bag was observed on the floor, which was identified as a potential source of infection. Staff interviews confirmed that the catheter bag should not be on the floor to prevent urinary tract infections, and it was the responsibility of the aides and nurses to ensure proper care.
Inoperable Laundry Equipment Affects Resident Services
Penalty
Summary
The facility failed to maintain essential laundry equipment in safe operating condition, affecting the laundry department's ability to meet the needs of its residents. Specifically, only one of two washing machines and one of two dryers were operable, which led to frequent breakdowns and a backlog in laundry services. This issue was highlighted during a Resident Council meeting where residents expressed concerns about the laundry delays. The Laundry Assistant Manager confirmed that the equipment had been inoperable since she started working at the facility a year ago and that the issue had been reported to upper management. Despite a repair company's visit, the washer was deemed too old to repair, and the dryer required frequent repairs. The Administrator, who had been employed since May 2024, acknowledged awareness of the issue and stated that the corporate office was informed and bids for new units were being sought. The Maintenance Director, employed since January 2025, confirmed the equipment's inoperability and mentioned switching to a new repair vendor. The facility lacked a policy for maintaining essential equipment for resident care, as confirmed by the Administrator. The ongoing equipment issues could potentially place residents at risk of unmet needs due to the inability to maintain timely laundry services.
Deficiency in Staff Training on Resident Rights and Facility Responsibilities
Penalty
Summary
The facility failed to provide the required education on the rights of the residents and the responsibilities of the facility to properly care for its residents. This deficiency was identified for nine out of sixteen employees reviewed for training, including CNAs, LVNs, an RN, and a social worker. The personnel records of these employees showed no evidence of training on resident rights and facility responsibilities, despite their hire dates ranging from 2014 to 2023. The lack of documented training suggests a systemic issue in the facility's training program. Interviews with the HR Personnel and the Director of Nursing (DON) revealed gaps in the training process. The HR Personnel indicated that she was only responsible for initial orientation training, while ongoing training was managed by the DON or Administrator. The DON stated that she conducted weekly meetings or in-services based on issues that needed addressing, but there was no set curriculum or guidelines followed. This ad-hoc approach to training may have contributed to the oversight in providing essential education on resident rights and facility responsibilities.
Inadequate Infection Control Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on infection prevention and control standards, policies, and procedures for seven staff members, including DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW. A review of personnel records revealed that these staff members, hired between 2014 and 2024, did not receive education on infection control topics as part of their annual training in-services. This lack of training was confirmed during interviews with the HR Personnel and the Director of Nursing (DON). The HR Personnel indicated that she was only responsible for initial orientation training, while all other training was managed by the DON or Administrator. The DON stated that she conducted weekly meetings or in-services based on issues that needed addressing, without following a set curriculum or guidelines. This approach resulted in the omission of infection prevention and control training for the staff members reviewed, potentially placing residents at risk of illness due to insufficient staff training.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide mandatory behavioral health training for 15 out of 16 employees reviewed, including MDS, CNAs, MAs, LVNs, RNs, and a social worker. The personnel records of these employees, with hire dates ranging from 2014 to 2024, showed no evidence of behavioral health training. This lack of training was identified through interviews and record reviews, indicating a systemic issue in ensuring staff received the necessary training to care for residents with behavioral health needs. During interviews, the HR Personnel stated that she was only responsible for initial orientation training, while ongoing training was the responsibility of the Director of Nursing (DON) or the Administrator. The DON mentioned conducting weekly meetings or inservices based on issues that needed addressing but admitted there was no set curriculum or guidelines followed for these trainings. This lack of structured training could potentially place residents at risk of being cared for by untrained staff.
Failure to Address Resident Grievance on Missing Personal Property
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal, as evidenced by the case of a resident who reported missing personal property, including two laptops, a wallet, DVDs, and food items. The resident, who had intact cognition and expressed a desire to stay in the facility long-term, reported the missing items after being temporarily relocated due to a bed bug infestation in his room. Despite filing a grievance, the facility did not fully investigate or resolve the issue, leaving sections of the grievance report incomplete and failing to assist the resident in replacing his identification and bank card. Interviews with staff revealed inconsistencies and a lack of proper documentation regarding the resident's personal belongings. The facility's staff, including the LVN, QA, and DON, acknowledged the absence of an inventory sheet for the resident, which is typically completed upon admission and updated as necessary. The social worker admitted to not completing an inventory sheet after the grievance was filed and did not assist the resident in replacing his missing identification and bank card. The administrator and other staff members expressed skepticism about the resident's claims, citing a lack of evidence and changing accounts of the number of missing laptops. The facility's grievance policy requires thorough investigation and documentation of grievances, but this was not adhered to in the resident's case. The administrator did not report the missing items to the state agency, as she did not believe it constituted misappropriation of property. The facility's failure to properly investigate and address the resident's grievance, as well as the lack of assistance in replacing essential personal items, highlights a deficiency in honoring residents' rights to voice grievances and have them resolved promptly and effectively.
Failure to Protect Resident's Belongings During Room Transfer
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when he was forced to leave his room due to a bed bug infestation. Upon returning, the resident discovered that his wallet, DVDs, snacks, and two laptops were missing. The resident, who has multiple sclerosis and an intact cognition for daily decision-making, reported the missing items to the facility and filed a police report. However, the facility did not find or replace the missing items. Interviews with staff revealed that there was no inventory sheet for the resident, which is typically completed upon admission. The staff, including the LVN, QA, and DON, were unaware of the resident's belongings, and no inventory sheet was found for the resident. The social worker did not complete an inventory sheet after the grievance was filed and did not assist the resident in replacing his ID or bank card, which were in the missing wallet. The facility's grievance report was incomplete, with blank sections for investigation findings and expected results. The administrator did not report the incident to the state agency, as she did not believe it constituted misappropriation since the resident did not explicitly state the items were stolen. The facility's policies on grievances and abuse investigation require reporting and investigating alleged violations, but these procedures were not followed in this case.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged violation involving the misappropriation of property for a resident who claimed his wallet, DVDs, snacks, and two laptops were missing. The resident, who had intact cognition for daily decision-making, reported the missing items to the facility and filed a police report. However, the facility did not report the incident to the state agency as required by their policy. The grievance report completed by the social worker was incomplete, with missing investigation findings and unresolved follow-up actions. Interviews with staff revealed inconsistencies in the handling of the resident's belongings and the inventory process. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged the absence of an inventory sheet for the resident, which is typically completed upon admission. The social worker admitted to not completing an inventory sheet after the grievance was filed and did not verify the resident's receipts for the missing items. The Administrator and staff expressed doubts about the number of laptops the resident owned and the circumstances under which they went missing. The facility's policy required all alleged violations of neglect, abuse, and misappropriation of property to be reported and investigated under state law. Despite this, the Administrator did not report the incident to the state agency, believing it was not misappropriation since the resident did not explicitly state the items were stolen. The Administrator also noted the resident's changing accounts of the missing items and planned to have him seen by psychiatric services. The facility's failure to report the incident and properly document the grievance process highlights a deficiency in adhering to regulatory requirements for reporting and investigating alleged violations.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a safe environment for Resident #47 by allowing an insulin needle to be left on her bedside table. Resident #47, a female with intact cognition and a history of type 2 diabetes mellitus, depression, hypothyroidism, and anxiety disorder, was observed with an unopened insulin pen needle on her dresser. The resident stated that staff had given her the needle, which she initially kept in her purse before placing it on the dresser. The Director of Nursing (DON) confirmed that residents require an assessment to self-administer medications and that all medications should be administered by staff. The presence of the needle without proper assessment and care planning posed a potential risk to the resident's safety. Additionally, the facility did not ensure a hazard-free environment for Resident #70, who had a power strip with a fan plugged into it in his room. Resident #70, a male with intact cognition and a history of hypertensive heart disease, edema, chronic obstructive pulmonary disease, obesity, repeated falls, bipolar II, insomnia, and generalized anxiety disorder, stated he used the fan due to room temperature issues. Despite the facility's policy prohibiting power strips, the resident continued to have one in his room, as confirmed by the Administrator. This oversight could lead to potential hazards and accidents, especially given the resident's history of falls.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis center for a resident requiring dialysis services. The resident, a male with chronic kidney disease stage 5 and type 2 diabetes, was admitted to the facility and required dialysis treatments on specific days. The facility's records indicated that the resident's dialysis communication sheets were incomplete or missing for several dates in February, which is crucial for maintaining continuity of care and monitoring the resident's condition. Observations and interviews revealed that the facility staff, including the LVN and CNA, were responsible for preparing and managing the dialysis communication sheets. However, there were multiple instances where the sheets were not filled out or returned from the dialysis center, and the facility did not have a policy in place to ensure the completion and return of these sheets. The Director of Nursing (DON) acknowledged the importance of these sheets for tracking the resident's health status and stated that it was the nurse's responsibility to follow up with the dialysis center if the sheets were not returned. The lack of a formal policy and procedure for managing dialysis communication sheets contributed to the deficiency. The DON and nursing staff were aware of the issue but did not consistently ensure that the communication sheets were completed and filed appropriately. This oversight could potentially affect the resident's care and treatment, as the dialysis communication sheets are essential for documenting vital signs, medication changes, and any health issues related to the dialysis treatment.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. For one resident, a medication aide prepared the medications, but a Licensed Vocational Nurse (LVN) administered them without verifying the medications. The LVN admitted to not knowing what medications were being given, which could result in incorrect medication administration. The Director of Nursing (DON) stated that while it is expected for the person who prepares the medication to administer it, it would be acceptable if a supervisor verified the medications before administration. In another case, an LVN did not administer the full prescribed dose of an arginine-based powder mixture to a resident with a PEG tube. The LVN discarded 15 mls of the mixture, believing it to be just water, despite it being part of the therapeutic dose. The DON confirmed that all of the mixed medicine should be administered for therapeutic effect. This oversight could compromise the resident's nutritional and wound management needs. The facility's policy on medication administration emphasizes that medications should be administered by the individual who prepared them and in accordance with prescribers' orders. The Texas Administrative Code also mandates that all medications be administered by the person who prepared them. These deficiencies highlight a failure to adhere to established protocols, potentially putting residents at risk for medication errors.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically with Dumpster #1, which was observed to be open on multiple occasions. On two separate observations, the side door of the dumpster was found open, and trash, including a food wrapper, used gloves, and used masks, was found on the ground behind the dumpster. Interviews with staff revealed that the dumpster is shared with the entire facility, and sometimes others leave it open. The Director of Services (DS) acknowledged that the open dumpster and trash on the ground could attract animals and should not be there. The Maintenance Staff (MS) stated they were responsible for picking up trash outside the facility and had done so the day before. The Administrator confirmed that maintenance was responsible for picking up trash outside, but any staff could assist, and an in-service had been conducted to remind staff to keep the dumpster closed.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to potential risks in their care. For one resident, the facility did not update the physician's orders to reflect changes in the resident's diet and medication administration. Despite the resident being evaluated by a speech-language pathologist and deemed safe to consume whole medications and a regular diet, the care plan continued to indicate the need for crushed medications and a mechanically altered diet. This discrepancy was acknowledged by the Director of Nursing (DON), who admitted that care plans were not being updated promptly, which is crucial for guiding staff in providing appropriate care. Another resident's medical records were not updated to reflect their current Do Not Resuscitate (DNR) status. Although the resident's face sheet and discussions with the resident indicated a DNR status, the physician's orders and care plan still listed the resident as Full Code. This inconsistency was noted by the DON, who confirmed that the resident was currently DNR and on hospice care. The MDS Coordinator, responsible for updating care plans, admitted to being overwhelmed and acknowledged that many care plans were missing or incomplete, including the one for this resident. These deficiencies in maintaining accurate medical records could lead to improper care due to staff following outdated or incorrect care plans. The facility's failure to update care plans promptly and accurately reflects a systemic issue in managing resident information, as acknowledged by both the DON and the MDS Coordinator.
Failure to Provide Privacy Curtain for Resident
Penalty
Summary
The facility failed to ensure full visual privacy for a resident, identified as Resident #66, by not providing a privacy curtain in his room. This deficiency was observed during a survey where it was noted that Resident #66, a male with multiple medical conditions including cerebral infarction, pressure ulcers, and encephalopathy, did not have a privacy curtain in his room. The resident was primarily bedbound and required assistance for all activities of daily living and mobility tasks. During an observation, it was found that the privacy curtain had fallen off a long time ago and was never replaced, as confirmed by the resident's roommate. Interviews conducted during the survey revealed that the Licensed Vocational Nurse (LVN) was unaware of the missing privacy curtain until it was brought to her attention, at which point she planned to inform maintenance. The Maintenance Manager (MM) also stated he was not aware of the missing curtain until the day of the interview and mentioned the need to order a new one. The Administrator acknowledged the absence of the privacy curtain and had already moved the resident to a room with a curtain, recognizing the importance of privacy and dignity for residents. The facility's policy on Resident Rights emphasized the importance of treating residents with respect and dignity, including ensuring their privacy and confidentiality.
Infection Control Breach by CNAs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of three CNAs who did not adhere to proper infection control protocols while providing peri care to two residents. CNA A, CNA B, and CNA C were observed handling clean items with dirty gloves, which could lead to the transmission of infections. Specifically, CNA A did not change gloves after touching a soiled brief and continued to handle clean items and surfaces, including a new brief, a cupboard, and a resident's sneakers, without changing gloves or sanitizing hands. CNA B also failed to change gloves during peri care, handling a new brief and other clean items with soiled gloves. She did not wash her hands before donning gloves and continued to use the same gloves throughout the care process, potentially spreading germs. Similarly, CNA C did not wash or sanitize her hands before starting peri care and used the same gloves to handle both soiled and clean items, only changing gloves after applying a new brief. The facility's Director of Nursing acknowledged the breach in infection control protocols, noting that the CNAs involved had a limited understanding of proper practices. The facility's policy on standard precautions clearly outlines the necessity of hand hygiene and changing gloves to prevent cross-contamination, but these guidelines were not followed by the staff involved in the incidents.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, specifically in the storage of nasal cannulas and tubing when not in use. The resident, a female with a history of hypertension and shortness of breath, had active orders for oxygen therapy at 2 liters by nasal cannula continuously. However, observations revealed that the nasal cannula and tubing were improperly stored, hanging over a wheelchair handle instead of being placed in a protective bag as per the facility's policy. Interviews with various staff members, including CNAs, a PRN nurse, and the ADM, indicated a lack of awareness and adherence to the proper storage procedures for oxygen equipment. While some staff members acknowledged the importance of storing the equipment in a bag to prevent infection, none noticed the improper storage in the resident's room. The facility's policy, revised in November 2011, clearly stated that oxygen cannulas and tubing should be kept in a plastic bag when not in use to prevent infection. The deficiency was further highlighted by the DON and ADON, who confirmed that staff were in-serviced on oxygen storage weekly and that improper storage could lead to infection control issues. Despite these measures, the staff failed to notice and correct the improper storage of the resident's oxygen equipment, potentially placing the resident at risk of cross-contamination and illness.
Failure to Provide Adequate Pain Management for Resident with Cancer
Penalty
Summary
The facility failed to provide adequate pain management for a resident diagnosed with malignant cancer, resulting in chronic pain. Despite having orders for methadone and hydromorphone, the medications were frequently unavailable, leading to numerous instances where the resident did not receive the prescribed pain relief. The resident, who had a BIMS score indicating no cognitive impairment, reported severe pain over several days, which was documented in her care plan and medical records. The resident's medical history included malignant neoplasm of peripheral nerves and autonomic nervous system, adrenocortical insufficiency, and chronic pain. Hospital records indicated that the resident had been experiencing worsening pain and swelling in her lower extremity, which was later found to be due to a broken femur. Despite this, the facility repeatedly failed to administer the prescribed pain medications, as documented in the medication administration records, which showed numerous instances of medications being unavailable. Interviews with staff, including the DON and LVN, revealed that the facility was aware of the resident's chronic pain and the importance of administering her pain medications. However, due to issues with obtaining the prescriptions, the resident often went without her necessary pain relief, leading to significant distress and pain. The resident herself reported being in constant pain and having to call EMS due to the severity of her condition, highlighting the facility's failure to meet her pain management needs.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with a diagnosis of malignant cancer, who suffered from chronic pain. Over a period of three consecutive months, the resident did not receive prescribed pain medications, including methadone and hydromorphone, due to the medications being unavailable. Documentation in the resident's paper medication administration records indicated multiple instances where the medications were not administered because they were not available, despite the resident experiencing severe pain. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed that the resident's pain medications were not administered because the prescriptions could not be filled due to insurance and paperwork delays. The DON acknowledged that the resident was in pain all the time and that it was not acceptable for the resident to go without pain medication. The facility's policy required that medications be administered in accordance with prescribed orders, but this was not adhered to, resulting in the resident experiencing unmanaged pain. Additionally, the facility failed to administer a chemotherapy medication, pazopanib, as prescribed for the resident's malignant terminal cancer. The medication was never administered, resulting in the resident missing 24 doses. The facility's failure to follow their policies and procedures for medication administration contributed to the resident not receiving the therapeutic benefits of the prescribed medications, which could have led to increased pain and diminished quality of life.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a critical component of ensuring that the resident's medical, nursing, and mental and psychosocial needs are met. The deficiency was identified during a review of the resident's care plan, which was found to be blank. This lack of a care plan means that the resident's needs, as identified in their comprehensive assessment, were not addressed, potentially placing the resident at risk for not receiving necessary care and services. The resident in question had a range of medical conditions, including moderately impaired cognition, an ostomy, a history of stroke, hypertension, seizure disorder, malnutrition, depression, and anxiety disorder. The resident also had issues with swallowing, was at risk for pressure ulcers, and was on medications such as antidepressants and anticoagulants. Despite these needs, the care plan was not developed, which was confirmed through interviews with the facility's Administrator and Director of Nursing. They acknowledged the importance of care plans in providing guidance for resident care and ensuring safety, yet the care plan for this resident was incomplete.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Observations revealed multiple food items in the refrigerator, freezer, and dry storage area that were not sealed, labeled, or dated. These included plastic bags of cheese, ham deli meat, prepped cups of orange juice, milk in a pitcher, prepped cups of condiments, a container of strawberries, and a plastic bag of lettuce in the refrigerator. In the freezer, items such as mini pizzas, chicken, waffles, hamburger meat, and dough squares were found unsealed, unlabeled, and undated. Similarly, dry storage items like containers of various cereals, flour, sugar, and rice were also not labeled, dated, or sealed. Interviews with kitchen staff and the administrator confirmed that all food items should be labeled, dated, and sealed once opened, but this was not done due to staff shortages and rushing to complete tasks. The facility's food storage policy and the 2022 Food Code by the U.S. Food and Drug Administration were not adhered to, which could lead to food contamination and potential health risks for residents.
Failure to Serve Meals Simultaneously to Residents at the Same Table
Penalty
Summary
The facility failed to treat two residents with respect and dignity during dining services. Specifically, Resident #1 and Resident #2 did not receive their meal trays at the same time as their tablemates, leading to delays of 10 and 17 minutes, respectively. This discrepancy was observed during a dining service, where other residents at the same table received their meals on time, while these two residents had to wait significantly longer. Both residents have severe cognitive impairments, as indicated by their BIMS scores, and were unable to express their concerns during interviews. Interviews with various staff members, including CNAs, kitchen staff, and the Director of Nursing (DON), revealed that the facility's policy mandates that all residents at the same table should be served their meals before moving on to the next table. However, there was a lack of communication and coordination between the kitchen and nursing staff, which led to the delay in serving the meal trays to Resident #1 and Resident #2. Staff members acknowledged that such delays could make residents feel ignored or upset, potentially leading to behavioral issues. The Administrator confirmed that the policy requires a coordinated effort between dining and dietary departments to ensure all residents at the same table receive their meals simultaneously. The failure to adhere to this policy was attributed to poor communication between departments. The Dining Experience Staff Responsibility Policy, dated 2013, also supports this requirement, emphasizing the importance of serving and assisting all individuals at the same table at the same time.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure resident rights for personal privacy for two residents. CNA B and CNA C did not provide privacy to a resident when providing care. Specifically, CNA B opened the door without informing CNA C, who was fastening the resident's brief, leaving the resident exposed with the door open and the privacy curtain not pulled closed. This incident was observed by the surveyor, and CNA B admitted to not communicating with CNA C about opening the door, which led to the resident's exposure. CNA C confirmed that she was not informed about the door being opened and acknowledged that this could cause the resident to feel insecure. Another incident involved a resident who was found lying in bed with no clothing on from the waist down, with the door open and the privacy curtain not pulled closed. The resident was asleep and did not respond to the surveyor's attempts to wake her. There were no staff present in the hall at the time, and the resident was visible from the hallway. Interviews with the staff, including the DON and Nurse A, confirmed that staff are trained to provide privacy by closing doors and pulling privacy curtains when providing care. However, in this case, the staff failed to follow these protocols. The Administrator confirmed that staff had been trained on resident rights and that they are expected to ensure residents have privacy and dignity when receiving care. The failure to communicate between the aides and the lack of adherence to privacy protocols led to the residents being exposed, which could affect their emotional state and sense of dignity. The facility's guidelines for nursing procedures also emphasize the importance of closing room doors and providing privacy for residents during care.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
