Granbury Rehab & Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Granbury, Texas.
- Location
- 2124 Paluxy Hwy, Granbury, Texas 76048
- CMS Provider Number
- 455929
- Inspections on file
- 27
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Granbury Rehab & Nursing during CMS and state inspections, most recent first.
During a lunch meal service, residents did not receive all menu items, including macaroni salad, and two residents on pureed diets did not receive the required pureed roll. Staff did not inform residents of missing items or provide immediate substitutes, and documentation of substitutions was completed only after the meal. Multiple prior grievances indicated ongoing issues with missing or incorrect food items, and facility policies for menu adherence and substitution documentation were not followed.
The facility did not provide timely or documented responses to the Resident Council regarding multiple grievances related to nursing, dietary, and housekeeping services. Despite the facility's policy requiring communication of grievance outcomes, interviews and record reviews showed that Council members were not informed of resolutions, and issues remained unresolved. Staff cited unclear processes and workload as contributing factors to the lack of follow-up.
Three residents did not have care plans that accurately reflected their current needs and interventions, including one with a pressure ulcer whose care plan listed negative pressure wound therapy without a physician order or actual use, another on hemodialysis whose care plan lacked dialysis monitoring and collaboration details, and a third whose care plan did not match her transfer requirements or code status. Staff interviews confirmed these discrepancies and lapses in updating care plans.
The facility did not ensure its activities program was directed by a qualified professional, as the activity director lacked required certification or training and had not completed a state-approved course within the expected timeframe. The administrator was aware of the deficiency, citing financial and logistical delays as reasons for non-compliance.
The facility did not serve meals at the posted times, with lunch service significantly delayed and the last trays delivered nearly two hours after the scheduled time. Multiple residents reported ongoing issues with late meals, and staff interviews revealed there was no policy in place for meal service timing. The dietitian expected meals to be served within 45 minutes of the scheduled time, but this was not consistently met, as confirmed by observations and grievance records.
The facility did not ensure proper monitoring and documentation of food temperatures during meal preparation and service. Staff pureed hot foods with cold milk, resulting in temperatures below required levels, and failed to reheat or recheck temperatures before serving. Multiple meals lacked documented temperature checks, and dietary leadership confirmed that these practices did not meet policy or regulatory standards.
The facility did not complete or maintain required EMR/NAR employability checks for two staff members, including an RN and a dietary manager, prior to their hire as mandated by policy. HR staff could not provide documentation of the checks, and the administrator confirmed the policy was not followed for both direct hires and contracted staff with resident contact.
Two residents did not have baseline care plans developed or updated within 48 hours of admission as required. For one, the facility reused an old care plan without updating it to reflect new medical orders and did not obtain updated signatures. For the other, there was no evidence that a summary of the baseline care plan was provided to the resident or their representative. Staff interviews confirmed lapses in following policy for care plan creation and communication.
A medication cart containing various prescription drugs and medical supplies was left unlocked and unattended in a hallway for several minutes while the responsible LVN was distracted by a family member. The cart was within reach of staff and residents, and the ADON confirmed it should not have been left unsecured. Facility policy requires medication carts to be locked when not attended by authorized personnel.
Staff failed to perform proper peri-care and hand hygiene during incontinent care for a resident with a history of metabolic encephalopathy and cystitis. Two CNAs did not wash their hands or use sanitizer throughout the procedure, and one reused a wipe before discarding it. The involved CNA acknowledged not following protocol due to lack of hand gel in the room, and the DON confirmed that facility policy requires hand hygiene after glove removal and care.
During a lunch meal service, several residents did not receive all items listed on the menu, including macaroni salad and pureed rolls for those on special diets. Staff did not inform residents of missing items or provide immediate substitutes, and documentation of substitutions was completed after the meal. Multiple prior complaints about missing food items and lack of communication were also noted.
The facility did not provide verbal or written responses to the Resident Council regarding grievances about nursing, dietary, and housekeeping services. Documentation indicated that grievances were marked as resolved through 'one-to-one' discussions, but residents reported not being informed of outcomes, and staff interviews confirmed a lack of consistent follow-up or communication with the Council.
Three residents did not have care plans that accurately reflected their current needs and interventions, including one with a pressure ulcer whose care plan listed negative pressure wound therapy not being provided, another on hemodialysis whose care plan lacked monitoring and communication interventions, and a third whose care plan did not match her transfer requirements or code status. Staff interviews confirmed that these discrepancies were due to lapses in updating and maintaining care plans.
The facility did not ensure its activities program was directed by a qualified professional, as the activity director lacked required certification or training and had not completed a state-approved course within the expected timeframe. Financial and logistical barriers delayed the AD's enrollment in the necessary program, and the deficiency was identified during record review and staff interviews.
The facility did not serve meals at the posted times, with lunch service significantly delayed for all residents. Staff and resident interviews confirmed ongoing issues with late meal delivery, and the facility lacked a clear policy on meal service timing. Multiple grievances had been filed about late and cold meals, and observations confirmed that meal trays were not served until well after the scheduled time.
The facility did not ensure proper monitoring and documentation of food temperatures during meal preparation and service. Staff pureed hot foods with cold milk and failed to reheat them to the required temperature, and did not consistently check or record holding temperatures before serving. Interviews revealed inconsistent understanding of food safety protocols among dietary staff and management, and review of logs showed multiple instances of missing temperature documentation, placing residents at risk for foodborne illness as noted by staff.
The facility did not complete or maintain required EMR/NAR checks for two employees, an RN and a DM, prior to their hire, as mandated by facility policy. HR staff could not provide documentation of these checks, and the Administrator confirmed that policy was not followed for both direct hires and contracted staff.
The facility did not develop or update baseline care plans within 48 hours of admission for two residents, including one with complex medical needs, and failed to provide a care plan summary to another resident or their representative. Staff interviews revealed confusion about responsibilities and processes for care plan completion and communication, resulting in incomplete documentation and lack of timely care planning.
A medication cart containing various prescription and over-the-counter drugs was left unlocked and unattended in a hallway, accessible to staff and residents, while the responsible LVN was distracted by a family member. The cart was out of the nurse's sight for several minutes, contrary to facility policy requiring medication carts to be locked when not attended by authorized personnel. The DON and ADON confirmed the expectation that carts remain secured at all times.
Two CNAs failed to perform proper hand hygiene and peri-care during incontinent care for a resident with a history of metabolic encephalopathy and cystitis. Neither staff member washed their hands or used sanitizer during or after care, and one reused a wipe before discarding it. The facility's policy requiring handwashing after glove removal and after care was not followed, and the lapse was confirmed in staff interviews.
The facility did not ensure residents received their mail on Saturdays, as reported by seven residents. Mail was only distributed Monday through Friday, with a resident clarifying she did not distribute mail on Saturdays despite claims from the Business Office Manager. The weekend receptionist retrieved Saturday mail, which was then sorted and distributed on Monday. The Administrator was unaware of this issue and confirmed there was no policy for mail distribution.
The facility did not post the HHSC complaint number and statement about filing complaints with the State Survey Agency. During an observation, it was found that this information was missing in the lobby area. A group interview with residents revealed they were unaware of how to contact the agency for complaints. The Administrator was unaware of the missing postings and confirmed the absence of a policy for required postings.
The facility failed to accommodate resident food preferences, specifically regarding the preparation of peanut butter and jelly sandwiches. Residents reported that the jelly was too thick and tore the bread, an issue linked to a change in supplier. Despite ongoing complaints, there was no policy to address these preferences, and the problem persisted for several months.
The facility failed to maintain food safety and hygiene standards in its kitchen. The fryer was left uncovered with grease debris, and sugar and flour containers were not sealed properly. Dietary Aide B did not follow proper hand hygiene during meal preparation, leading to potential cross-contamination. Additionally, containers for icing and broths were found with crumbs and particles, indicating inadequate cleaning. These observations highlight a failure to adhere to the facility's policies on equipment cleaning, food storage, and hand hygiene.
Failure to Follow Menus and Document Substitutions During Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed and that any substitutions were properly documented and communicated to residents during meal service across all four halls reviewed. On the specified lunch service, residents did not receive all food items listed on the menu, specifically macaroni salad, and two residents on pureed diets did not receive the required pureed roll. Observations confirmed that trays were served without the macaroni salad or an immediate substitute, and the pureed roll was omitted for two residents with special dietary needs. Staff interviews revealed that the kitchen did not have macaroni salad available, and residents were not informed of the missing item at the time of meal service. Multiple grievances had been previously logged by residents regarding missing food items, incorrect meals, and incomplete trays, indicating a pattern of similar issues. During the observed lunch, staff acknowledged that substitutions were not offered at the time of meal service, and alternative items such as chips or mashed potatoes were only provided later in the afternoon as a snack, rather than as part of the meal. The dietary manager and dietitian confirmed that all menu items should have been served or substituted with items of equivalent nutritional value, and that documentation of substitutions should occur prior to meal service. However, the substitution log for the day in question was only completed after the meal, and residents were not notified of the changes in a timely manner. One resident with severe protein-calorie malnutrition and dysphagia, who required a mechanically altered diet, did not receive the prescribed pureed roll and reported not having received bread options in the past. Staff interviews indicated confusion and lack of communication regarding menu substitutions and the process for notifying residents. The facility's own policies required that menu changes be documented and reviewed by the dietitian, and that substitutions be of equivalent nutritive value, but these procedures were not followed during the observed meal service.
Failure to Notify Resident Council of Grievance Resolutions
Penalty
Summary
The facility failed to consider and act promptly upon the grievances and recommendations of the Resident Council regarding issues of resident care and life in the facility. Specifically, for multiple grievances raised by the Resident Council in February, March, and August 2025, there was no evidence that the facility provided a verbal or written response to the Council addressing the reported concerns. The grievances included issues with nursing services, dietary services, and housekeeping services. Documentation in the grievance logs often indicated that residents were notified of resolutions through one-to-one discussions, but there was no documentation that the Resident Council as a group was informed of the outcomes, particularly for grievances submitted collectively by the Council. Interviews with residents revealed that none of the nine Resident Council members interviewed had received feedback regarding their grievances from August, and they stated that issues they had reported remained unresolved. Residents also reported that staff rarely attended Council meetings to discuss grievance resolutions, with only occasional attendance by the administrator and dietary manager. The Assistant Director (AD) confirmed that while she took notes and submitted grievances on behalf of the Council, there was no consistent follow-up or communication of resolutions to the Council members. The Social Worker (SW), responsible for handling grievances, stated that she would typically notify the Council president individually but had no documentation of such communication, and acknowledged that resolutions were not routinely shared with the Council as a group. The facility's grievance policy required that grievances be taken seriously, documented, investigated, and that findings and resolutions be communicated to the complainant in a timely manner. However, the policy was not followed in practice, as evidenced by the lack of documentation and communication with the Resident Council regarding the outcomes of their grievances. The administrator and other department heads believed that residents had been informed of resolutions, but resident interviews and record reviews did not support this. The failure to notify the Resident Council of grievance outcomes was attributed to workload issues and lack of a clear process for group communication.
Failure to Maintain Accurate and Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current needs and interventions for three residents. For one resident with severe cognitive impairment and a stage 4 pressure ulcer, the care plan included an intervention for negative pressure wound therapy, but there was no physician order for this therapy, and staff confirmed the resident was not receiving it. The care plan was not updated to reflect the actual wound care being provided, and the responsible staff indicated that the care plan should not have included this intervention if it was not in use. Another resident with moderate cognitive impairment and on hemodialysis did not have care plan interventions addressing the assessment and monitoring of her condition before and after dialysis treatments. The care plan only included Enhanced Barrier Precautions for the dialysis access device but lacked documentation of ongoing communication and collaboration with the dialysis facility or monitoring for complications related to dialysis. Staff interviews confirmed that dialysis care needs were not addressed in the care plan, and this omission was not identified during interdisciplinary team (IDT) reviews. A third resident, who was dependent on staff for transfers and had a history of sleeping in a recliner, had a care plan that did not accurately reflect her current transfer status or sleeping arrangements. The care plan indicated one-person assistance for transfers, while staff and the resident confirmed that a mechanical lift with two staff was required. Additionally, the care plan listed a full code status, but physician orders and documentation indicated a DNR status. Staff interviews revealed that care plans were not updated to match the resident's current needs and wishes, and there was confusion among staff regarding responsibility for maintaining accurate care plans.
Unqualified Activity Director Leads Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required. Record review showed that the activity director (AD), hired on July 17, 2024, did not have evidence of certification or training as a qualified therapeutic recreation specialist or as an activities professional meeting state licensing requirements. The AD acknowledged during an interview that she had not completed the required course due to financial and time constraints. The job description for the AD position, signed at the time of hire, specified that successful completion of a state-approved and certified course in patient activities was required within nine months of employment. The administrator (ADMN) confirmed awareness that the AD was not certified at the time of hire and stated that the AD was responsible for completing the required courses. The ADMN explained that financial issues delayed the AD's enrollment in the program and that it took additional time for the facility's corporate organization to agree to pay for the course. At the time of the survey, the AD had not yet received the course, and there was no documentation of completed certification or training in the employee file.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to provide meals and snacks at times consistent with residents’ needs, preferences, and posted schedules. On the observed date, lunch was scheduled for 11:45 a.m., but meal service did not begin until after 12:30 p.m., with the last trays being served at 1:32 p.m. Observations showed that food was served late to all areas, including the dining room and all four halls. The DON was observed instructing staff to serve food without a menu item due to the delay, acknowledging the residents were waiting. Nine residents interviewed reported that meals were consistently not served on time and had previously filed grievances about late meal service. Staff interviews revealed a lack of policy regarding meal service timing, with both the DM and DOO stating they were unaware of specific requirements. The dietitian stated her expectation was for all trays to be served within 45 minutes of the posted mealtime but noted that more education was needed for kitchen staff. Review of the facility’s grievance log showed multiple complaints throughout the year regarding late meal service and cold food, indicating an ongoing issue with timely meal delivery.
Failure to Monitor and Document Food Temperatures in Dietary Services
Penalty
Summary
The facility failed to ensure that all food service staff met local, state, and federal requirements regarding food safety, specifically in the areas of food temperature monitoring and documentation. During lunch service, staff pureed hot foods such as kielbasa sausage, green beans, and macaroni salad using cold milk as a thinning agent, resulting in food temperatures below the required threshold. The staff member responsible did not reheat the foods to the appropriate temperature after mechanically altering them and did not take additional temperature readings before serving. The dietary manager (DM) and other dietary leadership confirmed that food temperatures should be taken after preparation and prior to service, and that the use of cold milk could lower food temperatures below safe levels. Additionally, the facility failed to document required food temperatures on the temperature log for multiple meals over several days. There was no evidence that holding temperatures were taken or recorded for numerous breakfasts, lunches, and dinners within the reviewed period. The DM stated that cooks were responsible for obtaining and recording temperatures, and that she monitored compliance, but could not explain missing documentation for certain meals. The contracted dietary operations officer and the facility dietitian both stated that food temperatures should be checked after preparation and again before service, and that foods not at the correct temperature could cause illness. Facility policy and the FDA Food Code require that mechanically altered foods be reheated to at least 165°F for 15 seconds and that hot foods be held at or above 135°F. The policy also mandates that temperatures be taken and recorded prior to meal service. The review of facility records showed repeated failures to meet these requirements, with missing temperature documentation and improper handling of pureed foods, placing residents at risk for foodborne illness as directly stated by staff in the report.
Failure to Complete and Maintain Required Employability Checks for Staff
Penalty
Summary
The facility failed to follow its written policies and procedures designed to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not ensure that employability status checks (EMR/NAR) were completed and maintained for two employees, an RN and a dietary manager, prior to their hire dates as required by facility policy. Record reviews revealed that neither employee had documentation of an EMR/NAR check in their personnel files at the time of hire, and the checks were either not performed or not retained as evidence. Interviews with the HR staff confirmed that she was responsible for conducting and maintaining EMR checks but could not provide proof that the checks were completed for the RN and assumed the contracted company handled the check for the dietary manager. The administrator acknowledged that the policy was not followed and that all staff, including contracted employees with resident contact, were required to have EMR checks completed and documented. The lack of adherence to these procedures placed residents at risk of receiving care from individuals who may not have been eligible for employment.
Failure to Develop and Communicate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan or comprehensive care plan with necessary information within 48 hours of admission for two residents. For one resident, the facility used a prior baseline care plan upon readmission and did not update signatures or create a new baseline care plan as required by facility policy. This resident had multiple medical diagnoses, including pneumonia, acute respiratory failure, depression, cognitive communication deficit, and anemia, and had new physician orders upon readmission that were not reflected in an updated baseline care plan. For the other resident, there was no evidence that a summary of the baseline care plan was provided to the resident or their representative. Interviews with facility staff revealed confusion and lack of adherence to policy regarding the creation and updating of baseline care plans, especially in cases of readmission. The admitting nurse and RN on duty were responsible for updating and completing baseline care plans, while the DON was responsible for monitoring signatures. Staff acknowledged that a new baseline care plan should have been started for readmitted residents, and that the failure to do so was not in line with facility policy. There was also a lack of documentation regarding the provision of baseline care plan summaries to residents or their representatives.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart (Cart Hall D) was observed left unlocked and unattended for five minutes while not in use. During this time, three CNAs and residents were present in the hallway within arm's reach of the cart, and the responsible nurse was not in sight. The cart contained various medications, including controlled substances, anti-depressants, blood thinners, anti-diabetics, anti-psychotics, and other medical supplies. The Assistant Director of Nursing (ADON) confirmed that the cart should not have been left unlocked and stated that the responsible nurse, LVN A, was distracted by a family member and followed them down the hall, leaving the cart unsecured. LVN A stated she did not believe she had left the cart unlocked, but acknowledged that leaving medication carts unsecured could negatively affect residents. The Director of Nursing (DON) stated her expectation that all medication carts be locked when out of the nurse's direct vision and confirmed that she periodically checks the carts throughout the day. Facility policy requires that medication carts be locked when not attended by authorized personnel. The failure to secure the medication cart was attributed to poor judgment on the part of the nurse.
Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper peri-care and hand hygiene practices observed during incontinent care for a resident. During the observation, two CNAs performed peri-care for a female resident with a history of metabolic encephalopathy and cystitis, who was cognitively intact and had a care plan addressing incontinence. Neither CNA washed their hands or used hand sanitizer at any point during the peri-care process, and one CNA was observed folding and reusing a wipe before discarding it, despite the presence of a bowel movement. Interviews with the involved CNA revealed an awareness of the failure to follow proper peri-care and hand hygiene protocols, citing the absence of hand gel in the room as a reason for not performing hand hygiene between glove changes and after care. The CNA acknowledged the potential for cross-contamination and bacterial transfer. The DON confirmed that staff are expected to follow facility policy, which requires handwashing after glove removal and after providing care, and stated that staff are regularly monitored. Facility policy on incontinent care specifically outlines the need for hand hygiene at key points during the procedure, which was not followed in this instance.
Failure to Follow Menus and Document Substitutions During Meal Service
Penalty
Summary
The facility failed to ensure that its menus were followed and that any substitutions were properly documented and communicated to residents. On the date in question, multiple residents did not receive all food items listed on the lunch menu, specifically macaroni salad, and two residents on pureed diets did not receive the required pureed roll. Observations confirmed that trays were served without these items, and staff interviews revealed that the kitchen did not have macaroni salad available and did not inform residents of the missing item or provide an immediate substitute during the meal service. Resident records indicated that at least one resident had significant nutritional needs, including severe protein-calorie malnutrition and dysphagia, requiring a mechanically altered diet. The care plan for this resident specified that the prescribed diet should be followed. Despite this, the resident did not receive the pureed roll as ordered, and staff acknowledged the oversight. The facility's grievance log also documented multiple prior complaints about missing food items, incomplete trays, and lack of communication regarding menu changes. Staff interviews and policy reviews confirmed that substitutions should be of equivalent nutritive value, documented prior to meal service, and communicated to residents. However, the substitution log for the meal in question was completed after the fact, and residents reported that substitutes were only offered later in the afternoon, not during the meal. The dietitian and dietary manager both stated that all menu items should be served as planned or with appropriate substitutions at the time of service, and that failure to do so could impact residents' nutritional intake.
Failure to Notify Resident Council of Grievance Resolutions
Penalty
Summary
The facility failed to consider and act upon the views, grievances, and recommendations of the Resident Council regarding issues of resident care and life in the facility. Specifically, for multiple months, the Resident Council submitted grievances related to nursing, dietary, and housekeeping services, but there was no evidence that the facility provided a verbal or written response to the Council addressing these concerns. Documentation showed that the Social Worker (SW) often marked grievances as resolved through 'one-to-one' discussions, but there was no record of these discussions occurring with the Council or its members, and residents reported not being informed of resolutions. Interviews with residents and staff revealed that the process for addressing Resident Council grievances was inconsistent and lacked follow-up. Residents stated that they rarely received feedback about their grievances, and issues they raised remained unresolved. Staff interviews confirmed that while grievances were documented and distributed to department heads, there was no established process to ensure that resolutions were communicated back to the Resident Council. The SW and Assistant Director (AD) acknowledged that resolutions were not routinely shared with the Council, and there was confusion about who was responsible for this communication. The facility's own grievance policy required that grievances be investigated, documented, and that findings and resolutions be communicated to the person or group who raised the concern. However, the policy was not followed, as there was no documentation of follow-up with the Resident Council, and residents consistently reported a lack of feedback. This failure was observed for all nine Resident Council members reviewed, and included grievances about nursing, dietary, and housekeeping services, as well as issues such as assistance with smoke breaks.
Failure to Maintain Accurate and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current needs and interventions for three residents. For one resident with severe cognitive impairment and a stage 4 pressure ulcer, the care plan included negative pressure wound therapy as an intervention, despite there being no physician order or evidence that this therapy was ever provided. Staff interviews confirmed that the resident was not receiving negative pressure therapy, and the care plan was not updated to reflect the actual care being provided. Another resident, who was moderately cognitively impaired and receiving hemodialysis, had a care plan that only addressed enhanced barrier precautions for her vascular access device. The care plan did not include necessary interventions such as assessment and monitoring for complications before and after dialysis, nor did it document ongoing communication with the dialysis facility. Staff interviews revealed that the omission was not identified or corrected during interdisciplinary team (IDT) reviews, and the responsibility for updating the care plan was not clearly followed. A third resident, who was cognitively intact but dependent on staff for transfers and had a DNR order, had a care plan that did not accurately reflect her current transfer needs, sleeping arrangements, or code status. The care plan listed one-person assistance for transfers, while staff confirmed that a mechanical lift with two staff was required. Additionally, the care plan indicated a full code status, while the medical record and physician orders documented DNR status. Staff interviews indicated that these discrepancies were not addressed due to lapses in updating the care plan following changes in the resident's condition and preferences.
Unqualified Activity Director Leads Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by state regulations. Record review showed that the activity director (AD), hired on July 17, 2024, did not have evidence of certification or training as a qualified therapeutic recreation specialist or as an activities professional meeting state licensing requirements. The AD's job description required successful completion of a state-approved and certified course in patient activities within nine months of employment, but there was no documentation that this had been achieved. Interviews revealed that the AD experienced difficulties enrolling in the required course due to financial and time constraints. The administrator (ADMN) acknowledged awareness of the AD's lack of certification at the time of hire and stated that the AD was responsible for completing the necessary courses. The ADMN further explained that financial issues delayed the AD's enrollment, and it took additional time for the facility's corporate organization to agree to pay for the course. At the time of the survey, the AD had not yet received the required training or certification.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to provide meals and snacks at times consistent with residents’ needs, preferences, and posted schedules. On the observed date, lunch was scheduled for 11:45 a.m., but meal service did not begin until after 12:30 p.m., with the last trays being served at 1:32 p.m. Observations showed that food was served late to all areas, including the dining room and all four halls. The DON was observed instructing staff to serve food without a menu item due to the delay, acknowledging the residents were waiting. Nine residents interviewed reported that meals were consistently late and had previously filed grievances about the issue. Staff interviews revealed a lack of policy regarding meal service timing, with both the DM and DOO stating they were unaware of specific requirements. The dietitian expected trays to be served within 45 minutes of the posted mealtime but noted that more education was needed for kitchen staff. Review of the facility’s grievance log showed multiple complaints throughout the year regarding late meal service and cold food, indicating an ongoing issue with timely meal delivery.
Failure to Monitor and Document Food Temperatures in Dietary Services
Penalty
Summary
The facility failed to ensure that all food service staff met local, state, and federal requirements regarding food safety, specifically in the areas of food temperature monitoring and documentation. During lunch service, staff pureed hot foods using cold milk as a thinning agent and did not reheat the foods to the required temperature of 165°F after mechanical alteration. Temperature readings taken immediately after pureeing showed the foods were below the required temperature, and no further temperature checks were performed before the food was plated and served. The staff member responsible stated she believed the steam table would bring the food to the correct temperature and did not take additional steps to ensure compliance. Interviews with the Dietary Manager (DM), Director of Operations (DOO) for contracted dietary staff, and the dietitian revealed inconsistent understanding and implementation of food temperature protocols. The DM acknowledged that food should be heated to above 165°F for hot foods and below 40°F for cold foods after preparation, but did not require temperatures to be retaken before service if initial readings were appropriate. The DOO and dietitian both stated that food temperatures should be checked after preparation and again prior to service, and that the steam table was not suitable for reheating food. The dietitian also noted that adding cold milk to hot foods could lower the temperature below safe levels, increasing the risk of foodborne illness. A review of the facility's Food Temperature and Evaluation Log for multiple meals over several days showed missing documentation of required food temperatures, with no evidence that holding temperatures were taken for numerous meals. Facility policy and FDA Food Code require that mechanically altered foods be reheated to 165°F for 15 seconds and that hot holding temperatures remain at or above 135°F, with corrective action if temperatures fall below this threshold. The lack of adherence to these protocols and incomplete documentation placed residents at risk for foodborne illness, as directly stated by staff in the report.
Failure to Complete and Maintain Required Employability Status Checks for Staff
Penalty
Summary
The facility failed to follow its written policies and procedures designed to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not ensure that required Employability Status Checks (EMR/NAR) were completed and maintained for two employees, an RN and a Dietary Manager (DM), prior to their hire dates. Record reviews revealed that neither employee had documentation of an EMR/NAR check in their files as required by facility policy, which mandates that all team members, regardless of position, must have this verification completed before employment. Interviews with the HR staff confirmed that she was responsible for running and maintaining EMR checks but could not provide evidence that the checks were completed for the RN and DM before their hire. The HR stated that she may have run the check for the RN but could not locate the documentation, and for the DM, she assumed the contracted company handled the check, but no proof was available. The Administrator acknowledged that the policy was not followed and that all staff, including contracted employees with resident contact, should have had EMR checks completed and maintained in their files.
Failure to Complete and Communicate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, as required by policy. For one resident, the baseline care plan used upon readmission was not updated, and there was no evidence of updated signatures after the readmission. This resident had multiple medical diagnoses, including pneumonia, acute respiratory failure, depression, cognitive communication deficit, and anemia, and required specific treatments such as anticoagulant monitoring, anticonvulsant and antidepressant medications, and CPAP at night. The facility did not initiate a new baseline care plan or complete all new admission paperwork as required for a readmission, and the care plan was not updated to reflect the resident's current needs and orders. For another resident, there was no evidence that a summary of the baseline care plan was provided to the resident or their representative. Interviews with facility staff revealed confusion regarding responsibilities for updating and signing baseline care plans, as well as a lack of clarity about the process for residents who are readmitted. The facility's policy requires that baseline care plans be developed and implemented within 48 hours of admission and that summaries be provided to residents or their representatives, but these steps were not completed for the two residents reviewed.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on Hall D was observed to be left unlocked and unattended for approximately five minutes while not in use. During this time, three CNAs and residents were present in the hallway within arm's reach of the cart, and the responsible nurse was not in sight. The cart contained various medications, including anti-depressants, blood thinners, anti-hypertensives, diuretics, insulin pens, anti-psychotics, anti-anxiety medications, creams, syringes, liquid medications, alcohol pads, and over-the-counter medications. The Assistant Director of Nursing (ADON) confirmed that the cart should not have been left unlocked and unattended, and the Director of Nursing (DON) stated that her expectation is for all medication carts to be locked when out of direct vision of the nurse. The nurse responsible for the cart reported being distracted by an upset family member and followed them down the hall, leaving the cart unsecured. The facility's policy requires that medication carts be locked when not attended by authorized personnel. The DON acknowledged that the failure occurred due to poor judgment on the nurse's part and confirmed that she periodically checks to ensure medication carts are locked throughout the day.
Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinent care for a female resident with a history of metabolic encephalopathy and cystitis. During peri-care, neither CNA performed hand hygiene at any point, including after removing soiled gloves and after completing care, despite the presence of a bowel movement. One CNA was observed folding and reusing a wipe before discarding it. Both CNAs failed to follow the facility's policy, which requires handwashing after glove removal and after providing care. Interviews confirmed that the CNA was aware of the failure to perform proper peri-care and hand hygiene, attributing the lapse to not having hand sanitizer in the room. The CNA had received infection control and peri-care training three months prior. The DON acknowledged that staff should have followed policy and that the facility regularly monitors staff, but suggested the CNA's performance may have been affected by being observed by surveyors. The facility's policy on incontinent care clearly outlines the required steps for hand hygiene and glove use, which were not followed during the observed incident.
Failure to Distribute Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents' right to receive their mail on Saturdays, affecting seven residents who were interviewed. During a group interview, all seven residents reported that mail was only delivered Monday through Friday, coinciding with the business office's operating hours, and not on weekends. The Business Office Manager claimed that a resident volunteered to distribute mail on Saturdays, but this resident clarified that she did not distribute mail on Saturdays and waited until Monday to do so. The weekend receptionist retrieved the mail on Saturdays and took it to the business office, where it was sorted and then given to the resident for distribution on Monday. The Administrator was unaware of the issue and acknowledged the absence of a policy regarding mail distribution.
Failure to Post HHSC Complaint Information
Penalty
Summary
The facility failed to post the Health and Human Services Commission (HHSC) complaint number and a statement informing residents of their right to file a complaint with the State Survey Agency. This deficiency was identified during an observation of the facility's front lobby area, where it was noted that the required information was not displayed. Additionally, a confidential group interview with seven residents revealed that they were unaware of how to contact the State Survey Agency to file complaints. The facility's Administrator admitted to not knowing why the postings were absent and acknowledged the importance of having such information available to residents. Furthermore, the Administrator confirmed that there was no existing policy regarding the required postings.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their preferences, specifically regarding the preparation of peanut butter and jelly sandwiches. During a confidential group interview, seven residents expressed dissatisfaction with the way peanut butter and jelly were served, noting that the jelly was too thick and tore the bread when spread. This issue was attributed to a change in the jelly supplier to Company D, which provided a thicker jelly. The Dietary Manager acknowledged the residents' complaints about the jelly's thickness during monthly Food Committee meetings but noted the absence of a policy regarding resident preferences. The Consultant Dietitian confirmed that the Administrator had purchased jelly from a local store to address the residents' preferences temporarily. However, there was no specific policy in place to address food preferences, and the alternate list provided still included the problematic peanut butter and jelly option. The Resident Food Committee Meeting Minutes from April also reflected concerns about the jelly, indicating that the issue had been ongoing for several months without resolution.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The fryer was found uncovered with dark oil and grease debris, and the dietary staff was unsure of its last use. The fryer was supposed to be cleaned and have its oil replaced weekly, but it was not covered, which could lead to contamination. Additionally, the sugar and flour containers in dry storage were not sealed properly, with white particles observed on the lids, indicating a lack of cleanliness and potential for contamination. During meal preparation, Dietary Aide B did not practice proper hand hygiene. The aide was observed touching various surfaces and food items without washing hands between glove changes, which is against the facility's policy. This lapse in hygiene practices could lead to cross-contamination, as acknowledged by the Dietary Manager. The aide was working on a prn basis and had recently returned to the kitchen, which may have contributed to the oversight in following proper procedures. Further observations revealed that containers for icing, chicken broth, and beef broth had crumbs and particles on them, suggesting inadequate cleaning practices. The Dietary Manager was unsure of the source of the contamination but acknowledged that the containers should be clean. The facility's policies on equipment cleaning, dry food storage, and hand hygiene were not followed, as evidenced by the conditions observed in the kitchen.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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