Greenhill Villas
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Pleasant, Texas.
- Location
- 2530 Greenhill Rd, Mount Pleasant, Texas 75455
- CMS Provider Number
- 676241
- Inspections on file
- 42
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Greenhill Villas during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had a valid advance directive on file specifying limitations on life-sustaining treatments, but facility documentation was inconsistent and inaccurately communicated during a hospital transfer. Although the resident’s physician orders and care plan listed him as Full Code, the transfer form incorrectly indicated DNR status, and no copy of the advance directive was sent with EMS or to the hospital. The LVN who completed the transfer form admitted the error and acknowledged that the directive should have been provided, while the responsible party reported having asked staff to send the document. This conflicted documentation and failure to transmit the advance directive occurred despite a facility policy requiring accurate notation and respect for residents’ end-of-life wishes.
Two residents with sleep apnea and multiple comorbidities were receiving ordered nightly BiPAP therapy, documented in their care plans and TARs and confirmed by observation of BiPAP machines at bedside and resident reports of nightly use, but their Annual MDS assessments failed to code non-invasive mechanical ventilation in Section O. MDS staff acknowledged the assessments were incorrect despite long-standing BiPAP use, and leadership stated that MDS data are expected to accurately reflect resident needs and that improper coding could lead to inaccurate treatment plans and billing.
A medication aide failed to remain with a resident and directly observe the administration of prescribed medications, leaving the medication at the bedside and exiting the room before confirming ingestion. The resident, who was cognitively intact and had multiple chronic conditions, did not take the medication in the aide's presence, contrary to facility policy requiring observation during medication administration.
A resident with severe cognitive loss and multiple comorbidities did not receive required incontinent care, turning, or repositioning over two consecutive nights, as confirmed by video footage and staff interviews. This lack of care led to the development and worsening of pressure injuries, including a sacral wound with eschar and heel wounds, which were not promptly identified or treated due to missed assessments and documentation lapses.
Staff failed to use required PPE and implement Enhanced Barrier Precautions for multiple residents with wounds or indwelling devices. Care was provided without gowns or proper signage, and staff were unaware of EBP requirements, despite facility policy mandating these precautions for high-contact care activities.
A resident with dementia and other mental health conditions eloped from a facility and was found 38.1 miles away due to inadequate supervision and failure to monitor exit alarms. The resident bypassed a door requiring a code by holding it for 15 seconds, as instructed by a sign. Staff failed to conduct a thorough search when the alarm sounded, and the facility's elopement prevention policies were not effectively implemented.
A facility failed to provide a resident's medical records to her legal representative after a request was made. The resident, who had multiple health conditions, had her records requested by her family member and the ombudsman during a care plan meeting. The facility required a PHI form and fee before releasing records, which were not completed, leading to the deficiency.
A resident with Alzheimer's disease was incorrectly administered Aricept and Meloxicam during a respite care stay at an LTC facility. The resident was supposed to receive Meloxicam once daily, but it was given three times a day, and Aricept was administered despite being discontinued. The error was due to incorrect entry of medication orders by a nurse, leading to the administration of incorrect medications. The resident's family raised concerns after noticing the resident's lethargy and injuries upon discharge.
A resident with a laceration on the right lower leg did not receive prescribed wound care due to the treatment nurse's failure to transcribe and document the physician's orders in the EMR. This oversight led to the resident's hospitalization with cellulitis. The facility did not assess, document, or monitor the wound properly, and the weekend RN supervisor was unaware of the necessary wound care due to the lack of communication.
A resident's medical confidentiality was breached when a treatment nurse used a personal cell phone to send a picture of the resident's wound to a wound care NP, including the resident's name. This action violated HIPAA regulations as it involved unsecured transmission of sensitive information. The facility lacked a system to monitor such violations, compromising the resident's privacy.
A resident with severely impaired cognition was found with a laceration on her right lower leg, and the incident was unwitnessed. The facility failed to report the injury of unknown origin to the abuse coordinator or HHSC within the required timeframe. The RN attempted to contact the DON, ADON, and Administrator but was unsuccessful. The Administrator learned of the incident the following morning, and no thorough investigation was conducted.
A resident with severe cognitive impairment was found with a laceration and significant blood loss, but the LTC facility failed to report the injury of unknown origin to HHSC within the required two-hour timeframe. The incident was discovered by a CNA, assessed by an RN, and later reported to the DON and Administrator, but not in a timely manner as per facility policy.
A resident with severe cognitive impairment sustained a laceration on her right lower leg, but the LTC facility failed to conduct a thorough investigation. Despite the presence of blood and the resident's inability to recall the incident, the facility did not document how the injury occurred. The RN attempted to report the incident but was unable to reach the necessary personnel, and the Administrator learned of the incident the following day. The facility's policy required comprehensive investigations for such incidents, but this was not followed.
The facility failed to maintain food safety standards by not properly dating, labeling, and sealing food items in refrigerators and freezers, risking food spoilage and contamination. Additionally, a staff member was observed not wearing a required facial hair covering, violating infection control policies.
A CNA failed to adhere to infection control protocols while caring for a resident with MDROs, including not changing gloves, handling dirty linen improperly, and neglecting hand hygiene. The resident had a history of dementia, UTIs, a stage 4 pressure ulcer, and was under enhanced barrier precautions. These lapses were observed despite clear facility policies requiring PPE and hand hygiene to prevent infection spread.
The facility failed to update care plans for two residents after significant changes. One resident returned from the hospital with a urinary catheter, but the care plan lacked interventions for its care, and the resident refused its removal. Another resident was placed on hospice, but this was not reflected in the care plan. Staff interviews revealed a lack of adherence to the facility's policy for revising care plans, potentially impacting residents' well-being.
A resident in an LTC facility was transferred using a mechanical lift without following safety protocols, as the lift's legs were not spread to the wide position and the wheels were not locked. Despite the presence of multiple staff members, the transfer was conducted unsafely, posing a risk to the resident, who was dependent on staff for mobility due to multiple health conditions.
Two residents with urinary catheters in an LTC facility did not receive appropriate care, leading to potential risks of infection. One resident lacked a securement device for her catheter, while another returned from the hospital without specific orders for catheter care. Staff interviews revealed a failure to adhere to physician orders and update care plans, increasing the risk of complications.
A resident with a history of malnutrition and dehydration did not receive the recommended tube feeding, resulting in insufficient caloric intake. The facility also failed to adhere to its weight monitoring policy, missing weekly weigh-ins after the resident's hospital readmission. Staff interviews revealed communication lapses and a lack of follow-through on dietary recommendations, contributing to the resident's continued malnutrition and potential wound deterioration.
A resident with multiple medical conditions, including spastic hemiplegia and paraplegia, experienced verbal abuse by a CNA who told him to 'hush' during an interaction. The resident, who was cognitively intact and dependent on staff for daily activities, felt scared and potentially neglected. The facility's investigation confirmed the incident as verbal abuse, aligning with their policy on abuse and neglect.
A resident with severe cognitive impairment and a history of wandering eloped from a memory care unit due to a malfunctioning door lock system. The facility failed to provide adequate supervision and did not conduct in-service training on elopement response. The resident was found outside by a staff member and returned to the unit. The door system malfunctioned during a power outage, and staff were not positioned to monitor exits, contributing to the incident.
Failure to Accurately Communicate and Transmit Advance Directive During Hospital Transfer
Penalty
Summary
The facility failed to ensure accurate communication of a resident's advance directive information during a transfer to the hospital. An older male resident with Alzheimer's disease, COPD, BPH, hypertension, and hyperlipidemia had a valid Directive to Physicians and Family or Surrogates on file that elected all treatments other than those needed to keep him comfortable be withheld, and specified no ventilator and no feeding tube. Despite this, his physician orders and care plan documented him as Full Code, with interventions including initiation of BLS/CPR if without a heartbeat. On the transfer form completed for his hospital transfer, the section on advance directives incorrectly indicated that the resident had a DNR, which directly contradicted both the Full Code status in his orders and care plan and the content of his directive. A copy of the advance directive was not provided to EMS or hospital staff at the time of transfer. The LVN who completed the transfer form acknowledged that she made an error by marking DNR and confirmed that the resident was Full Code at that time. She also stated she should have provided EMS with a copy of the advance directive to send with the resident. The resident’s responsible party reported having reminded the discharge nurse to send the advance directive with the resident. The physician stated he expected nursing staff to relay appropriate advance directive information and provide hard copies of documents on all transfers. Subsequent observation found the resident in bed with a bandage at the tracheal site indicating intubation tubing had been removed, and he was non-responsive to verbal or tactile stimuli. The facility’s policy on Self Determination End of Life Measures stated that the facility would respect residents’ wishes as outlined in advance directives and that the primary nurse would note resuscitation status on all applicable clinical records and document whether an advance directive had been executed, which was not accurately carried out in this case.
Inaccurate MDS Coding for Non-Invasive Ventilation Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected the use of non-invasive mechanical ventilation (BiPAP/CPAP) for two residents. For the first resident, an older male with obstructive sleep apnea, diabetes mellitus type II, dementia, hypertension, and hyperlipidemia, the Annual MDS documented severe cognitive impairment, mobility limitations, and extensive ADL assistance needs. However, the MDS did not indicate that the resident utilized a non-invasive mechanical ventilator, despite existing documentation elsewhere in the record. Record review for this resident showed a care plan focus area initiated and revised over time that identified the need for BiPAP use related to sleep apnea, and a Treatment Administration Record (TAR) order for BiPAP at bedtime for obstructive sleep apnea. During observation, the resident’s BiPAP machine was seen on the nightstand, and the resident stated he used the BiPAP every night. Interviews with MDS staff confirmed that the Annual MDS was incorrect because the resident had been receiving non-invasive ventilation therapy for an extended period according to the care plan. For the second resident, an older male with sleep apnea, diabetes mellitus type II, end stage renal disease, atrial fibrillation, hypertension, congestive heart failure, and hyperlipidemia, the Annual MDS documented intact cognition, lower extremity range of motion impairment, wheelchair use, and extensive assistance needs with ADLs. As with the first resident, the MDS did not indicate use of a non-invasive mechanical ventilator. The care plan documented a focus area for BiPAP use related to sleep apnea, and the TAR contained an order for BiPAP every night shift. Observation showed the BiPAP on the nightstand, and the resident reported staff applied it every night. MDS staff and the Regional Reimbursement Nurse acknowledged that the non-invasive ventilator item on the MDS had not been correctly coded, despite the residents’ ongoing BiPAP therapy, and the DON and Administrator stated that the MDS is expected to accurately reflect resident needs and that inaccurate coding could result in improper treatment plans and billing.
Failure to Ensure Direct Observation of Medication Administration
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure a resident took her prescribed medications during a medication pass. The aide entered the resident's room, handed her a medication cup, and was told by the resident that she would take the medication later. Despite this, the aide instructed the resident to take the medication immediately but then left the room before confirming that the medication was actually taken. Video evidence confirmed that the aide left the medication at the bedside and exited the room prior to the resident ingesting the medication. The resident involved was a cognitively intact female with multiple diagnoses, including COPD, diabetes, hypertension, peripheral vascular disease, and congestive heart failure. Facility records indicated that the resident had impaired visual function and required assistance with activities of daily living. The facility's medication administration policy required staff to observe residents taking their medications and to monitor for adverse effects, contraindications, and effectiveness, which was not followed in this instance.
Failure to Provide Timely Incontinent Care and Repositioning Leads to Worsening Pressure Injuries
Penalty
Summary
A resident with a history of atherosclerotic heart disease, anxiety, depression, and hypertension, and who was assessed as having severe cognitive loss, was admitted to the facility and identified as being at risk for pressure ulcers. The resident's care plan included interventions for bladder incontinence and required that incontinent care be provided at least every two hours. Despite these interventions, the resident did not have any unhealed pressure ulcers at admission, and initial assessments indicated only redness to the buttocks with barrier cream applied. On two consecutive nights, certified nursing assistants (CNAs) failed to provide required incontinent care, turning, and repositioning for the resident, as confirmed by video footage showing no such care was given during overnight shifts. Staff interviews revealed that the CNAs were either short-staffed or too busy to provide care, and neither the charge nurse nor other staff were notified of the missed care. As a result, the resident's skin condition deteriorated, with a hospice nurse later identifying a stage II sacral wound, which progressed to include a right heel abrasion, a left heel blister, and a sacral wound with eschar within days. Documentation and progress notes were also missing for the period when the wounds developed. The facility failed to identify the new wounds prior to the hospice nurse's visit and did not initiate wound care orders promptly after the wounds were discovered. There was no system in place to ensure that CNAs were consistently turning and repositioning residents, and the charge nurses did not adequately monitor or document these interventions. The facility's own policy required regular skin assessments, timely notification of changes, and documentation, but these procedures were not followed, resulting in the resident's wounds worsening.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Observations revealed that a treatment nurse did not use the required personal protective equipment (PPE) beyond gloves while providing wound care to a resident with a sacral wound. Additionally, certified nursing assistants (CNAs) provided incontinent care to the same resident without using gowns or other PPE, and both staff members were unaware of the EBP requirements. There was also no EBP signage or PPE cart visible outside the resident's room during these care activities. Further review showed that two other residents, both with conditions requiring EBP (such as open wounds or indwelling catheters), also did not have EBP signage or PPE available outside their rooms. Staff members providing care to these residents were not informed about the need for EBP, and one CNA reported not receiving a report from the previous shift regarding necessary precautions. The facility's policy required the use of gowns and gloves for high-contact care activities for residents with wounds or indwelling devices, but this was not consistently communicated or implemented. Interviews with the Director of Nursing (DON) and the Administrator confirmed that it was their expectation and responsibility to ensure proper signage, PPE availability, and staff awareness for residents requiring EBP. However, these measures were not in place for the residents reviewed, resulting in a failure to follow the facility's own infection control policy and potentially increasing the risk of communicable disease transmission among residents and staff.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically for a resident who was at high risk for elopement. This deficiency resulted in the resident leaving the facility unsupervised and being found at a gas station 38.1 miles away. The resident, who had a history of dementia with behaviors, delusional disorder, hallucinations, psychosis, depression, and anxiety, was able to leave the facility through a door that required a code to exit, which she managed to bypass by holding the door for 15 seconds as instructed by a sign. The resident's elopement risk assessments indicated an increasing risk score, yet the facility did not implement sufficient measures to prevent her from leaving. On the day of the incident, the resident was last seen walking around the dining room before disappearing. Staff failed to conduct a thorough search of the surrounding area when a door alarm sounded, and it was later discovered that the resident had left through the laundry room door. The facility's response was inadequate as they did not immediately realize the resident was missing, and the door alarm was not properly investigated. Interviews with staff revealed a lack of awareness and training regarding the resident's elopement risk and the proper response to door alarms. The facility's policies on elopement prevention and response were not effectively implemented, as evidenced by the staff's failure to monitor the resident adequately and the lack of immediate action when the door alarm was triggered. The resident was eventually found in another town, having been transported by an unknown individual, highlighting the serious oversight in supervision and security measures at the facility.
Failure to Provide Resident's Medical Records
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records upon request, as required by regulations. The deficiency involved Resident #2, an elderly female with multiple diagnoses including type 2 diabetes, Alzheimer's disease, heart failure, and anxiety. The resident's family member and the ombudsman requested access to the medical records during a care plan meeting, but the facility did not fulfill this request. The facility's process required the completion of a PHI form and payment of a fee before releasing medical records. Despite the ombudsman providing a copy of the state regulation indicating her access rights, the facility insisted on the completion of their form. The family member did not return the signed form, relying on the ombudsman to handle the request. Consequently, the records were not released, and the facility maintained that the family had the right to the records if they followed the policy. Interviews with facility staff, including the MDS Coordinator, DON, and Medical Records personnel, confirmed that the request for records was acknowledged but not processed due to the lack of a completed PHI form. The facility's policy required verification of the requestor's identity and legal authority, completion of the authorization form, and payment of a fee before records could be released. This process was not completed, resulting in the failure to provide the requested records.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident during their stay for respite care. The resident, who had severe cognitive impairment due to Alzheimer's disease, was incorrectly administered Aricept and Meloxicam after these medications were discontinued. The resident was supposed to receive Meloxicam once daily, but it was administered three times a day, and Aricept was given despite being discontinued. This error was discovered after the resident's family raised concerns following the resident's return home. The medication errors were attributed to incorrect entry of medication orders into the system by a nurse who was in a hurry and did not verify the orders properly. The charge nurse was responsible for entering the orders into the system, but the process was not followed correctly, leading to the administration of incorrect medications. Interviews with staff revealed that the medication aide and nurses were aware of the five rights of medication administration, but the error still occurred due to the initial incorrect entry of orders. The resident's family reported that the resident had a fall during their stay, resulting in a bruise and a black eye, and upon discharge, the resident was lethargic and unable to open her eyes or transfer into a vehicle. The facility's Director of Nursing acknowledged the importance of correct order entry to ensure residents receive the care they require. The error was discovered through an audit, and the facility took steps to address the issue, including terminating the nurse responsible for the error.
Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The treatment nurse did not transcribe the physician's orders for wound care for a resident's right lower shin, nor did they provide the necessary wound care from August 23 to August 31, resulting in the resident's hospitalization with a diagnosis of cellulitis. The resident had a history of type 2 diabetes mellitus and a laceration on the right lower leg, which required specific wound care that was not administered as ordered. The facility also failed to assess, document, and monitor the resident's wound properly. The treatment nurse did not document the wound care in the electronic medical records (EMR) and failed to notify the charge nurses, ADON, and DON of the wound care orders. This lack of documentation and communication led to the wound care not being performed over the weekend, as the weekend RN supervisor was unaware of the orders. The wound care NP had provided specific treatment orders via text, which were not entered into the system, leading to a lack of proper wound management. Interviews with facility staff revealed that the treatment nurse admitted to forgetting to input the orders into the EMR and acknowledged the risk of infection due to this oversight. The DON was unaware of the orders not being placed in the system and stated that the treatment nurse was responsible for ensuring the implementation of wound care orders. The facility's policy required wound assessments and treatment plans to be documented promptly, which was not adhered to in this case.
Removal Plan
- Resident #1 has returned to the facility and all wound treatment orders initiated. Treatment nurse completed wound care per physicians' orders.
- All residents in the facility received a skin assessment by the ADON/Tx Nurse/Regional compliance nurse/MDS nurse. No new skin issues identified.
- Wound treatment records audited to verify that all residents with skin conditions orders are in place and match current wound care physician orders. Completed by ADON and Treatment nurse.
- A 1:1 in-service was completed by the Regional Compliance Nurse with the DON/ADON/Tx Nurse on entering orders for treatments in EMR, completing all ordered treatments and documenting in EMR, and Assessing and reporting new or worsened wounds to the physician and family and documenting notification in EMR.
- The Medical Director was notified of the immediate jeopardy situation.
- An ADHOC QAPI meeting was conducted to include the IDT Team to discuss the immediate jeopardy and subsequent plan of removal.
- DON or designee will monitor clinical alerts daily for any new skin issues and follow up to assure all skin conditions proper orders, assessments, and notifications in place in EMR.
- Skin integrity Management policy reviewed and no changes made to current policy.
- All charge nurses were in-serviced on entering new physicians' orders in EMR without delay, completing all orders treatments and documenting treatments in EMR, and new or worsened wound should be assessed, and the physician and family notified and documented in EMR. All staff not present for in-servicing will not be allowed to resume their scheduled assignment until in-serviced. All new hired staff will be in-serviced during facility orientation. All agency staff will be in-serviced prior to start of their shift. Verification of comprehension will be made through a post test for topics in-serviced on.
HIPAA Violation Due to Use of Personal Device for Medical Communication
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, specifically for a resident with type 2 diabetes mellitus and a laceration on the right lower leg. The treatment nurse used a personal cell phone to send a picture of the resident's wound, along with the resident's name, to the wound care nurse practitioner (NP) to request treatment orders. This action was identified as a violation of HIPAA regulations, as it involved the use of an unsecured telephonic device to transmit sensitive medical information. The incident was discovered during a state surveyor's intervention, and the facility administrator acknowledged the lack of a system to oversee and monitor HIPAA violations. The facility's policy on resident rights emphasizes the importance of treating residents with respect and maintaining the confidentiality of their personal and medical records. However, the absence of a secure method for transmitting medical images led to the breach of the resident's privacy and confidentiality.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse and neglect policy and procedure regarding the reporting of an injury of unknown origin for a resident. The policy required facility employees to report any allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injury of unknown source to the facility administrator, who would then report to the Health and Human Services Commission (HHSC) if the incident met certain criteria. However, in the case of a resident with a laceration on the right lower leg, the facility did not follow these procedures. The resident, who had a severely impaired cognition and required assistance with daily activities, was found with a laceration on her right lower leg while sitting in her wheelchair. The incident was unwitnessed, and the resident was unable to recall how the injury occurred. Despite the severity of the situation, the incident was not reported to the abuse coordinator or HHSC within the required two-hour timeframe. The RN who assessed the resident attempted to contact the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator but was unsuccessful. The Administrator, who was the facility's Abuse Coordinator, only learned of the incident the following morning during a meeting. Although the ADON and Administrator later obtained statements from the resident and her family, no thorough investigation was conducted. The failure to report the incident in a timely manner and conduct a proper investigation could potentially place the resident at risk for infection, abuse, or neglect.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident's laceration to the right lower leg to the Health and Human Services Commission (HHSC) within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 5, who was found with a laceration and a significant amount of blood in her room. Despite the resident's inability to recall how the injury occurred, the facility did not report the incident immediately as required by their policy. The incident was first discovered by a CNA who heard the resident calling for help and found her with a bleeding leg. The CNA alerted an RN, who assessed the situation and called EMS for further evaluation. The RN attempted to contact the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator but was unsuccessful. The DON was notified via text but did not see the message until the following morning. The Administrator, who is the facility's Abuse Coordinator, was informed of the incident during a morning meeting the next day. The facility's policy requires that any allegations of abuse, neglect, or injuries of unknown origin be reported to the administrator and then to HHSC within two hours if they involve abuse or result in serious bodily injury. However, this protocol was not followed, as the incident was not reported within the required timeframe. The failure to report timely was acknowledged by the DON and the Administrator, who both emphasized the importance of timely reporting to ensure resident safety and to verify if anyone was connected to the abuse.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident involving a resident who sustained a laceration on her right lower leg. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was found with a significant amount of blood around her after calling for help. Despite the presence of blood and the resident's inability to recall the incident, the facility did not document how the injury occurred or conduct a comprehensive investigation. The incident was initially reported by a CNA who found the resident and called for an RN to assess the situation. The RN attempted to contact the DON, ADON, and Administrator but was unsuccessful. The RN recognized the importance of timely reporting to ensure resident safety but was unable to reach the necessary personnel. The DON was informed of the incident via text the following morning, acknowledging that the incident should have been reported to the state within two hours due to its unwitnessed nature and the resident's inability to explain what happened. The Administrator, who also served as the Abuse Coordinator, learned of the incident during a morning meeting the day after it occurred. She admitted that a thorough investigation was not completed and emphasized the importance of timely reporting to prevent potential risks such as infection, abuse, or neglect. The facility's policy required comprehensive investigations for all allegations of abuse, neglect, and injuries of unknown origin, but this protocol was not followed in this case.
Food Safety and Infection Control Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that several food items in Refrigerator #1, Refrigerator #2, and Freezer #2 were not properly dated or labeled. Specifically, various food items such as a thick yellow food item, round purple food items, and red food items were found without any date or label. Additionally, a large plastic bag containing an unknown meat in Freezer #2 and a round dark brown patty in Refrigerator #1 were also not labeled. This lack of proper labeling and dating could lead to food spoilage and potential health risks for residents. Further observations revealed that food items in Freezer #1 were not properly sealed, with an open bag of onion rings exposed to air and an onion ring found outside the bag. This improper sealing could result in food contamination and freezer burn, compromising the quality and safety of the food served to residents. The facility's policy mandates that open packages of food should be stored in closed containers or sealed bags and dated, which was not followed in these instances. Additionally, the facility did not ensure that all kitchen staff adhered to infection control policies. Dishwasher E was observed handling silverware near the steam table without wearing a facial hair covering, despite having a beard and mustache. This was acknowledged by the Dietary Manager, who stated that all male staff were required to wear facial hair coverings to prevent hair from contaminating food or dishes. The lack of compliance with these infection control measures poses a risk of food contamination, potentially affecting the health of the residents.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in protocol by a certified nursing assistant (CNA) while providing care to a resident. The resident, who had a history of dementia, urinary tract infections, a stage 4 pressure ulcer, diabetes, and urine retention, was under enhanced barrier precautions due to the presence of multidrug-resistant organisms (MDROs). Despite these precautions, the CNA did not adhere to the required infection control measures, such as changing gloves after providing incontinent care and before touching clean items, handling dirty linen appropriately, and performing hand hygiene before handling the resident's personal items. During an observation, the CNA was seen entering the resident's room without donning a gown, which was required under the enhanced barrier precautions. The CNA proceeded to provide incontinent care without changing gloves between tasks, allowing her clothing to come into contact with the resident, and handling soiled items without proper hand hygiene. These actions were contrary to the facility's infection control policies, which required the use of personal protective equipment (PPE) and hand hygiene to prevent the spread of infections. Interviews with the CNA and facility staff revealed a lack of awareness and adherence to the enhanced barrier precautions. The CNA admitted to not following the required protocols, which could lead to cross-contamination and increased risk of infection for the resident and others. The facility's policies clearly outlined the need for PPE and hand hygiene, yet these were not followed, indicating a significant deficiency in the infection control program.
Failure to Update Care Plans for Residents with Significant Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for two residents. Resident #25's care plan was not updated after returning from the hospital with a urinary catheter. Despite having a urinary catheter, the care plan did not include any interventions for its care. Additionally, there were no orders for the urinary catheter, and the resident refused to have it removed, which was not documented in the care plan. Interviews with staff revealed that the responsibility for updating care plans lay with the nursing staff, ADON, or DON, but this was not done, leading to an increased risk of infection or neglect. Resident #34's care plan was not updated to reflect that the resident was placed on hospice. Although the resident was receiving hospice services, this was not documented in the care plan. The MDS nurse acknowledged missing this update, and the ADON confirmed that care plans should communicate the care and needs of each resident, including hospice services. The lack of documentation in the care plan could lead to a failure in providing individualized care. The facility's policy indicated that care plans should be reviewed and revised after each assessment, including significant changes. However, this was not adhered to, resulting in deficiencies in the care plans for both residents. The failure to update care plans with necessary interventions and services could potentially impact the residents' ability to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Unsafe Mechanical Lift Transfer in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision during a mechanical lift transfer for a resident. The resident, who was cognitively intact and dependent on staff for transfers, was transferred using a mechanical lift by CNA A, assisted by CNA B and CNA H. During the transfer, the mechanical lift's legs were kept in a narrow position, and the wheels were not locked, which could have led to instability and potential injury. The resident involved was an elderly individual with multiple diagnoses, including osteoarthritis, chronic pain, depression, hemiplegia, and high blood pressure. The resident was dependent on staff for transfers and used a wheelchair for mobility. Despite the resident's cognitive awareness and the presence of multiple staff members during the transfer, the procedure was not conducted according to safety protocols, as the mechanical lift's legs were not spread to the wide position, and the wheels were not locked. Interviews with the staff involved, including CNA A and CNA B, revealed a lack of adherence to the facility's mechanical lift policy. Both CNAs acknowledged the importance of locking the wheels and spreading the lift's legs to the wide position for stability. The Assistant Director of Nursing and the Regional Compliance Nurse confirmed that the staff did not follow the expected procedures, which could have resulted in the mechanical lift tipping over, posing a risk to the resident's safety.
Failure to Provide Proper Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents with urinary catheters, leading to potential risks of urinary tract infections and other complications. Resident #17, who had a history of urinary tract infections and other medical conditions, was observed without a securement device for her indwelling urinary catheter. Despite having an order for a catheter strap, the staff member providing care was unaware of its necessity and did not report its absence. This oversight left the catheter unsecured, increasing the risk of dislodgement and infection. Resident #25, who was admitted to hospice care, returned from the hospital with a new urinary catheter but lacked specific orders for its care. The resident's care plan did not include interventions for the catheter, and there was no documentation of catheter care in the treatment administration record. Despite the resident's refusal to have the catheter removed, the facility did not update the care plan or obtain necessary orders from hospice, leaving the resident at risk of inadequate care and potential infection. Interviews with facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, revealed a lack of adherence to physician orders and care plan updates. The staff acknowledged the importance of securement devices and proper catheter care to prevent complications but failed to implement these measures. The facility's policy and CDC guidelines emphasize the need for securement devices and documented care to prevent catheter-associated urinary tract infections, which were not followed in these cases.
Failure to Maintain Nutritional Parameters and Weight Monitoring
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as Resident #66, who was reviewed for nutrition. The resident, who had a history of dehydration, protein-calorie malnutrition, diabetes, and required a gastrostomy tube for feeding, did not receive the recommended tube feeding as per the dietician's orders. The dietician had recommended Glucerna 1.2 at 474 ml four times a day to meet the resident's caloric needs of 2275 calories per day. However, the facility administered only 355 ml four times a day, providing only 1704 calories, which was insufficient for the resident's needs. Additionally, the facility did not adhere to its weight policy for Resident #66, who experienced a significant weight loss of 15 pounds from admission to readmission. The resident was not weighed weekly for four weeks after readmission from the hospital, as required by the facility's policy. Furthermore, no weight was obtained within 24 hours after the resident's readmission from the hospital, which was another deviation from the facility's policy. This lack of monitoring and follow-up on the resident's weight could have contributed to the resident's continued malnutrition and potential deterioration of pressure ulcers. Interviews with facility staff, including the dietician, LVN, ADON, and Regional Compliance Nurse, revealed a lack of communication and follow-through on dietary recommendations and weight monitoring. The dietician's recommendations were not implemented, and there was confusion about who was responsible for updating resident orders and ensuring weights were completed. The facility's policy required weights to be obtained and documented at admission, readmissions, and monthly, with more frequent monitoring for residents with significant weight changes or unresolved pressure ulcers. The failure to follow these protocols placed the resident at risk for further weight loss, dehydration, and wound deterioration.
Verbal Abuse Incident by CNA in LTC Facility
Penalty
Summary
The facility failed to ensure the right of a resident to be free from abuse and/or neglect, specifically verbal abuse, by a Certified Nursing Assistant (CNA). The incident involved a male resident with multiple medical conditions, including spastic hemiplegia, neuromuscular dysfunction of the bladder, depressive disorder, anxiety disorder, paraplegia, and multiple sclerosis. The resident was cognitively intact, as indicated by a BIMS score of 15, and was totally dependent on staff for activities of daily living. The deficiency occurred when CNA A told the resident to 'hush' in a non-threatening manner during an interaction where the resident was upset and had requested assistance. This interaction was perceived by the resident as verbal abuse, leading to feelings of fear and potential neglect of care. The investigation revealed that CNA A had a history of multiple infractions and was aware of the facility's policies and procedures, as indicated by her signature on the Employee Handbook Acknowledgement form. During interviews, other staff members confirmed hearing CNA A tell the resident to 'hush,' and the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator in Training all agreed that such behavior could be considered verbal abuse. The facility's policy on abuse and neglect defines verbal abuse as any use of language that includes disparaging and derogatory terms to residents, which aligns with the actions of CNA A in this incident.
Resident Elopement Due to Door Lock Malfunction
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a resident in the memory care unit, leading to an elopement incident. The resident, a female with severe cognitive impairment and a history of wandering, was able to exit the memory care unit due to a malfunction with the door locking system. The resident was found outside the facility by a laundry aide, who then returned her to the unit. At the time of the incident, the doors were not locking properly, and staff were not adequately monitoring the exits. The resident's care plan identified her as at risk for wandering, with interventions such as disguising exits and distracting her with pleasant diversions. However, these measures were not effectively implemented, as evidenced by the resident's ability to leave the secure unit. The facility's failure to monitor and supervise the resident, particularly during the door system malfunction, contributed to the elopement. Interviews with staff revealed that there was a lack of awareness and response to the door system's failure, and no staff member was positioned to monitor the exits during the incident. Additionally, the facility did not conduct an in-service training on elopement response prior to the incident, which may have contributed to the inadequate supervision. The maintenance supervisor acknowledged that the door system could go offline during power outages or fire alarms, but there was no immediate inspection or resolution to prevent future occurrences. The lack of a timely and effective response to the door malfunction and the absence of a comprehensive elopement response plan highlight the facility's deficiencies in ensuring resident safety.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
