Greenview Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Waco, Texas.
- Location
- 401 Owen Ln, Waco, Texas 76710
- CMS Provider Number
- 455638
- Inspections on file
- 51
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Greenview Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide immediate access to residents and records for an HHSC surveyor conducting a Priority One investigation, when the ADM refused entry and the surveyor was instructed to leave, causing a four-hour delay before the entrance conference and investigation began. The ADM later acknowledged acting between corporate staff and HHSC and reported there was no facility policy addressing impeding surveys or access to medical records. At the time, there were 93 residents in the facility, and governing body policy and state regulations required allowing HHSC representatives to enter and conduct necessary inspections and investigations.
Surveyors found multiple improperly stored food items in the kitchen, including unsealed dry goods, unlabeled and undated containers of white granulated substances, uncovered and unlabeled fruit cups in Styrofoam cups in the refrigerator, an unsealed bag of shredded cheese, and an unsealed bag of frozen cookie dough in an opened box in the freezer. The DM and dietary staff acknowledged that all staff had been trained on proper food storage, including sealing, labeling, dating, and first-in/first-out rotation, and recognized that items had been left open or without required date marking. Facility policies required dry foods in bins to be labeled and dated, and all refrigerated and frozen foods to be covered, labeled, and dated, with the person opening or preparing food responsible for date marking, but these procedures were not consistently followed.
Surveyors found that a room’s call light system was non-functioning and pulled out of the wall, while two residents with mobility limitations, fall history, and cognitive and physical impairments were left without reliable, accessible means to summon staff. One resident, cognitively intact but dependent for toilet transfers and with osteoarthritis, COPD, neuropathy, and prior falls, had a non-working call light placed within reach and a bell placed out of reach, and reported using the bathroom call button solely to get help. Another resident with dementia, repeated falls, muscle weakness, and abnormal gait had a non-functioning call light within reach and reported sometimes yelling for help. The Maintenance Director, DON, and Administrator acknowledged awareness of the broken call system and the use of bells as interim measures, while facility maintenance records documented ongoing call light problems in that room over several months.
Two residents shared a room where the wall-mounted call light system was non-functional and pulled out of the wall, yet the inoperative call buttons were still placed within reach as if usable. One resident reported the call system had been broken for months and that the alternative bell provided was out of reach, requiring the resident to go to the bathroom to use the call button there when needing assistance. The Maintenance Director, DON, and Administrator all acknowledged awareness of the broken call system, and maintenance records documented a malfunctioning and later completely broken call light, despite facility policies requiring a safe, accommodating environment.
A resident with COPD, muscle weakness, Type 2 DM with complications, and prior cerebral infarction had an admission MDS showing moderate cognitive impairment and total dependence for chair/bed-to-chair transfers requiring assistance of two or more helpers. Although the CNA Kardex indicated a two-person transfer and the resident was care planned for pressure injury risk related to decreased mobility, the comprehensive care plan did not address ADLs or specify the mode of transfer, and there was no physician order for mechanical lift use. The DON stated that mechanical lift use should be supported by a physician order and reflected in the care plan, and the MDS nurse acknowledged she had overlooked care planning the mechanical lift transfer despite facility policy requiring all identified needs from the MDS and CAAs to be incorporated into a person-centered care plan with measurable objectives and timeframes.
A resident with COPD, muscle weakness, Type 2 DM with complications, a history of cerebral infarction, and moderate cognitive impairment was documented on the MDS and CNA Kardex as dependent for chair/bed-to-chair transfers requiring two-person assistance. The resident’s care plan addressed pressure injury risk but did not include ADLs or transfer method. Despite facility policies and training requiring two staff for mechanical lift transfers, a CNA, who knew two staff were required, independently transferred the resident using a mechanical lift because another CNA was busy and the resident was urging to be gotten up quickly, resulting in a failure to provide adequate supervision and assistance during the transfer.
Dietary staff did not label or date food items in the refrigerator and freezer, and kitchen air conditioning vents were found with a black substance. Staff interviews revealed confusion about responsibilities for labeling food and cleaning vents, despite facility policies requiring these practices.
A resident's personal refrigerator was found with a brown substance, a food-encrusted butter knife, and lacked a temperature log. Staff interviews confirmed that required weekly cleaning and temperature checks were not performed, despite facility policy assigning these responsibilities to maintenance and housekeeping.
A resident with dementia and a history of frequent physical aggression was not provided with continuous 1:1 supervision as previously recommended by the psychiatric provider, despite repeated altercations with another resident. The decision to discontinue close monitoring was made by the IDT without input from the psychiatric nurse practitioner, and staff interviews confirmed ongoing aggressive behaviors and concerns about resident safety.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
A resident with dementia and a high risk of elopement exited a secure unit unsupervised after the assigned RN left to respond to a code and the only CNA was on break. The resident was able to leave through a door that did not latch properly, walked through the building, exited a side door, and entered a parked fire truck without staff present. Staff interviews revealed unclear protocols for code response and supervision, and a lack of recent in-service training on elopement prevention.
A resident with spastic quadriplegic cerebral palsy developed a wound on his right calf from wheelchair friction, but did not receive weekly skin assessments, timely wound care orders, or a therapy consult as required. The wound was not properly monitored or treated for several weeks, leading to deterioration. Staff interviews revealed lapses in wound care processes and documentation, and the facility's policy for regular skin assessments was not followed.
A resident with Parkinson's Disease and other chronic conditions did not receive prescribed doses of Rytary (Carbidopa-Levodopa) within the required one-hour window on multiple occasions. The resident experienced increased tremors and slurred speech due to these delays. Interviews with the DON and MD confirmed awareness of the issue, which was attributed to agency nurse unfamiliarity and staffing challenges. Facility policy required timely administration, but this standard was not met.
The facility did not maintain a sanitary kitchen environment, as multiple dead cockroaches and food debris were observed in key kitchen areas, including the entryway, under storage racks, and around the ice machine. Staff interviews revealed inconsistent cleaning practices, lack of cleaning logs, and insufficient staffing, all contributing to unsanitary conditions in violation of the facility's sanitation policy.
A CNA was observed serving and assisting residents with their meals without performing hand hygiene between each tray passed. The CNA admitted to not following hand hygiene protocols despite prior training. Both the DON and ADM confirmed that staff are expected to sanitize hands before and between passing trays, in accordance with facility policy, to prevent cross contamination and infection.
A resident with severe cognitive impairment, legal blindness, and muscle weakness was found twice with his call light out of reach, making it inaccessible for requesting assistance. Staff interviews confirmed it was their responsibility to ensure call lights were within reach, but they were unaware of the issue. Facility policy required call lights to be accessible and secured for each resident, but this was not followed in this case.
The facility did not report an allegation of resident-to-resident physical abuse to the State Survey Agency within the required 24-hour timeframe. Two residents, one with moderate cognitive impairment and another cognitively intact, were involved in a hallway altercation where one pushed or hit the other in the chest. The incident was reported internally but not to authorities until several days later, as the ADM delayed reporting while investigating conflicting accounts.
The facility failed to maintain food safety and hand hygiene standards, with observations revealing improperly labeled and dated food, unsanitary kitchen conditions, and staff neglecting to take food temperatures. Additionally, an LVN and a CNA did not practice proper hand hygiene while distributing food, increasing the risk of cross-contamination and infection spread.
The facility failed to provide a private space for resident meetings, using a dining room with inadequate curtains for privacy. Residents reported unresolved grievances about food quality and missing clothing, with no follow-up from staff. The facility lacked a social worker to handle grievances, leading to ineffective communication and resolution.
The facility failed to provide a safe, sanitary, and comfortable environment for residents, as observed in multiple rooms with unclean and disrepaired conditions. Residents' rooms and bathrooms were found with dust, dirt, mold, and unemptied trash, while maintenance issues like leaking toilets were unresolved. Interviews with staff revealed inconsistencies in following cleaning schedules and maintenance protocols, contributing to the deficiencies.
Two residents in a facility were found without access to their call lights, compromising their ability to request assistance. One resident, with moderate cognitive impairment and multiple health conditions, had her call light out of reach on the floor. Another resident, with severe cognitive impairment, was left in the middle of the room without a call light, unable to remove his sweater and unattended for nearly 10 minutes. Staff interviews confirmed that these situations were not typical or acceptable, highlighting a failure to adhere to facility policies on call light accessibility.
A privacy breach occurred when an RN left a laptop open and unattended in a hallway, displaying a resident's medical information during wound care. The resident, who was severely cognitively impaired, had multiple medical conditions. Despite training on privacy and HIPAA regulations, the RN admitted to inadvertently leaving the laptop open, violating the facility's policy on resident rights.
A facility failed to obtain necessary hospice documentation for a resident admitted to hospice care, including the hospice plan of care, physician orders, and contact information for hospice personnel. This lack of documentation could lead to confusion about the resident's care and services provided.
A resident with severe cognitive impairment due to dementia was involved in two unreported resident-on-resident abuse incidents. The first incident involved physical assault on a roommate, which was not reported to the state office due to a lack of perceived threat and no documented injuries. The second incident involved the same resident using a wheelchair to abuse another roommate, which was reported. Staff interviews revealed inconsistencies in reporting procedures, highlighting a failure to adhere to the facility's policies on abuse and neglect.
A resident with severe cognitive impairment and a history of aggressive behavior was involved in multiple altercations with roommates. The facility failed to update the resident's care plan after an initial incident, leaving other residents at risk. Despite staff opinions that the incident should have been reported as abuse, the administration did not perceive the resident as a threat. This inaction led to a subsequent altercation, highlighting the need for timely care plan updates and reporting.
A resident with severe cognitive impairment hit his roommate, leading to a bruise on the roommate's arm. The incident was not reported to the state office within the required two-hour timeframe, and no follow-up investigation was conducted. The facility's administrator decided not to report the incident, citing the absence of injuries and the belief that the resident was not a threat to others.
The facility failed to accommodate residents' needs by not ensuring a functional phone system, leading to missed calls from family and providers. Staff and family members reported ongoing issues with calls disconnecting or going unanswered, particularly on weekends. The problem persisted despite previous attempts to fix it, and staff had to use personal cell phones to maintain communication. The facility's policy on resident rights was compromised due to these phone system issues.
The facility failed to provide scheduled showers and document refusals for two residents with impaired cognition and physical functioning. Despite being scheduled for regular showers, the residents received fewer than expected, with no documentation of refusals or negotiation of ADL times. Staff interviews revealed an expectation to document refusals and educate residents, but this was not consistently done, potentially affecting residents' hygiene and dignity.
The facility failed to maintain proper infection control practices as MAs did not sanitize a wrist blood pressure monitor between uses on multiple residents. This oversight involved residents with conditions like hypertension and diabetes, increasing their risk of infection. Despite training, one MA misunderstood the importance of sanitizing equipment between residents, believing end-of-shift cleaning was sufficient. The DON acknowledged the deficiency and noted the lack of recent specific training on equipment disinfection.
A resident with end-stage renal disease frequently refused hemodialysis (HD) treatments, and the facility failed to update the care plan to reflect this behavior or notify the kidney center (KC) as required. Despite the resident's awareness of the importance of HD, he missed several appointments, leading to hospitalization. Facility staff acknowledged the lack of communication with the KC and the absence of interventions in the care plan.
A resident with dementia and Parkinson's disease was admitted to a facility for respite care and later hospitalized with severe dehydration and rhabdomyolysis. The facility failed to notify the resident's physician or representative about the resident's declining condition and did not address nutritional or hydration needs. The care plan lacked interventions for fluid intake, and the facility did not track fluid intake or document supplemental shake consumption. The resident had not eaten or drunk anything for three days, leading to hospitalization.
A resident with dementia and Parkinson's disease was hospitalized due to severe dehydration and rhabdomyolysis after the facility failed to monitor and address his nutritional and hydration needs. The resident's care plan lacked interventions for these needs, and there was no physician's order for diet or fluid intake. Despite decreased meal intake and known swallowing issues, the facility did not adequately document or provide necessary interventions, leading to the resident's decline and subsequent hospice care placement.
The facility failed to report a resident's fall and a resident-on-resident abuse incident in a timely manner. The fall resulted in a facial injury and the resident's subsequent death, while the abuse incident involved one resident attempting to grab another's pants. Both incidents were not reported to the state agency as required by the facility's policy.
A resident with multiple diagnoses fell and was found on the floor by EMTs. The facility failed to investigate and report the incident within the required five working days. The DON and AD acknowledged gaps in communication and understanding, leading to the failure to follow the facility's policy on investigating and reporting allegations of abuse and neglect.
The facility failed to store, label, and sanitize food products and kitchen equipment according to professional standards, risking resident health. Observations showed improperly sealed and unlabeled food items, unsanitary kitchen equipment, and inadequate staff training. Interviews with staff revealed a lack of adherence to food safety protocols and insufficient oversight by the IDT.
Failure to Provide Immediate Access for Priority One State Investigation
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate access to residents for a state representative of HHSC conducting a Priority One (P1) investigation. On 03/03/2026 at 10:05 a.m., an HHSC surveyor entered the facility, checked in at the reception desk, and was taken to the conference room. At 10:11 a.m., the administrator entered the conference room and informed the surveyor that she would not be allowed into the building to conduct the P1 investigation, even after being advised that it was a P1 investigation. At 10:43 a.m., the surveyor was instructed by phone from the program manager to leave the facility. The program manager then contacted the associate regional director and briefed her on the incident. The surveyor was not allowed to re-enter and begin the entrance conference and P1 investigation until 2:00 p.m., resulting in a four-hour delay in surveyor access. During an interview on 03/03/2026 at 2:00 p.m., the administrator apologized for the situation and stated he was acting like a “ping pong ball” between corporate staff and HHSC. In a subsequent interview on 03/05/2026 at 12:30 p.m., the administrator stated the facility did not have a policy on impeding a survey or access to medical records. Review of the facility census showed there were 93 residents at the time. Review of the facility’s governing body policy indicated the governing body is responsible for establishing and implementing policies regarding management and operation of the facility. Review of state law (Health and Safety Code Ch. 242.043) and HHSC Provider Letter PL 18-26 confirmed that HHSC or its representatives may enter an institution at reasonable times to conduct inspections, surveys, or investigations and that providers must grant access to records, underscoring that the administrator’s refusal and the resulting delay were contrary to these requirements.
Improper Food Storage and Labeling Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, where multiple food items were not labeled, dated, sealed, or stored in accordance with facility policy and professional standards. During a kitchen observation, surveyors found a clear plastic container with a white granulated substance lying on the pantry floor with its lid off and the contents spilled, an unsealed zip bag of pasta, an unsealed bag of tortilla chips, an open box containing an unsealed bag of rice, and an unsealed, unlabeled, and undated plastic tote of a white granulated substance on pantry shelves. In the refrigerator, they observed an unsealed zip bag of yellow shredded cheese and more than a dozen uncovered, unlabeled, and undated Styrofoam cups containing a fruit substance. In the chest freezer, they found an opened box with an unsealed bag of frozen cookie dough. These conditions were inconsistent with the facility’s written policies requiring dry foods in bins to be removed from original packaging, labeled, dated, and rotated using first-in/first-out, and requiring all refrigerated and frozen foods to be covered, labeled, and dated. During interviews, the Dietary Manager (DM) acknowledged the opened items in the pantry and stated that all dietary staff were responsible for ensuring food was stored correctly, but also indicated he often corrected improperly stored food himself without always addressing it with the responsible staff. A dietary staff member reported he had been trained on proper food storage and rotation, including use of zip bags and labeling and dating, and stated he had seen the sugar tub with the lid off and would close it or notify the DM. Another dietary staff member confirmed she had been trained on proper storage, acknowledged the open shredded cheese should have been sealed, and stated that all dietary staff were supposed to store food properly. The Administrator stated his expectation that all food be stored properly and that it was the DM’s responsibility to ensure staff knew and followed the process. Facility policies on Food Receiving and Storage and Date Marking for Food Safety specified that foods must be stored in compliance with safe food handling practices, including covering, labeling, and dating, and that the individual opening or preparing food is responsible for date marking at the time of opening or preparation.
Failure to Provide Accessible Call Systems and Alternatives for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences for calling staff, specifically by not ensuring functioning call systems or accessible alternative devices for two residents. Surveyors observed that the call light system in a shared room was not functioning and the entire call light box was out of the wall. Despite this, the non-functioning call buttons were still placed within reach for both residents. For one resident, a bell intended as an alternative call device was placed on the nightstand but out of the resident’s reach, and there was no visible bell available for the other resident. One resident was an older female with osteoarthritis of the right shoulder and knee, COPD, muscle weakness, joint pain, a history of falls, poor balance, unsteady gait, and impaired physical functioning. Her MDS showed a BIMS score of 15 (no cognitive impairment), partial/moderate assistance needed for bed-to-chair transfers, and total dependence for toilet transfers. Her care plan documented pain related to impaired mobility and neuropathy, as well as an actual fall and impaired physical functioning. During interview, she reported that her room call system had been broken for about six months, that she could not reach the bell on the nightstand, and that when she needed help she would go into the bathroom and use the bathroom call button, even though she did not use the toilet there. The second resident was an older female with repeated falls, muscle weakness, lack of coordination, abnormal gait and mobility, and a need for assistance with personal care. Her MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and her care plan noted impaired cognitive function/dementia, difficulty making decisions, impaired decision making, psychotropic drug use, and impaired physical functioning. She stated she did have a bell to call for help but sometimes yelled for assistance. The Maintenance Director reported the room call system had broken sometime the prior week and that he had ordered a replacement part and provided bells to both residents, and he stated he verbally informed staff of the broken system. The DON and Administrator both acknowledged awareness of the broken call system and that bells were to be used and kept within reach, and facility TELS work orders and an invoice documented call light malfunction and a completely broken call light station in that room over the preceding months.
Failure to Maintain Functional Call System in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident rooms were adequately equipped with a properly functioning call system that relayed calls directly to staff or a centralized work area. Surveyor observation on 01/29/2026 with the Maintenance Director showed that the call light system in the shared room of Resident #2 and Resident #3 was not functioning and the entire call light box was out of the wall. In Resident #2’s area, the non-functioning call button was placed on the bed within reach, and a bell intended as an alternative was on the nightstand but out of reach. In Resident #3’s area, the non-functioning call light was also placed within reach despite not working. The report states this failure placed residents at risk of being unable to obtain assistance for ADLs or in an emergency. During interviews, the Maintenance Director stated the call system in that room had broken sometime the previous week, that he had ordered a replacement part, and that he had provided bells to both residents and verbally informed staff of the problem. However, Resident #2 reported that her call system had been broken for about six months and that she could not reach the bell on the nightstand, so she went to the restroom and used the bathroom call button when she needed help. The DON and the Administrator both acknowledged awareness of the broken call system in that room; the DON was unsure how long it had been broken, while the Administrator estimated it had been broken for a couple of months. Review of the facility’s TELS work orders showed entries for a malfunctioning call light that was unscrewed and unplugged from the wall and, later, a call light completely broken out of the wall and separated from wiring, as well as an invoice for a replacement bedside patient station. Facility policies on Accommodation of Needs and Safe and Homelike Environment required the facility to provide a safe environment and make reasonable accommodations in residents’ physical environment, including bedrooms and bathrooms.
Failure to Care Plan and Obtain Order for Mechanical Lift Transfers
Penalty
Summary
Surveyors identified a failure to develop and implement a person-centered, comprehensive care plan that included measurable objectives and timeframes for a resident’s identified needs, specifically related to transfers. The resident was an older female admitted with COPD, muscle weakness, unspecified pain, Type 2 DM with complications, and a history of cerebral infarction. Her admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and Section GG documented a score of 1 for chair/bed-to-chair transfer, meaning she was dependent and required the assistance of two or more helpers for transfers. Despite these documented needs, the resident’s care plan initiated on 10/25/2025 addressed risk for pressure injury related to decreased bed mobility/transfers, incontinence, poor nutrition, history of skin breakdown, fragile skin, Braden risk score, and sensory perception, but did not address ADLs or specify the means of transfer. The CNA Kardex, printed on 01/29/2026, indicated that the resident required a two-person assist for chair/bed-to-chair transfers, but this information was not reflected in the comprehensive care plan. Additionally, review of the physician orders showed there was no order for transfer via mechanical lift, even though the resident required this level of assistance. During interviews, the DON stated that if a resident required a mechanical lift transfer, there should be a physician order, and that staff would learn of this need through shift report and the CNA Kardex. The DON acknowledged there was a safety issue when a resident was not care planned for mechanical lift transfer and there was no corresponding order. The MDS nurse, who was responsible for completing care plans, stated that the resident’s mechanical lift transfer should have been care planned and that she must have overlooked it, despite the MDS documenting that the resident was dependent for transfers. The facility’s own comprehensive care plan policy required development of a person-centered care plan within 7 days of the comprehensive MDS, inclusion of all triggered CAAs, and measurable objectives and timeframes to meet identified needs, but these requirements were not met for this resident’s transfer needs.
Failure to Use Two-Person Mechanical Lift Transfer as Required
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices during a mechanical lift transfer for one resident. The resident was an older female with COPD, muscle weakness, unspecified pain, Type 2 DM with complications, and a history of cerebral infarction. Her admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and Section GG documented that she was dependent for chair/bed-to-chair transfers, requiring the assistance of two or more helpers. Her care plan, initiated earlier, addressed risk for pressure injury related to decreased mobility, incontinence, poor nutrition, history of skin breakdown, fragile skin, Braden risk score, and sensory perception, but did not address ADLs or means of transfer. On the day of the incident, the CNA Kardex for this resident indicated that her chair/bed-to-chair transfer required two persons. Despite this, a CNA was observed transferring the resident alone from bed to chair using a mechanical lift, with no other staff present. The DON, upon arriving at the scene, stated that two people were needed for mechanical transfers. In an interview, the CNA acknowledged she had been trained that two staff were required for mechanical lift transfers for the safety of residents and staff, but reported she proceeded alone because the other CNA on the hall was busy and the resident, who was her family member, was urging her to get her up quickly. Interviews and record review showed that the facility had established policies and training requiring two staff for mechanical lift transfers. The DON stated that staff were informed of residents’ mechanical lift needs during shift report and that CNAs used the Kardex to identify transfer requirements. The MDS nurse stated she was responsible for care plans and that the resident’s need for mechanical lift transfer should have been care planned but was overlooked, even though the MDS documented the resident as dependent for transfers. Facility policies on mechanical lifts, safe resident handling/transfers, and accident and supervision all required two staff for mechanical lift transfers and emphasized safe handling based on the resident’s individual plan of care and assessed needs, but in this case the resident’s transfer method was not included in the care plan and the transfer was performed by a single CNA contrary to policy and documented requirements.
Failure to Label Food and Maintain Clean Kitchen Vents
Penalty
Summary
Dietary staff failed to properly label and date food items stored in the walk-in refrigerator and freezer, as observed during a kitchen tour. Items such as ravioli, hash browns, and pancakes were found in clear plastic bags without any labels or dates. Multiple staff interviews confirmed that all items should be sealed, labeled, and dated, but there was confusion among staff regarding who was responsible for this task. The facility's own Food Receiving and Storage policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Additionally, the kitchen's air conditioning vents were observed to be visibly soiled with a black substance, which some staff identified as possible mold or dust buildup. Staff interviews revealed a lack of awareness and uncertainty about who was responsible for cleaning the vents. The facility's Sanitization policy states that kitchen surfaces not in contact with food should be cleaned regularly to prevent grime accumulation. No interviews could be conducted with the Dietary Manager due to illness, and both the Maintenance Director and other staff were unaware of the issue prior to the survey.
Failure to Maintain Sanitary Resident Refrigerator and Temperature Monitoring
Penalty
Summary
The facility failed to maintain a policy regarding the use and storage of foods brought in by family and visitors for residents, specifically for one resident who was reviewed for food and nutrition services. During observation and interview, it was found that the resident's personal refrigerator contained a brown substance stuck to the bottom of both the refrigerator and freezer compartments, as well as a food-encrusted butter knife. There was no temperature log present for the refrigerator, and the resident reported that staff did not clean her refrigerator, although she occasionally stored food in it. Interviews with facility staff revealed that both housekeeping and maintenance were responsible for checking the cleanliness and temperatures of residents' refrigerators, but these tasks had not been performed. The facility's policy required maintenance staff to record refrigerator temperatures weekly and for nursing or housekeeping staff to clean the refrigerators weekly and discard any non-compliant foods. The lack of adherence to these procedures resulted in unsanitary conditions and the absence of temperature monitoring for the resident's refrigerator.
Failure to Maintain Required 1:1 Supervision for Aggressive Resident
Penalty
Summary
The facility failed to protect residents from physical abuse and neglect, specifically by not ensuring continuous one-to-one monitoring for a resident with a documented history of aggressive behavior towards another resident. The resident in question had multiple diagnoses, including frontotemporal neurocognitive disorder and vascular dementia with behavioral disturbances, and was known to display physical and verbal aggression towards others every 1–3 days. Despite repeated incidents—such as attempting to stab a roommate with a utensil, hitting another resident with a broom, and striking a resident in the face—interventions in the care plan were limited to documentation, physician notification, and psychiatric referral as needed. The care plan was updated to reflect the risk, but the resident was removed from 1:1 monitoring following an IDT meeting that did not include the psychiatric nurse practitioner (PNP), who had previously recommended continued 1:1 supervision due to ongoing aggression. The decision to discontinue 1:1 monitoring was made by the IDT, which included the Administrator, DON, and other staff, but excluded the PNP and did not document the information reviewed. Staff interviews revealed that the resident continued to display fixation and aggression towards the targeted resident, and that staff felt 1:1 monitoring was necessary to prevent further incidents. Multiple staff members, including nurses and CNAs, described ongoing altercations and the inability to keep the two residents separated within the secured unit. The psychiatric provider and several staff members expressed concern that removing 1:1 monitoring increased the risk of harm, but their input was not included in the decision-making process. Facility policy required monitoring, prompt reporting, and care plan updates for resident-to-resident altercations, as well as psychiatric consultation and possible transfer if care could not be provided safely. However, the facility did not follow these protocols consistently, as evidenced by the lack of continuous 1:1 monitoring and incomplete interdisciplinary involvement in care planning. The failure to maintain required supervision and to include all relevant providers in care decisions resulted in repeated aggressive incidents and placed residents at risk for harm.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Unsupervised Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with dementia and a high risk of elopement exited a secure unit unsupervised. The resident, who had a history of wandering and moderate cognitive impairment, was able to leave the secure unit after the assigned RN left the area to respond to a code elsewhere in the building. At the time, the only CNA assigned to the unit was on lunch break, leaving the secure unit without staff supervision. The secure unit door did not latch properly behind the RN, allowing the resident to follow and exit the unit. The resident proceeded through a side exit and entered the passenger seat of a parked fire truck in the facility's parking lot. Video footage confirmed that the resident left the secure unit, walked through the building, exited through a side door, and entered the fire truck without any staff or emergency personnel present in the area. The resident was later redirected back to the secure unit by another staff member after being observed near the facility's main entrance. Interviews with staff revealed a lack of clear protocols regarding code response and supervision coverage for the secure unit. The RN who left the unit stated he had not received training on code response teams and believed he was required to respond to all codes, despite no formal direction from the facility. The DON and other staff confirmed there was no policy specific to the secure unit, and staff had not received recent in-service training on elopement prevention or supervision. The facility's failure to ensure adequate supervision and secure door function resulted in the resident's unsupervised exit and placed residents at risk.
Failure to Provide Consistent Pressure Ulcer Prevention and Wound Care
Penalty
Summary
A deficiency occurred when a male resident with spastic quadriplegic cerebral palsy and other medical conditions developed a wound on his right calf due to friction from his wheelchair. Despite being identified as at risk for pressure ulcers, the resident did not have any wound care or therapy consult orders in place for nearly two months. Progress notes indicated that the wound was first documented as an abrasion with redness and was treated with normal saline, TAO, and a dry dressing, but there was no further documentation or follow-up on the wound for almost a month. Weekly skin assessments, as required by facility policy, were not completed for the resident. The last documented skin assessment before the deficiency was on 4/10, with the next not occurring until 5/29, despite the presence of a wound. During this period, there was no evidence of ongoing wound care, therapy consultation, or reassessment, and the wound deteriorated, developing granulation tissue and slough. The resident reported ongoing pain and that the wound had worsened due to continued friction from the wheelchair, with only a towel provided as a temporary measure. Interviews with staff revealed lapses in the facility's wound care processes, including a gap in wound care nurse coverage and issues with the electronic medical record system not generating skin assessment reminders. The charge nurses were responsible for weekly skin assessments during the interim, but these were not completed as required. The facility's own policy mandates weekly full-body skin assessments and thorough documentation, which was not followed in this case, resulting in inadequate care and monitoring of the resident's wound.
Failure to Administer Parkinson's Medication on Time
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for a resident diagnosed with multiple conditions, including Parkinson's Disease, Type 2 Diabetes, Asthma, Hypertension, major depressive disorder, and Epilepsy. The resident had a physician's order for Rytary (Carbidopa-Levodopa) to be administered three times daily for Parkinson's Disease, with the facility's policy requiring medications to be given within one hour before or after the scheduled time. Record review revealed multiple instances over a 14-day period where the resident's Parkinson's medication was administered late, ranging from over an hour to more than five hours past the scheduled time. The care plan specifically noted the need to administer medications as ordered to prevent complications related to Parkinson's Disease. Interviews with the resident, DON, and MD confirmed awareness of the late medication administration. The resident reported increased tremors, difficulty holding objects, and slurred speech when medications were late, particularly with the first and last doses of the day. The DON acknowledged ongoing issues with late medication administration, attributing delays to the use of agency nurses unfamiliar with residents and medication routines. The MD also confirmed knowledge of the problem and emphasized the importance of timely administration for Parkinson's medications. Facility policy review supported the expectation for timely medication administration, which was not met in this case.
Failure to Maintain Sanitary Kitchen Environment Due to Pest Infestation and Inadequate Cleaning
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary kitchen environment, as evidenced by multiple observations of dead cockroaches and food debris in various areas of the kitchen, including the entryway, underneath storage racks, inside a floor drain beneath a prep sink, and around the ice machine. The kitchen floors were found to be stained and dirty, with visible debris and dead insects present during multiple observations. Staff interviews revealed that the kitchen was short-staffed, and cleaning was not consistently performed as required. The dietary supervisor acknowledged the presence of dead bugs and stated that pest control was expected soon, but thorough cleaning was lacking due to staffing shortages. The maintenance supervisor confirmed the presence of American cockroaches and indicated that pest control visits occurred, but also noted that kitchen staff were responsible for daily cleaning, which was not being logged or consistently performed. Further interviews with the DON and ADM revealed a lack of awareness regarding the extent of the infestation and inconsistencies in cleaning practices. The DON was unaware of the cockroach problem in the kitchen and noted that trays were sometimes left unwashed late into the evening, while the ADM stated that kitchen staff should immediately remove bugs and maintain cleanliness, but admitted there was no log to track cleaning activities. The facility's sanitation policy required the food service area to be kept clean and free from pests, but these standards were not met, resulting in unsanitary conditions that could affect food safety.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
A certified nursing assistant (CNA) failed to perform proper hand hygiene while serving and assisting residents with their meals in the facility's only dining room. During observation, the CNA was seen carrying meal trays from the kitchen cart to residents and assisting them by setting up trays, unwrapping utensils, and opening drinks, without using hand hygiene between each tray passed. The CNA admitted during an interview that he had passed four trays without performing hand hygiene, despite having received training on the importance of hand hygiene between each tray. He acknowledged that this practice was not acceptable and could lead to cross contamination and illness among residents, particularly those who are older and more vulnerable. The Director of Nursing (DON) and the Administrator (ADM) both confirmed their expectations that staff should sanitize their hands before and in between passing trays, either by washing hands or using hand sanitizer. Both expressed concerns about the risk of cross contamination and infection, especially given the facility's population at risk for infection. Review of the facility's hand hygiene policy indicated that all personnel are to follow hand hygiene procedures, including before and after handling food or assisting residents with meals. The failure to adhere to these procedures was observed and acknowledged by staff, placing residents at risk for the development and transmission of communicable diseases and infections.
Failure to Ensure Call Light Accessibility for Resident with Severe Impairments
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. The resident, a male with severe cognitive impairment, legal blindness, muscle weakness, and dependence on staff for multiple activities of daily living, was observed twice in his wheelchair with his call light hanging over his nightstand approximately two feet away, making it inaccessible. The resident stated he was unaware of the call light's location due to his legal blindness and reported that staff never clipped the call light to him, leaving him unable to call for assistance unless he moved himself into the hallway or waited for staff to enter his room. Interviews with CNAs, the DON, and the administrator confirmed that it was the responsibility of all staff to ensure call lights were within reach of residents at all times. Both CNAs working the hall where the resident resided were unaware that the call light was not accessible to the resident. The facility's policy required staff to secure call lights within reach and to evaluate residents for special accommodations to use the call system, but these procedures were not followed for this resident.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation of resident property were reported to the State Survey Agency within 24 hours as required. Specifically, an incident occurred in which one resident pushed or hit another resident in the chest area while passing in the hallway. The incident was reported to the charge nurse by the affected resident, and the Administrator (ADM) was informed on the same day. However, the ADM delayed reporting the alleged abuse to the Health and Human Services Commission (HHSC) until three days after the incident, despite being responsible for timely reporting. The delay occurred as the ADM was conducting an internal investigation and receiving conflicting accounts from the residents involved. Both residents involved had significant medical histories, including end stage renal disease, hypertension, osteoarthritis, cerebral infarction, type 2 diabetes, and vascular dementia. One resident was cognitively intact, while the other had moderate cognitive impairment. Interviews with both residents indicated that neither felt unsafe or injured after the incident, and both described the event as a push to get by in the hallway. The Director of Nursing (DON) confirmed that it was the ADM's responsibility to report such incidents promptly to prevent further abuse, and the ADM acknowledged the failure to report within the required timeframe.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies in food storage, preparation, and distribution. Observations revealed that food items in the pantry and walk-in refrigerator were not properly labeled or dated, with some items being out of date or moldy. Additionally, the kitchen environment was unsanitary, with dirty vents, utensils stored in a dirty drawer, and a dirty fryer with grease. The cereal containers were not properly labeled or sealed, and there was blood on the walk-in refrigerator floor. These conditions were observed during a survey, indicating a lack of compliance with infection prevention and control measures. Furthermore, the facility staff failed to take the temperatures of all food items being served to residents, which is a critical step in ensuring food safety. Specific food items such as hot dogs, beans, chili, meatloaf, mashed potatoes, tomato soup, gravy, and Salisbury steak were not temperature-checked before being served. This oversight in monitoring food temperatures could potentially lead to serving food at unsafe temperatures, increasing the risk of food-borne illnesses among residents. Additionally, staff members, including an LVN and a CNA, did not practice proper hand hygiene while distributing food and drinks in the secure unit dining room. Despite being aware of the facility's hand hygiene policy, both staff members admitted to neglecting to sanitize their hands before and after handling food trays. This lapse in hand hygiene practices poses a risk of cross-contamination and the spread of infections among residents. The facility's infection control policy emphasizes the importance of maintaining a safe and sanitary environment, yet these deficiencies highlight significant gaps in adherence to these standards.
Lack of Privacy and Grievance Resolution in Resident Meetings
Penalty
Summary
The facility failed to provide residents and family groups with a private space for meetings, as observed during a survey. The dining room was used as the designated meeting area, with only a temporary curtain providing minimal privacy. This setup did not adequately obstruct the view or sound, compromising the residents' ability to discuss their needs and preferences openly. Interviews with residents revealed that they were unaware of who the grievance official was and felt that their grievances were not being addressed or resolved. The facility also failed to follow up on concerns and requests expressed in resident council meetings over several months. Residents reported ongoing issues with food quality, such as cold meals and excessive pasta, as well as unresolved grievances about missing clothing items. Specific residents expressed dissatisfaction with the dietary options and the condition of drinks served. Additionally, there were complaints about infrequent changes of bed sheets and missing personal items from the laundry. Interviews with staff, including the DON and ADM, indicated that the facility did not have a social worker on staff to handle grievances, leading to a lack of follow-up and resolution. The DON and ADM claimed to be managing grievances in the interim, but residents reported not being informed of outcomes. The facility's grievance process was not effectively communicated or executed, leaving residents feeling that their concerns were not prioritized.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations of unclean and disrepaired conditions in residents' rooms and bathrooms. During the survey, it was noted that the facility did not repair cracks and holes in the walls, clean dust and dirt from ceilings and air vents, or maintain the cleanliness of toilets and bathroom floors. Additionally, trash was not regularly emptied, and bathroom vents were not properly repaired. These deficiencies were observed in the rooms and bathrooms of several residents, including Resident #59, Resident #74, and Resident #6. Resident #59's room and bathroom were found to be particularly neglected, with dust and dirt on the ceiling and air vents, mold around the air vent, and a leaking toilet with a stained towel at its base. The bathroom floor was dirty, and the toilet seat and rim were stained with feces. Resident #59 reported that his room had not been cleaned for several days and that housekeeping services were irregular and inadequate. Similar conditions were observed in Resident #74's and Resident #6's rooms, with dirty floors, stained walls, and unemptied trash cans. Resident #6, who is mostly non-verbal, indicated a desire for her room to be cleaned. Interviews with facility staff, including housekeeping and maintenance personnel, revealed that while there are cleaning schedules and maintenance protocols in place, they are not consistently followed. Housekeeping staff reported being familiar with their duties and schedules, but acknowledged that the size of the facility and its needs sometimes led to delays in completing tasks. Maintenance staff also noted that unresolved issues could pose safety hazards to residents. The facility's policies on cleaning and maintenance were reviewed, indicating that surfaces should be cleaned regularly and maintenance issues addressed promptly, but these standards were not met, leading to the observed deficiencies.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodations for their needs and preferences, specifically regarding the accessibility of call lights. Resident #68, a moderately cognitively impaired female with multiple health conditions including congestive heart failure and cerebral infarction, was observed on two occasions with her call light out of reach, lying on the floor at the end of her bed. Despite being dependent on staff for various activities, the resident was unable to demonstrate reaching the call light, which was confirmed by a CNA who acknowledged the resident's inability to reach it and the importance of call light accessibility. Similarly, Resident #55, a severely cognitively impaired male with diagnoses including mood disorder and schizophrenia, was observed sitting in the middle of the room without access to a call light. The resident was moaning and attempting to remove his sweater without success, remaining unattended for nearly 10 minutes before staff assistance arrived. Interviews with multiple CNAs and the DON confirmed that the resident's placement in the middle of the room without a call light was not typical or acceptable, and it was acknowledged that such a situation could lead to potential falls or unmet needs. The facility's policy on call light accessibility, revised in July 2023, emphasizes the importance of ensuring call lights are within reach to facilitate timely responses to residents' needs. Despite staff training on resident rights and call light placement, the observations and interviews revealed a failure to adhere to these guidelines, potentially compromising the safety and well-being of the residents involved.
Privacy Breach: Resident's Medical Information Exposed
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal medical records. During an observation, a registered nurse (RN) left a laptop open and unattended in the hallway, displaying a resident's information while performing wound care. This occurred after the RN had closed the resident's door, leaving the laptop visible to others in the hallway, including other residents and staff. The RN acknowledged that she usually closed her computer but had inadvertently left it open, despite being trained on resident privacy and HIPAA regulations. The resident involved was a male with multiple diagnoses, including sepsis, pleural effusion, dementia, and chronic kidney disease. He was severely cognitively impaired and required assistance with daily activities. The facility's administration and director of nursing confirmed that staff had been trained on maintaining resident privacy and confidentiality, and acknowledged that leaving a resident's information exposed violated HIPAA laws. The facility's policy on resident rights emphasized the importance of privacy and confidentiality, which was not upheld in this instance.
Failure to Obtain Hospice Documentation for Resident
Penalty
Summary
The facility failed to obtain necessary hospice documentation for Resident #246, who was admitted to hospice care. This included the hospice nursing documentation, the most recent hospice plan of care, the hospice election form, physician certification and recertification of the terminal illness, names and contact information for hospice personnel, hospice medications information, and physician orders. This deficiency was identified during a review of Resident #246's records and interviews with facility staff. Resident #246, a male with a history of sepsis, heart failure, hypertension, and chronic kidney disease, was admitted to hospice care with Hospice Medicaid Texas as the primary payor. Despite being on hospice care, there was no order specifying the hospice company providing care, and the necessary hospice documentation was not available in the resident's medical record. The lack of documentation could lead to confusion about the resident's care and the services being provided. Interviews with facility staff, including an LVN and the DON, revealed that the charge nurses were responsible for obtaining hospice orders and placing them into the electronic medical record. However, Resident #246 did not have a hospice folder with the required documentation, which could result in confusion about the hospice services being provided. The facility's policy requires coordination with hospice representatives and obtaining specific documentation to ensure quality care, but this was not adhered to in the case of Resident #246.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to protect its residents from abuse, specifically in two incidents involving resident-on-resident altercations. In the first incident, a resident with severe cognitive impairment due to dementia physically assaulted his roommate by punching him. This incident was not reported to the state office, as the facility's administration did not perceive the aggressor as a threat, and no injuries were documented. The resident's care plan was not updated following this incident, which may have contributed to a subsequent altercation. In the second incident, the same resident engaged in another altercation with a different roommate, where he used a wheelchair to physically abuse the roommate. This incident was reported to the state office, as it was discovered by staff and involved possible physical contact, although no injuries were reported. The facility's administration again did not view the resident as the aggressor, and the resident was subsequently moved to a private room in the Memory Care Unit. Interviews with staff revealed a lack of clarity and consistency in reporting procedures for resident-on-resident abuse. Some staff members believed the initial incident should have been reported within the required two-hour window, as per the facility's policy. The facility's policies on abuse, neglect, and resident rights emphasize the importance of immediate reporting and intervention to prevent further incidents, yet these protocols were not adequately followed in the first incident.
Failure to Implement Comprehensive Care Plan for Resident with Aggressive Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan (CCP) for a resident with severe cognitive impairment, who was involved in multiple resident-on-resident altercations. The resident, diagnosed with dementia, exhibited physical behaviors due to poor impulse control. Despite incidents of aggression towards roommates, the facility did not update the resident's CCP after an altercation on August 18, 2024, where the resident hit a roommate. This lack of action left other residents at risk of physical harm and mental anguish. The resident's CCP, initiated and revised on August 22, 2024, included interventions for nursing staff to analyze triggers, assess needs, and modify the environment to prevent agitation. However, these interventions were not implemented following the initial incident. The facility did not report the August 18 incident to the state office, as there were no injuries, and the administration did not perceive the resident as a threat. This decision was made despite staff opinions that the incident constituted abuse and should have been reported. Subsequently, on August 22, 2024, the resident was involved in another altercation with a different roommate, which was reported to the state office. The facility's failure to update the CCP after the first incident and the lack of timely reporting contributed to the recurrence of aggressive behavior. Interviews with staff revealed a consensus that addressing the initial incident in the CCP could have prevented the subsequent altercation. The facility's CCP policy required updates when desired outcomes were not met, but this was not adhered to in this case.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an incident of physical abuse between two residents within the required two-hour timeframe. On 8/18/2024, Resident #1, who had severe cognitive impairment due to dementia, hit his roommate, Resident #2, after being disturbed while sleeping. Despite the incident being documented in the progress notes, it was not reported to the state office as required by the facility's policies. The facility's administrator decided not to report the incident, citing the absence of injuries and the belief that Resident #1 was not a threat to others. Resident #2, who also had severe cognitive impairment and was diagnosed with legal blindness and schizoaffective disorder, was found with a bruise on his left upper arm following the altercation. The bruise was noted during a skin assessment, and Resident #2's responsible party was informed of the incident. Despite this, the facility did not complete a 5-day provider investigation as required. Interviews with staff revealed a lack of clarity on why the incident was not reported, and the administrator confirmed the decision not to report was his own. The facility's policies on abuse reporting and resident-to-resident altercations were not followed, as the incident was not reported within the two-hour window, and no follow-up investigation was conducted. Staff interviews indicated that they were trained on abuse, neglect, and resident-on-resident altercations, yet the administrator's decision overrode these protocols. The failure to report and investigate the incident could have placed residents at risk of further harm and mental anguish.
Phone System Malfunction Affects Resident Communication
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodation of their needs and preferences, specifically regarding the functionality of the phone system. Interviews and record reviews revealed that the facility's phone system was not consistently working, leading to issues with receiving incoming calls. Family members reported that calls to the facility would ring only a couple of times before disconnecting, and some calls went unanswered. This problem had been ongoing for a couple of months, and staff members, including the social worker and nurses, had to provide their personal cell phone numbers to family members to ensure communication. Staff interviews indicated that the phone issues were more prevalent on weekends, with ringers sometimes turned off or down, preventing calls from being noticed. The Director of Nursing (DON) and other staff members were aware of the problem and had reported it to the administration. The Maintenance Supervisor (MS) mentioned that the phones ran off the internet, making troubleshooting more challenging. Despite a technician reprogramming the phones three months prior, the issue persisted, and a technician was scheduled to address the problem. The facility's policy on resident rights emphasized the importance of communication access, which was compromised due to the phone system issues.
Failure to Provide Scheduled Showers and Document Refusals
Penalty
Summary
The facility failed to ensure that two residents, who were unable to perform activities of daily living independently, received necessary services to maintain good hygiene. Resident #1, a male with multiple diagnoses including hypertension, Crohn's disease, and schizoaffective disorder, required partial/moderate assistance with bathing. Despite being scheduled for showers on Mondays, Wednesdays, and Fridays, he only received five showers over a month-long period. There was no documentation of bathing being offered or refused, nor any negotiation of ADL times as per his care plan. Resident #1 expressed dissatisfaction, stating he felt neglected by the staff. Resident #2, also a male with diagnoses including type 2 diabetes and dementia, required supervision or touching assistance for bathing. He was scheduled for showers on alternate days but only received seven showers in the same period. The facility's records did not document any refusals of bathing, and Resident #2 could not recall how often he was offered showers. The facility's staff, including the ADON and CNAs, acknowledged the expectation to document refusals and educate residents on the importance of bathing, but there was a lack of consistent documentation. Interviews with facility staff, including the DON, ADON, and CNAs, revealed that there was an expectation for CNAs to notify nurses if a resident refused a shower, and for nurses to document the refusal and any education provided. However, there was no evidence of such documentation for the residents in question. The facility had conducted in-service training on shower schedules and refusals, but the deficiency in documentation and adherence to scheduled bathing persisted, potentially impacting residents' hygiene and dignity.
Inadequate Infection Control Practices with Blood Pressure Monitor
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of medical assistants (MAs) who did not sanitize a wrist blood pressure monitor between uses on multiple residents. Specifically, MA A used the monitor on two residents consecutively without cleaning it, and MA B, while supervising MA C, also failed to sanitize the monitor between residents. This oversight was observed during a survey, and the MAs involved did not adhere to the facility's infection control protocols. The residents involved in this deficiency had various medical conditions, including hypertension, diabetes, dementia, and cognitive impairments, which could make them more vulnerable to infections. The failure to sanitize the blood pressure monitor between uses on these residents could potentially increase the risk of disease transmission. Despite receiving training on infection control, MA A expressed a misunderstanding of the importance of sanitizing medical equipment between residents, believing that cleaning at the end of the shift was sufficient. The Director of Nursing (DON) acknowledged the deficiency and noted that the facility's policy clearly outlines the need for sanitizing medical equipment between residents. However, the in-service records revealed that there had been no specific training on the disinfection of medical equipment in recent months. The DON recognized the need for further education for staff, particularly for MA A, who demonstrated limited insight into proper infection control practices.
Failure to Implement Comprehensive Care Plan for Dialysis Compliance
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with end-stage renal disease, who was non-compliant with hemodialysis (HD) treatments. The care plan did not include the resident's behavior of refusing HD and lacked interventions to address this issue. Despite the resident's intact cognition and awareness of the importance of attending dialysis, he frequently refused treatment due to feeling unwell, leading to missed appointments. The facility also failed to notify the kidney center (KC) about the resident's refusal to attend HD sessions on specific dates, which was a requirement outlined in the care plan. The nursing staff documented the resident's refusal and notified the nurse practitioner (NP), but there was no record of communication with the KC. The KC attempted to contact the facility multiple times without success, resulting in the resident being sent to the emergency room after missing several HD sessions. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the care plans were not updated to reflect the resident's refusal of care. The DON acknowledged that the nursing staff was responsible for notifying the KC and that the care plan should have included interventions for the resident's non-compliance. The facility's policy emphasized the need for comprehensive, person-centered care plans with measurable objectives and timeframes, which were not adhered to in this case.
Failure to Address Resident's Nutritional and Hydration Needs
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there was a significant change in the resident's physical status. A resident was admitted to the hospital with severe dehydration and non-traumatic rhabdomyolysis, conditions that were not promptly identified or addressed by the facility. The resident's meal intake had decreased, but the facility did not notify the nutritionist, nurse practitioner (NP), or primary care physician (PCP) to address these nutritional or hydration concerns. The resident, who had a history of dementia, Parkinson's disease, anxiety, and depression, was admitted to the facility for respite care. The care plan did not include interventions for nutritional or fluid intake needs, and there were no physician's orders for the resident's diet or fluid intake. The resident's representative was not informed of the resident's declining condition, and the PCP was not contacted regarding any issues related to the resident. The facility's Director of Nursing (DON) stated that fluid intake was not tracked unless there was an order, and supplemental shakes were provided without documentation of consumption. Interviews revealed that the resident had not eaten or drunk anything for three days, leading to severe dehydration and rhabdomyolysis. The facility did not have a hydration policy, and the DON admitted that the facility did not address the eating or drinking issues with the NP or PCP, relying instead on the resident's representative's advice. The hospital treating physician confirmed that the resident's condition was consistent with lying in bed without nutrition or hydration for an extended period.
Failure to Monitor Nutritional and Hydration Needs Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, leading to severe dehydration and non-traumatic rhabdomyolysis. The resident, who had a history of dementia, Parkinson's disease, anxiety, and depression, was admitted to the hospital after showing signs of lethargy, inability to stand, pale skin, and purple fingertips. The facility did not identify the resident's decreased meal intake or notify the nutritionist, nurse practitioner, or primary care physician to address these concerns. The resident's care plan did not include interventions for nutritional or fluid intake needs, and there was no physician's order for the resident's diet or fluid intake. Meal intake records showed that the resident consumed less than 25% of his dinner on several occasions, and there was no record of dinner eaten on one day. Despite being informed of the resident's swallowing problems, the facility did not adequately monitor or document the resident's fluid intake or provide necessary interventions. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's nutritional and hydration needs. The Director of Nursing admitted that the facility did not have a hydration policy and relied on standard protocol without documenting interventions. The resident's condition deteriorated, resulting in hospitalization and a subsequent decision to place the resident on hospice care. The facility's failure to monitor and address the resident's nutritional and hydration needs contributed to the resident's decline in health.
Failure to Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report an incident involving Resident #1's fall in a timely manner. Resident #1, who had multiple diagnoses including COPD, dementia, and congestive heart failure, fell on 4/15/2024, resulting in a facial injury. Despite the fall being witnessed by staff and EMTs, the incident was not reported to the state agency immediately. Interviews with staff revealed confusion and a lack of communication regarding the incident, with the DON only informing the AD on or about 4/22/2024, after Resident #1 had passed away in the hospital. The facility's policy on abuse and neglect reporting was not followed, as the incident was not reported within the required timeframe. The facility also failed to report an incident of resident-on-resident abuse involving Resident #2 and Resident #3. On 4/03/2024, Resident #3 attempted to grab Resident #2's pants. The incident was documented by the DON, who assessed both residents and found no signs of trauma. However, the incident was not reported to the state agency as required. The DON and the administrator concluded that the incident was not reportable, despite the facility's policy stating that all allegations of abuse must be reported immediately. Interviews with the DON and the administrator revealed a lack of understanding and adherence to the facility's abuse reporting policy. The DON stated that she followed the administration's advice not to report the incident, while the administrator acknowledged that the incident should have been reported. The facility's failure to report these incidents in a timely manner could place residents at risk for abuse, neglect, and a decreased quality of life.
Failure to Investigate and Report Allegation of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report the results of an allegation of abuse and neglect involving a resident who fell. The resident, a [AGE] year-old female with multiple diagnoses including COPD, dementia, hypertension, congestive heart failure, mood disorder, acute respiratory distress, and chronic pain, was found on the floor by EMTs. Despite the incident, the facility did not complete an investigation or report the findings within the required five working days. The Director of Nursing (DON) and the Assistant Director (AD) both acknowledged gaps in communication and understanding of the incident, which led to the failure to investigate and report appropriately. The DON stated that she was informed by RN A about the resident being sent to the ER and later about the resident being found on the floor. The Therapy Director provided conflicting accounts about the incident, which added to the confusion. The AD admitted to not being aware of the unwitnessed fall and did not ensure an investigation was conducted. The facility's policy on abuse, neglect, exploitation, or misappropriation requires all allegations to be thoroughly investigated and reported, but this protocol was not followed in this case.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage, labeling, and sanitation practices in the kitchen. Observations revealed that food products were not sealed in airtight containers, lacked labels indicating the product name, open date, or discard date, and were not disposed of after their expiration dates. Specific instances included a box of pineapple tidbits stored directly on the floor and various food items in the walk-in cooler and freezer that were not properly sealed or labeled. Additionally, the facility's kitchen equipment and food preparation areas were not adequately cleaned and sanitized. The industrial can opener and its mounting bracket were found to be coated with a dark brown substance and food particles, while the dishwasher and its surrounding area had accumulations of white grit, food particles, and grime. These unsanitary conditions posed a risk of cross-contamination and the spread of food-borne pathogens, potentially endangering the health of residents. Interviews with staff, including the Dietary Aide (DA), Kitchen Manager (KM), Director of Nursing (DON), and Administrator (ADM), highlighted a lack of adherence to established food safety protocols. The KM admitted that the failure to properly label and date food products and sanitize preparation areas was due to staff not following instructions and inadequate training. The DON and ADM acknowledged the existence of facility policies on food safety and sanitation but noted that the kitchen's non-compliance was not reported or addressed by the Interdisciplinary Team (IDT).
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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