Harker Heights Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Harker Heights, Texas.
- Location
- 415 Indian Oaks Dr, Harker Heights, Texas 76548
- CMS Provider Number
- 675909
- Inspections on file
- 57
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Harker Heights Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to follow care-planned interventions for multiple residents requiring assistance with incontinence care and personal hygiene. Several residents with bowel and bladder incontinence, self-care deficits, and cognitive impairment reported long delays in call light response, sometimes up to an hour or more, and described being left wet or soiled for extended periods, including overnight. One resident with severe cognitive impairment was observed crying for help while a call light went unanswered for over 14 minutes until a surveyor alerted staff. Another resident with paraplegia and a history of sacral MASD reported waiting 7–8 hours at night to be changed, and observation showed pink, dry skin breakdown on her sacrum and thighs. Staff interviews confirmed that call lights were expected to be answered promptly and that rounds should occur every two hours, yet they acknowledged that with current assignments, call lights were not always answered in a timely manner and residents were not consistently checked and changed as required by their care plans.
Surveyors found a medication cart assigned to one hall left unattended, unlocked, and accessible in a main lobby area, with the locking mechanism protruding and drawers easily opened. An RN acknowledged responsibility as charge nurse for ensuring carts remained locked, and an LVN assigned to the cart confirmed that policy required carts to be locked at all times because someone could access them and residents were at risk of taking medications not prescribed to them. The DON and administrator both stated that all nurses were expected to know and follow the policy that medication carts must remain locked when not in use, and facility policy documents confirmed that medication carts and their contents must be kept closed, secured, and/or in line of sight when not in use.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room due to a non-functioning bathroom, but neither the resident nor her responsible party received written notice of the change. Facility staff confirmed that room changes were communicated verbally and not in writing, and the facility's policy did not require written notification. This resulted in a failure to honor the resident's right to receive written notice before a room or roommate change.
A facility failed to enforce its smoking policy when a CNA was observed using a vape device while providing care to a cognitively impaired resident with multiple medical conditions. The incident occurred in a non-designated area, contrary to facility policy, and was confirmed through video evidence and staff interviews.
A deficiency was cited for not ensuring a resident's right to a safe, clean, comfortable, and homelike environment, including the safe provision of treatment and daily living supports.
Surveyors found that multiple food items in the kitchen refrigerator, including salad greens, pasta noodles, and a yellow liquid with chunks, were not labeled with opened or discard by dates. Both the DM and interim ADM confirmed that staff were responsible for labeling and that failure to do so could result in serving spoiled food.
A facility failed to provide appropriate pain management for a resident with severe cognitive impairment by using an incorrect numerical pain scale instead of a pain ad assessment. The resident, who had a history of falls and was unable to verbalize pain, was repeatedly assessed with a pain level of 0/10, despite his condition. Staff interviews revealed inconsistent training and understanding of proper pain assessment tools, and the facility lacked a policy on assessment accuracy.
A resident with a history of tremors was not provided a modified cup with a lid, leading to a coffee spill. The NAIT, unfamiliar with the resident's needs, served coffee in a standard mug, resulting in the spill. The resident's care plan required a modified cup due to her condition, but the NAIT did not know how to access the Kardex to verify this requirement.
The facility failed to maintain accurate records and periodic reconciliation of controlled drugs, with missing documentation on Narcotic Count Sheets for several shifts across different halls. Despite training and expectations for nurses to count narcotics together and sign the sheets, compliance was not ensured, leading to potential risks of drug diversion.
The facility failed to provide palatable and properly prepared meals, with residents receiving lukewarm, unseasoned food. The dietary staff lacked proper measuring equipment, leading to inconsistencies in puree diet preparation. Residents expressed dissatisfaction, with some resorting to alternative food options.
The facility failed to maintain residents' dignity during meal times, affecting four residents. A CNA fed three residents simultaneously, contrary to training, while another resident waited 45 minutes for her meal, causing distress. Staff interviews revealed a lack of adherence to expected care standards, and no policy on meal service was provided.
The facility failed to maintain proper kitchen sanitation practices. A dietary staff member did not wash or sanitize her hands while preparing pureed meals, potentially contaminating the food. Another staff member did not wear a beard guard correctly, leaving his facial hair exposed over a food prep table. The facility's sanitation policy requires hand hygiene and hair restraints, but training records were not provided.
The facility failed to provide adequate assistance and care for two residents. A resident with a history of cerebral infarction and other conditions was left without assistance by an ADON, despite needing help with bed mobility. Surveillance footage showed the resident struggling and calling for help, with a delayed response from staff. Another resident was fed by an unqualified Activity Assistant, posing a risk of aspiration. The DON and Administrator acknowledged the need for qualified staff to assist residents.
Two residents with severe cognitive impairment did not receive proper nail care, resulting in poor hygiene and potential health risks. Observations showed blackish/brownish substances under their nails and uneven edges, despite care plans requiring regular maintenance. CNAs were responsible for nail care, except for diabetic residents, but staff were unaware of any refusals and did not recall training dates.
Two residents in a facility were served meals that did not accommodate their dietary needs. One resident, with cognitive impairments, was served beef despite disliking it, while another resident with a gluten allergy was served gluten-containing foods. Staff interviews revealed a lack of awareness and adherence to dietary restrictions, and the facility lacked gluten-free products.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter. Two CNAs provided care without wearing gowns, despite EBP requirements. A CNA was unaware of the resident's EBP status due to missing information in the Kardex. The DON confirmed that staff should use the Kardex to verify precautionary measures.
A resident with severe cognitive impairment was sent to the hospital for low blood pressure during dialysis, but the facility failed to notify the responsible party (RP) as required. Interviews revealed that the LVN assumed the dialysis center would inform the RP, leading to a lapse in communication. The facility's policy mandates notifying the RP of changes in condition, which was not followed in this case.
A resident was admitted to a facility with hospital discharge orders for insulin due to type II diabetes, but the order was not instated. Instead, the resident was given anti-seizure medications without a seizure diagnosis, leading to a sudden change in consciousness and hospitalization. The facility failed to ensure accurate medication reconciliation and verification of orders, resulting in an Immediate Jeopardy situation.
A resident admitted with a hip fracture and existing skin issues did not receive timely wound care, leading to a stage III pressure ulcer. The facility failed to implement standing treatment orders upon admission, and the WCN was not notified promptly. This delay in care highlighted a systemic issue in the facility's wound management practices.
The facility failed to have certified Activities Directors (ADs) for its activities program, as required by their policy. The newly hired AD, previously a CNA, was not yet certified, and neither the AD for the secured memory care unit nor the AD for the rest of the residents were certified. This lack of certification resulted in fewer activity opportunities for residents, potentially affecting their quality of life.
A resident with severe cognitive impairment sustained a black eye of unknown origin, and the facility failed to notify the resident's representative in a timely manner. The injury was observed by staff, but the representative was not informed until several hours later, and there was a lack of clarity among staff regarding notification procedures.
A resident with severe cognitive impairment and dependency on staff for ADLs had an unclean wheelchair with brown spots and a foul odor. Interviews revealed confusion among staff about who was responsible for cleaning wheelchairs, with no consistent oversight or schedule in place. The facility's policies were not effectively implemented, leading to the resident's wheelchair remaining unclean, impacting their dignity and potentially their health.
A resident with severe cognitive impairment was found with a black eye, and the LTC facility failed to report the incident to the State Agency within the required 24-hour timeframe. Despite staff awareness, the injury was not reported due to assumptions about its cause, contrary to facility policies. This deficiency in reporting placed residents at risk of potential abuse or neglect.
Failure to Provide Timely Incontinence Care and Call Light Response per Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinence care, personal hygiene, and call light response in accordance with residents’ person-centered care plans and stated preferences. Multiple residents with bowel and bladder incontinence, self-care deficits, and cognitive impairment had care plans requiring staff to check and change them on rounds and as needed, keep their skin clean and dry, and conduct routine safety rounds. Despite these documented interventions, staff did not consistently perform timely rounds or respond promptly to call lights, resulting in residents remaining wet or soiled and waiting extended periods for assistance. One resident with severe cognitive impairment, hemiplegia, dementia, and incontinence had a care plan for personal hygiene assistance, turning and repositioning on rounds and as needed, and incontinence care with check and change on rounds and as needed. Nursing notes documented a family complaint that this resident had been left soaking wet with urine for hours, although staff later documented the brief as dry. During observation, this resident was heard crying for help; when the call light was activated, no staff responded for 14 minutes and 9 seconds until a surveyor notified staff at the nursing station. No nursing staff were visible on the hall, and a housekeeper present in the area did not respond to the call light. Another resident with intact cognition and bowel and bladder incontinence, whose care plan required incontinence care every shift and as needed, reported that staff did not check on him every two hours as needed and that sometimes no one checked on him all night. He stated he needed to be changed and repositioned and that he had previously voiced these concerns to nursing staff without improvement. A resident with vascular dementia, diabetes, and frequent bladder incontinence, whose care plan required monitoring for incontinence every 2–3 hours and as needed with application of skin barrier, reported that it took staff 30–45 minutes on different shifts to answer call lights for changing. Her responsible party stated that it typically took 45 minutes to an hour for call lights to be answered and that staff often said they would return but did not. A resident with hemiparesis, frequent bladder incontinence, and a care plan requiring check and change on rounds and as indicated, toileting/incontinence care with assistance, and keeping skin clean and dry with barrier cream, reported that her call light was not answered promptly. She described an incident where she was wet, called for help, and waited one hour and 26 minutes for a CNA to respond. She also reported waiting 15–30 minutes for assistance to get up from the commode, despite needing help due to left leg weakness and pain. Another resident with paraplegia, bowel and bladder incontinence, and a history of sacral moisture-associated skin damage, whose care plan required check and change on rounds and as needed and keeping skin clean and dry with barrier cream, reported developing bed sores on her bottom from not being changed in a timely manner. She stated that the sore had been healing but broke out again when she was not changed, including an episode where she was not changed overnight when one CNA had the whole hall, and she sometimes waited 7–8 hours during night shifts in her own waste. This same resident reported that when she pressed the call light, nobody came, and staff sometimes entered, turned off the call light, and said they would return when they had time, with actual waits of 30 minutes to an hour. Observation of her peri care revealed pink, dry skin breakdown around the sacrum and medial thighs. Multiple CNAs, an LVN, and an RN confirmed that call lights were expected to be answered immediately or within a few minutes, that rounds should be conducted every two hours, and that unanswered call lights and delayed incontinence care could lead to falls and skin breakdown. They acknowledged that not answering a call light for extended periods, such as over an hour, could be considered neglect. Despite a written policy and prior in-services emphasizing timely response to call lights and resident needs, staff interviews and resident/family reports showed that call lights were frequently unanswered for prolonged periods and that routine rounds and incontinence care were not consistently performed as care planned.
Unattended, Unlocked Medication Cart Accessible in Lobby
Penalty
Summary
Surveyors identified a deficiency related to improper storage and security of medications when one of three medication carts reviewed was found unattended, unlocked, and accessible in the main lobby area. During an observation, the medication cart assigned to the 300 hall was located in an unsecured public area with the locking mechanism protruding outward, allowing the surveyor to open drawers and take photographs without being noticed by the RN or LVN on duty. The cart contained drugs and biologicals that were not secured in accordance with facility policy and professional standards, and it was accessible to staff, residents, and passers-by. In interviews, the RN stated the cart belonged to the LVN assigned to the 300 hall and acknowledged that residents could access the cart and take medications not intended for them. The RN also stated she was the charge nurse and supervisor on duty and responsible for ensuring medication carts remained locked. The DON stated that medication carts were supposed to be locked at all times with no exceptions and that all nurses should have known this practice, referencing an existing facility policy on medication cart security. The LVN, who had worked at the facility for 15 or 16 years and was responsible for the 300 hall cart, acknowledged that policy required carts to remain locked at all times because someone could access them, and confirmed that residents were at risk of taking medications not prescribed to them. The administrator similarly stated that medication carts were to be locked at all times when not in use and that the assigned nurse, as well as any staff or management who observed an unlocked cart, were responsible for ensuring its security. Review of the written policy confirmed that medication carts and their contents were to be kept closed, secured, and/or in line of sight when not in use.
Failure to Provide Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide written notice to a resident and her responsible party (RP) prior to changing the resident’s room assignment. The resident, an elderly female with severe cognitive impairment (BIMS score of 3), multiple diagnoses including idiopathic normal pressure hydrocephalus, Alzheimer’s disease, and adult failure to thrive, was moved to a new room due to a non-functioning bathroom in her previous room. The move was discussed verbally with the RP by the Director of Nursing (DON) and Administrator (ADM), but no written notification was provided, and the RP did not have the opportunity to see the new room before the move occurred. Interviews with facility staff, including the social worker (SW), assistant director (AD), and licensed vocational nurse (LVN), confirmed that the facility’s practice was to notify residents and families of room changes verbally, not in writing. The SW and AD stated that verbal consent was documented in the electronic health record, and the SW was generally responsible for coordinating room changes. The ADM and DON both indicated that the urgency to move the resident was due to a directive from a state surveyor to ensure the resident had access to a working bathroom, but acknowledged that written notice was not provided as required. The facility’s policy and procedure for resident rights, as reviewed, did not specify the requirement for written notification prior to room changes, and staff interviews confirmed that written notice was not part of the facility’s standard process. The lack of written notice and documentation of the reason for the room change constituted a failure to honor the resident’s right to receive written notice before a change in room or roommate, as required by regulation.
Failure to Enforce Smoking Policy and Ensure Smoking Safety
Penalty
Summary
The facility failed to establish and implement policies regarding smoking, smoking areas, and smoking safety in accordance with applicable laws and regulations, specifically as it relates to both residents and staff. An incident was observed in which a certified nursing assistant (CNA) was seen on video using what appeared to be a vape device while providing care to a resident in the restroom, with another CNA present. The resident involved had significant medical conditions, including normal pressure hydrocephalus, Alzheimer's disease, adult failure to thrive, hyperlipidemia, hypertension, and depression, and was assessed as cognitively impaired and at risk for falls. The resident required assistance with transfers and toileting due to generalized weakness and poor balance. The facility's policy stated that team members were only permitted to smoke in approved designated areas and that smoking, including the use of electronic devices, was prohibited in all other areas, especially where it could create hazardous or unsafe conditions. Despite this policy, the CNA admitted to using a vape device while caring for the resident, which was corroborated by video evidence and interviews. The resident was not aware of the incident until informed by a family member who had seen the video footage. The facility's records indicated that this was the CNA's first such incident and that there had been no prior grievances filed against her.
Failure to Ensure Safe, Clean, and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, nor are there direct observations or events described beyond the general statement of noncompliance with the requirement.
Failure to Label and Date Food Items in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to properly label and date food items stored in the kitchen refrigerator. Specifically, salad greens in a metal container covered with plastic wrap, pasta noodles in a metal container covered with tinfoil, and a yellow, non-opaque liquid with chunks in a metal container covered with tinfoil were all found without labels indicating the date opened or discard by dates. During interviews, both the Dietary Manager and interim Administrator confirmed that all kitchen staff were responsible for labeling and dating food items, and acknowledged that the lack of labeling could result in staff not knowing when food had spoiled. Review of the U.S. Public Health Service Food Code confirmed that ready-to-eat foods must be discarded if not properly dated.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with severe cognitive impairment, specifically in the area of pain recognition and management. The resident, who had a history of cerebral infarction, epilepsy, repeated falls, and dementia, was unable to verbalize his pain levels due to his cognitive condition. Despite this, staff consistently used a numerical pain scale, which was inappropriate for the resident's condition, as he could not communicate his pain level effectively. The resident experienced multiple falls in January and February, during which staff failed to accurately assess his pain levels. The facility's staff, including RNs and LVNs, used numerical pain assessments instead of the pain ad assessment, which is designed for residents who cannot verbalize their pain. This led to repeated documentation of a pain level of 0/10, despite the resident's inability to communicate his pain accurately. Interviews with staff revealed a lack of consistent training and understanding of the appropriate pain assessment tools for cognitively impaired residents. The deficiency was further highlighted by the facility's lack of a policy on the accuracy of assessments, as well as inconsistent in-servicing on pain recognition and management. Staff interviews indicated that while some were aware of the need to use the pain ad assessment for non-verbal residents, this was not consistently applied in practice. The failure to use the correct pain assessment tool placed the resident at risk of not receiving timely and effective pain management, as evidenced by the resident's multiple falls and subsequent injuries.
Failure to Provide Assistive Device Leads to Coffee Spill
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents. A resident, who had a history of tremors and spastic movements, was not given a modified cup with a lid when served coffee. Instead, the resident was given coffee in a standard mug, which led to the resident spilling the hot coffee onto her hand and the table. This incident occurred because the nurse aide in training (NAIT) was not aware of the resident's need for an assistive device and did not know how to access the Kardex to verify the resident's requirements. The resident involved had a complex medical history, including unspecified psychosis, a history of traumatic brain injury, seizures, epilepsy, muscle weakness, and cognitive communication deficit. The resident's care plan specifically required the use of a modified cup with a lid to prevent accidents due to her tremors and altered movements. Despite this, the NAIT, who was still in training and unfamiliar with the resident, failed to provide the necessary assistive device, resulting in the spill. Interviews with staff revealed that the NAIT relied solely on meal tickets to determine the need for assistive devices and was not trained to access the Kardex. The Director of Clinical Education and the Director of Nursing confirmed that the expectation was for staff to check both meal tickets and the Kardex to ensure residents received the appropriate assistive devices. The failure to provide the required assistive device could have resulted in injury to the resident, highlighting a gap in staff training and supervision during meal services.
Failure to Maintain Accurate Narcotic Count Records
Penalty
Summary
The facility failed to maintain accurate records and periodic reconciliation of controlled drugs, as evidenced by missing documentation on Narcotic Count Sheets for several shifts across different halls. Specifically, the Change of Shift Narcotic Counts for the 100 Hall on February 5, 2025, revealed missing documentation for the night shift on February 4, 2025. Similarly, the 200/300 Hall count sheet showed missing documentation for the night shift on February 3, 2025, and both day and night shifts on February 4, 2025. The 600 Hall count sheet lacked documentation for the night shift on February 1, 2025, and the 700 Hall count sheet was missing documentation for the night shift on February 1, 2025, and February 3, 2025. Interviews with the Director of Nursing (DON) and the WFM revealed that the facility's expectation was for the off-going and on-coming nurses to count narcotics together and sign the Narcotic Count sheet. Despite training provided through online avenues and a three-day in-person orientation, the facility did not ensure compliance with these expectations. The DON acknowledged that missing signatures could lead to drug diversion, and the Pharmacy consultant's audits were intended to identify trends. However, the lack of consistent adherence to narcotic count procedures was evident, as demonstrated by the missing documentation on the count sheets.
Deficiency in Food Quality and Preparation
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. During an observation of a lunch test tray, the meal was found to be lukewarm, unappetizing in appearance, and lacking in seasoning and flavor. The beef stroganoff pasta noodles were overcooked and mushy, the gravy was greasy and watered down, and the green beans were unseasoned. Multiple residents expressed dissatisfaction with the meal, noting that it was not appealing, lacked flavor, and was served cold. Some residents resorted to ordering fast food or alternative menu items due to the poor quality of the meal. The facility also failed to follow the puree diet recipe, specifically for scrambled eggs, due to the absence of proper measuring equipment. The dietary staff had to guess the amount of thickener to add, as there was no tablespoon available, and the recipe manual lacked a recipe for oatmeal. This led to uncertainty in preparing pureed foods, potentially affecting the nutritional intake of residents on puree diets. The dietary manager acknowledged the lack of proper equipment and the absence of a puree oatmeal recipe, which could result in inconsistencies in food preparation. Interviews with the dietary manager and administrator revealed expectations for a fine dining experience for residents, with food that is flavorful, well-presented, and palatable. However, the facility did not have a specific policy related to food palatability, and the administrator was unable to provide a protocol for following recipes and preparing food. The lack of proper equipment and adherence to recipes could lead to residents not receiving the correct consistency of pureed food, potentially impacting their nutritional needs.
Failure to Maintain Dignity During Meal Times
Penalty
Summary
The facility failed to treat residents with respect and dignity, particularly during meal times, which affected four residents. Resident #30, Resident #50, and Resident #108 were not assisted with feeding in a dignified manner. A CNA was observed feeding these three residents simultaneously by moving between them on a rolling chair, which was not conducive to maintaining their interest in eating. This method of feeding was contrary to the facility's training, which emphasized feeding one resident at a time to ensure proper encouragement and attention. Resident #190 experienced a delay in receiving her meal, which compromised her dignity. She was left waiting for approximately 45 minutes after her tablemate was served, causing her distress and anxiety about not receiving her food. The LVN on duty acknowledged that the meal tray was missing and had to be retrieved from the kitchen, indicating a lapse in the meal service process. This oversight led to Resident #190 observing others eat while she remained without food, highlighting a failure in the facility's responsibility to ensure timely meal service. Interviews with staff, including the CNA, LVN, Director of Nurses, and the Administrator, revealed a lack of adherence to the expected standards of care during meal times. The CNA admitted to the difficulty of feeding multiple residents simultaneously and acknowledged the need for encouragement to maintain residents' interest in eating. The LVN and Administrator recognized the dignity issue and the expectation for one-on-one feeding. However, the Director of Nurses suggested that feeding more than one resident was not unusual, despite the potential negative impact on residents with dementia. The absence of a policy on serving meals in the dining room further underscores the facility's deficiency in maintaining residents' dignity during meal times.
Deficiencies in Kitchen Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. During an observation, a dietary staff member, DC K, did not practice proper hand hygiene while preparing pureed meals. DC K was seen touching various potentially contaminated surfaces, such as her clothes, a menu manual, and a plastic bag, without washing or sanitizing her hands before handling food. This lack of hand hygiene was acknowledged by DC K, who admitted to not washing her hands during the entire food preparation process, potentially leading to food contamination. Additionally, another dietary staff member, DC L, was observed not wearing a beard guard correctly while standing over a food preparation table. His beard guard was positioned under his chin, leaving his facial hair exposed. DC L acknowledged the improper use of the beard guard and recognized the potential for hair to fall onto food, which could lead to contamination. The Dietary Manager confirmed that all staff with facial hair were expected to wear beard guards and that the failure to do so could result in food contamination. The facility's Employee Sanitation Policy requires staff to wear hair restraints and practice hand hygiene to prevent contamination. However, the in-service training records for hand hygiene and beard guard use were not provided at the time of the survey exit. The Administrator and Dietary Manager both acknowledged the potential for cross-contamination due to these lapses in protocol, although they could not determine the specific health risks without knowing the type of bacteria involved.
Failure to Provide Adequate Assistance and Qualified Feeding
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for two residents. For Resident #400, the Assistant Director of Nursing (ADON A) observed the resident sliding out of bed and did not provide the necessary assistance to help the resident with bed mobility. Surveillance footage showed Resident #400 attempting to sit up and calling for help, but ADON A left the room without assisting. The resident's family member had to call the nurses' station for help, and it took 10 minutes for someone to assist the resident back into bed. The Director of Nursing (DON) and Administrator acknowledged that the staff should have provided assistance, and the failure to do so could have resulted in a fall. Resident #400 was an elderly female with a history of cerebral infarction, acute pulmonary edema, acute kidney failure, and other conditions that required assistance with activities of daily living (ADL). Her care plan indicated she needed one-person assistance for bed mobility and repositioning. Despite this, ADON A did not provide the necessary help, and the family member expressed dissatisfaction with the facility's response time and care, leading to the resident's discharge. For Resident #188, the facility failed to ensure a qualified staff member fed the resident. An Activity Assistant, who was not trained or certified to feed residents, was observed feeding Resident #188 in the dining room. The Activity Assistant admitted to not being qualified and expressed concerns about the potential for choking. The DON and Administrator confirmed that only qualified staff, such as CNAs, nurses, or speech therapists, should feed residents. The lack of qualified staff during feeding times posed a risk of aspiration for Resident #188, who had a self-care deficit and required assistance with eating.
Inadequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, leading to poor hygiene and potential health risks. Resident #30, a female with Alzheimer's disease and severe cognitive impairment, was observed with a blackish/brownish substance under her fingernails and uneven nail edges. Her care plan indicated she required assistance with personal hygiene, but her nails were not properly maintained, which could lead to hygiene issues and potential health risks. Similarly, Resident #80, who also had severe cognitive impairment and required substantial assistance with personal hygiene, was found with similar nail conditions. Her care plan specified that her nails should be checked, trimmed, and cleaned on bath days and as needed. However, observations revealed that her nails were not smooth, and there was a blackish/brownish substance underneath them, indicating a lack of proper nail care. Interviews with CNAs and the ADON revealed that CNAs were responsible for nail care, except for residents with diabetes, whose nails were managed by nurses. Despite being in-serviced on nail care, staff members did not recall the training dates and were unaware of any refusals of nail care by the residents. The Director of Nurses confirmed that all residents should receive nail care during showers and as needed, and any changes in nail conditions should be reported to the nurse supervisor.
Failure to Accommodate Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for two residents. Resident #50, who has Alzheimer's disease and other cognitive impairments, was served pureed taco beef meat despite her meal ticket indicating a dislike for beef. The CNA responsible for feeding her did not notice the meal ticket, and the LVN who checked the meal trays did not pay attention to the residents' likes and dislikes. Resident #241, who has multiple diagnoses including encephalopathy and type 2 diabetes, was served food items containing gluten despite having a documented allergy to gluten. Her meal ticket clearly stated her allergies, but she was still served oatmeal, a blueberry muffin, a dinner roll, and egg noodles, none of which were gluten-free. The dietary manager confirmed that the facility did not have gluten-free products in stock prior to the incident. Interviews with staff revealed a lack of awareness and adherence to the residents' dietary needs. The RN and CNA involved in meal service were not fully aware of the residents' dietary restrictions, and the dietary manager admitted that gluten-free products were not available. The Director of Nursing stated that the facility had gluten-free items in stock, but this was contradicted by the dietary manager. The failure to accommodate these dietary needs placed the residents at risk of consuming allergens and receiving meals that did not align with their preferences.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling urethral catheter. The resident, a woman with a history of Type 2 Diabetes Mellitus and Neuromuscular Dysfunction of the Bladder, was observed receiving perineal and catheter care from two CNAs who did not adhere to the required EBP protocols. Despite a sign indicating EBP outside the resident's room, the CNAs only wore gloves and did not use gowns during the care process, which is a necessary component of EBP to prevent the spread of infections. The deficiency was further compounded by a lack of communication and documentation errors. One of the CNAs was unaware of the resident's EBP status, mistakenly believing that the precautions were no longer necessary due to the healing of a sacral wound. This misunderstanding was exacerbated by the absence of EBP information in the resident's Kardex, a tool used by staff to verify care instructions. The Director of Nursing acknowledged that staff should be informed of precautionary measures through the Kardex, highlighting a gap in the facility's infection control practices.
Failure to Notify Responsible Party of Resident's Hospitalization
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) of a resident when there was a significant change in the resident's physical status. Specifically, the facility did not inform the RP when the resident was sent to the hospital for low blood pressure during a dialysis treatment. The resident, who had end-stage renal disease and unspecified dementia with a severe cognitive impairment, was not able to communicate effectively about his condition. The lack of notification was confirmed through interviews and record reviews, which showed no documentation of a call made to the family on the day of the incident. Interviews with the resident's RP, the Regional Nurse, LVN A, and the Administrator (ADM) revealed that the facility's staff did not follow the expected protocol of notifying the RP about the resident's hospital transfer. LVN A admitted to not contacting the RP, mistakenly assuming that the dialysis center would handle the notification. This oversight was acknowledged by both the Regional Nurse and the ADM, who confirmed that it was the facility's responsibility to inform the RP to ensure their involvement in the resident's care plan. The facility's policy on changes in resident condition, which mandates notifying the resident, attending physician, and RP, was not adhered to in this instance.
Medication Errors Lead to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, which led to an Immediate Jeopardy situation. Upon admission from the hospital, the resident's order for insulin was not instated, despite having a diagnosis of type II diabetes. Additionally, the resident was administered two anti-seizure medications, Lacosamide and Divalproex Sodium, without having a diagnosis for seizures, epilepsy, or a psychiatric/mood disorder. This resulted in a sudden change in the resident's consciousness and responsiveness, necessitating a transfer to the hospital. The resident, a female with a history of stroke, type II diabetes, and end-stage renal disease, was admitted to the facility with hospital discharge orders that included insulin administration and blood sugar monitoring. However, these orders were not accurately transcribed into the facility's records. Instead, the resident received medications for seizures, which were not part of her medical history or hospital discharge instructions. The resident's blood sugar levels were recorded as significantly elevated, yet the insulin order was not implemented until after she was sent to the hospital. Interviews with facility staff revealed a lack of proper medication reconciliation and verification of hospital discharge orders. The resident's nurse practitioner and medical doctor indicated that the administration of anti-seizure medications without a proper diagnosis could lead to sedation and other adverse effects, which likely contributed to the resident's hospitalization. The facility's failure to accurately transcribe and administer medications as per the hospital's discharge orders placed the resident at risk and resulted in a critical incident.
Removal Plan
- Licensed nurse should conduct appropriate medication reconciliation as well as blood glucose monitoring orders in relation to the hospital discharge orders and ensure that all hospital discharge orders to include medications, treatments and blood glucose monitoring orders are reviewed and confirmed with the accepting attending physician upon admission.
- Post reconciliation of the medication/treatment/blood glucose monitoring order, the licensed nurse should review each medication and/or treatment and blood glucose monitoring orders as well as insulin orders, to ensure that they are accurately transcribed as per the hospital discharge orders as well as any new orders provided by the attending physician/medical provider are accurately transcribed into the electronic health record.
- Clinical leadership/assigned licensed nurse will conduct a post admission review of all new admission/re-admission orders to include but not limited to insulin orders, blood glucose monitoring orders, correct medication orders and treatment orders against the hospital discharge order to validate the accuracy of medication reconciliation and proper transcription of physician orders. Should any discrepancies be identified, the licensed nurse should immediately report the discrepancy, clarify with the attending physician/medical provider, and complete a medication error report as indicated.
- Director of Clinical Operations/Assistant Director of Nursing initiated in-service training for licensed nurses regarding the process for medication reconciliation, confirming orders upon admission/re-admission and transcribing orders into the electronic health record.
- Licensed nurses will complete a test to validate the process for proper medication reconciliation, confirming orders upon admission/re-admission and transcribing orders into the electronic health record to validate competency of the facility's expected practices.
- Director of Clinical Operations/Assistant Director of Nursing will conduct 100% audit of all current in-patient new admissions/re-admissions' medication and treatment orders reconciliations to validate accuracy of the admission/re-admission orders entered into the electronic medical record.
- Director of Clinical Operations/Administrator suspended the licensed nurse pending investigation who was responsible for completing an accurate medication reconciliation and accurately entering the correct hospital discharge orders after confirming the medication and treatment orders with the accepting medical provider upon admission.
- Director of Clinical Operations/Assistant Director of Nursing will provide the same in-service trainings with all newly hired licensed nurses going forward as a part of the on-boarding process for nurses.
- Director of Clinical Operations/Assistant Director of Nursing will ensure all licensed nursing staff will be re-educated to include any licensed nurse on leave/agency/PRN staff. All licensed nurses will be in-serviced prior to assuming next shift. Director of Clinical Operations/Administrator will ensure administrative nursing staff is available to provide in-service/education prior to the licensed nurses working their next assigned shift.
- Director of Clinical Operations/Assistant Director of Nursing will conduct random weekly audit of new admission/re-admission physician orders to validate the accuracy of the medication reconciliation and transcription process of the physician/medical provider confirmed orders within the E.H.R against the hospital discharge orders to validate medication, insulin and treatment accuracy.
- Director of Nursing/Assistant Director of Nursing will conduct daily reviews during clinical start-up meeting review of new/re-admission orders, progress notes, and the 24-hour report to ensure that appropriate interventions and/or all needed follow up has been assigned.
- Administrator, Director of Clinical Operations, and the Medical Director conducted an Ad Hoc QAPI meeting to review the identified deficient practice and plan of removal (corrective action plan) implemented.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for a resident who was admitted with a hip fracture requiring surgery. Upon admission, the resident had shearing to her sacrum, which was not treated promptly, leading to the development of a stage III pressure ulcer. The resident's admission care plan indicated she was at risk for skin impairment due to frail and fragile skin and decreased mobility, yet appropriate wound treatment orders were not instated until several days after her admission. The resident's hospital discharge paperwork noted redness to the sacrum, and the facility's admission assessment identified an open area to the buttock and shearing. Despite these findings, the facility did not implement standing wound treatment orders immediately upon admission. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's wound care needs. The Wound Care Nurse (WCN) was not notified of the resident's condition, and the admitting nurse did not initiate standing treatment orders, resulting in a delay in care. The facility's policy required that new admissions with skin impairments have treatment orders initiated at the time of admission. However, the admitting nurse failed to follow this protocol, and the resident's wound care was not addressed until the WCN assessed the wound days later. This oversight placed the resident at risk for further deterioration of the wound, infection, and pain, highlighting a systemic issue in the facility's wound management practices.
Facility Lacks Certified Activities Directors
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by their policy and job description. The Activities Director (AD) was recently hired and previously worked as a Certified Nursing Assistant (CNA). Although she was enrolled in an AD certification and training program, she was not yet certified. Additionally, the facility's Administrator (ADM) confirmed that neither the AD for the secured memory care unit nor the AD for the rest of the facility's residents were certified as qualified therapeutic recreation specialists or certified activity professionals. The facility's job description for the Activities Director position required current certification as a Certified Activities Director. Furthermore, the facility's policy on the activities program, dated January 2023, stipulated that the program should be directed by a qualified professional who is either a certified therapeutic recreation specialist or a certified activity professional, and who is licensed or registered by the state, if applicable. The ADM acknowledged that the lack of certified ADs resulted in fewer activity opportunities for the residents, which could potentially impact their quality of life.
Failure to Notify Resident Representative of Injury
Penalty
Summary
The facility failed to notify the resident representative (RP) of an accident involving a resident that resulted in an injury with the potential for requiring physician intervention. Specifically, the facility did not inform the RP of a resident's black eye, which was observed by staff on 10/27/24 at 1:30 PM, until later that evening at 7:39 PM. Additionally, the RP was not informed of any incidents that occurred on 10/25/24 until 10/27/24, indicating a delay in communication that could affect the resident's quality of life and safety. The resident involved was a female with severe cognitive impairment, as indicated by a BIMS score of 6, and had multiple diagnoses including unspecified dementia and generalized muscle weakness. Her care plan noted communication difficulties due to her cognitive impairment and language barrier, requiring frequent checks by nursing staff. Despite these needs, there were no interventions in place to ensure timely notification of the RP or family in the event of an incident. Interviews with staff revealed a lack of clarity and consistency in the notification process. Several staff members, including LVNs and CNAs, were unsure of the exact procedures for notifying families and the importance of doing so promptly. The facility's policies on changes in resident condition and abuse reporting emphasize the need for immediate notification of the resident's physician and family, yet these protocols were not followed, as evidenced by the delayed communication with the resident's RP.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident who was dependent on staff assistance for activities of daily living (ADLs), except for eating. The resident's wheelchair was observed to be unclean, with brown-colored spots, a foul odor, and dried-up substances on the armrests, seat, and wheel. Despite the resident's severe cognitive impairment and communication difficulties, the staff did not ensure the cleanliness of her wheelchair, which could potentially lead to neglect, infection, and a diminished quality of life. Interviews with various staff members revealed a lack of clarity and accountability regarding the cleaning of residents' wheelchairs. Certified Nursing Assistants (CNAs) were generally responsible for cleaning wheelchairs, but there was no consistent oversight or schedule to ensure this task was completed. Some staff members believed the night shift CNAs were responsible, while others thought it was a shared responsibility among all shifts. The Director of Nursing (DON) and other supervisory staff were unaware of the specific condition of the resident's wheelchair and did not have a system in place to monitor the cleanliness of wheelchairs. The facility's policies and position agreements indicated that CNAs and charge nurses were expected to address and report concerns immediately, but this was not effectively implemented. The facility's cleaning and disinfection policy required non-critical surfaces, such as wheelchairs, to be disinfected with an EPA-registered disinfectant, but this was not adhered to in practice. The lack of communication and oversight led to the resident's wheelchair remaining in an unclean state, impacting the resident's dignity and potentially their health.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident who was found with a black eye within the required 24-hour timeframe. The resident, a female with severe cognitive impairment and a history of dementia, was discovered with bruising around her left eye on 10/27/24. Despite multiple staff members being aware of the injury, the incident was not reported to the State Agency (SA) as required by the facility's policies and state regulations. The resident's medical history included severe cognitive impairment, dementia, and a history of falls, which complicated the investigation into the cause of the injury. Interviews with various staff members, including CNAs, LVNs, and the DON, revealed a lack of clarity and communication regarding the reporting process for injuries of unknown origin. Several staff members, including the DON and ADM, assumed the injury might have been caused by the resident's bedside table due to her history of nodding off at the table. However, no definitive cause was determined, and the facility's decision not to report the incident was based on assumptions rather than concrete evidence. The facility's policies required reporting injuries of unknown origin, but the staff did not follow these protocols, leading to a deficiency in reporting. The facility's documentation and interviews indicated that no in-services or additional training were provided to staff following the incident, which may have contributed to the lack of proper reporting. The ADM and DON believed that the injury was not suspicious or of unknown origin, and therefore did not report it to the SA. This decision was contrary to the facility's policies, which required reporting all unexplained injuries to ensure resident safety. The failure to report the incident in a timely manner placed residents at risk of potential abuse or neglect.
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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