Harmony Care At Golfcrest
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 6150 S Loop East, Houston, Texas 77087
- CMS Provider Number
- 675233
- Inspections on file
- 26
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 27 (2 serious)
Citation history
Health deficiencies cited at Harmony Care At Golfcrest during CMS and state inspections, most recent first.
Surveyors found multiple environmental and sanitation deficiencies on two halls, including unsecured baseboards, peeling paint, broken blinds, non-functioning overbed lighting, and an uncovered electrical outlet between beds. Several resident rooms and bathrooms had dirty floors with trash, dust, food crumbs, overflowing trash containers, and soiled privacy curtains, as well as a bathtub and shower area containing a dirty shower chair, disposable brief, wet tissue, and broken sheetrock. Cords and antennas were observed on floors, and one room had black buildup under a window. Resident care equipment, including a G-tube feeding pole, an air mattress and its pump, and an O2 concentrator, were visibly soiled with dried beige and dark substances. Staff interviews confirmed housekeeping and maintenance routines, but at the time of observation, the environment and equipment did not meet the facility’s own policy for a safe, clean, and homelike setting.
The facility failed to maintain an effective pest control program on two of three halls, where surveyors observed dead flies, live flies on a resident’s forehead, gnats in bathrooms, and both dead and live roaches on room floors. Several residents reported that flies, gnats, and roaches were always present in their rooms, even though a pest control company regularly treated the building. Maintenance staff described routine walkthroughs and pest treatments, but record review showed that rooms later found with roaches and gnats were not included on a recent treatment list, despite a facility policy requiring an ongoing program to keep the building free of insects and rodents.
A resident with Alzheimer’s disease, multiple comorbidities, and significant ADL dependence repeatedly refused showers and requested bed baths instead, with multiple refusals documented in progress notes and shower sheets. The resident reported problems getting showers and stated he was not bathed as often as he would like, while staff described episodes where the resident initially agreed to a shower, then yelled and refused once in the shower chair or on the shower bed, subsequently requesting a bed bath and calling his daughter to report not receiving a shower. Despite staff awareness of this ongoing pattern and the facility’s policy requiring the IDT to revise care plans as conditions or information changed, the comprehensive care plan did not include any problem, goal, or interventions addressing the resident’s shower refusals, constituting a failure to review and revise the care plan accordingly.
A resident who was fully dependent on staff for ADLs and had multiple chronic conditions did not receive timely incontinent care, as night shift staff repeatedly failed to respond to her call light over an extended period. The resident was left in soiled conditions for hours, experienced verbal abuse, and felt neglected and belittled. Despite complaints from the resident, her family, and other staff, management denied awareness of the issue, and incident reports did not document the neglect.
Three residents with cognitive and physical impairments were able to smoke unsupervised and without required smoke aprons, outside of scheduled smoking times, due to lapses in staff supervision and inconsistent enforcement of facility policy regarding the storage of smoking materials. Staff interviews confirmed that residents sometimes accessed cigarettes and lighters on their own, and that these practices were known to administration but not consistently addressed.
A CNA failed to properly handle soiled linens for two residents on enhanced barrier precautions, placing a wet Hoyer sling and bedsheet in a trash bin instead of the linen barrel for one resident, and attempting to reuse a blanket that had been on the floor for another. These actions did not comply with infection control policies requiring proper handling of contaminated linens to prevent the spread of infection.
A resident with severe physical and cognitive impairments was found without a functioning call light at the bedside, as the device was missing its push button component. Multiple staff members, including the DON, CNAs, and maintenance, were unaware of the issue prior to observation, despite facility policy requiring regular checks and maintenance of call systems. The deficiency was identified through observation and interviews, with no prior documentation of the broken call light.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A medication aide failed to administer a phosphate binder (Sevelamer) with meals as ordered for a resident with end stage renal disease on dialysis. The medication was given without food, contrary to pharmacy label instructions and facility policy, resulting in a deficiency in pharmaceutical services.
A nurse left a medication cart unlocked and unattended in a hallway outside an open resident room. The cart contained various resident-labeled medications, with controlled substances secured in a separate locked compartment. The nurse admitted to forgetting to lock the cart after being called away, and the DON confirmed that staff are responsible for ensuring medication carts are locked and accessible only to authorized personnel.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Two red biohazard-labeled containers without lids were found outside the facility, containing deteriorated red bags and trash. Staff interviews revealed no knowledge of the containers' origin or contents, and the containers were not part of the facility's approved medical waste disposal process.
The facility failed to implement an effective infection control program, as CNAs were observed transporting soiled linen without clear trash bags, and personal care equipment was improperly stored. Interviews confirmed staff awareness of proper procedures, but these were not consistently followed, posing a risk of cross-contamination.
The facility failed to maintain a safe and sanitary environment in two resident halls, with issues such as non-functioning lights, broken fixtures, peeling paint, and strong odors. The Maintenance Supervisor, new to the role, was unaware of some issues but planned to address them. These deficiencies contradict the facility's policy of providing a clean and homelike environment.
The facility failed to maintain an effective pest control program, leading to the presence of roaches and gnats in two halls. Observations revealed live and dead roaches in resident rooms, and interviews with residents confirmed persistent pest issues. The pest control company increased visit frequency, but recent treatments did not include all affected rooms.
A resident with hypertension was given Metoprolol despite blood pressure readings below the physician-ordered parameters. The medication was administered on several occasions when the resident's blood pressure was too low, contrary to the prescribed instructions. Interviews with nursing staff revealed inconsistencies in medication administration and documentation, with one LVN admitting to possible documentation errors and another emphasizing the importance of checking vital signs before administration. The DON confirmed the medication should not have been given under these conditions.
The facility's kitchen failed to meet food safety standards, with unsealed and undated food items found in the pantry, and a dented can stored improperly. Staff interviews confirmed that these practices could lead to foodborne illnesses, affecting 89 residents.
A medication aide administered blood pressure medications to a resident despite their blood pressure being below the physician's recommended parameters. Initially, the aide denied administering the medications, claiming they were discarded, but later admitted to the error. The facility's policy requires holding medications if vitals are out of parameters and notifying the nurse and physician.
The facility did not submit complete and accurate direct care staffing information to CMS for the first quarter of fiscal year 2024. An outside HR company was responsible for the submission, but due to a lapse, the contract was terminated. The Administrator was unaware of the issue until the survey team highlighted it. This deficiency meant the facility did not accurately report staffing levels, impacting the ability to meet residents' needs.
Environmental and Sanitation Deficiencies on Two Halls
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, functional, and homelike environment on two of three halls, specifically the 100 and 200 halls. Surveyor observations on multiple dates found numerous environmental issues in resident rooms and common areas. In several rooms, baseboards were not affixed to the walls, there was peeling paint behind beds, and broken blinds were present in the hallway between the two halls. One room had an overbed light that did not illuminate when turned on, and another room had an uncovered electrical outlet between two beds. Nightstands in some rooms had peeling strips on the front, and one bed had a worn sheet with brown stains. Additional observations showed significant cleanliness and sanitation problems. One bathroom contained a dirty bathtub with blackened strips, a dirty shower chair, a disposable brief, wet tissue paper, and a box with gloves, along with broken sheetrock at the base of the shower pipe. Multiple rooms had dirty floors with trash, dust, food crumbs, and dirt, including rooms where trash containers were filled and overflowing. Some rooms had antennas and cords or electric cords lying on the floor. One room had an accumulation of black material in the corner under the window, and another had stained floors, trash on the floor, and soiled privacy curtains with a dark dry substance on them. Surveyors also identified unclean resident care equipment. In one room, a G-tube feeding pole was soiled with copious amounts of dried beige substance similar in color to the enteral feeding in the bag at the bedside. The resident’s air mattress had stains, and the pump at the foot of the bed was soiled with dried dark brown drips and dried beige streaks and drips of unknown substances. The O2 concentrator at the bedside had drips of dried beige substance down the sides and back. Staff interviews confirmed that housekeeping was responsible for room cleaning and that environmental rounds were conducted, but at the time of survey, the rooms and equipment remained in the deficient conditions described. The facility’s own policy stated residents were to be provided a safe, clean, and homelike environment with clean linens and adequate lighting, which was not met in these observed instances.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program to keep two of three halls (Hall 100 and Hall 200) free of pests, resulting in multiple resident rooms containing roaches, flies, and gnats. During observations on 1/15/2025 between 11:30 a.m. and 2:00 p.m., surveyors noted dead flies in one resident room and flies and gnats in that room’s bathroom, a live fly on a resident’s forehead in another room, and dead roaches on the floors of additional rooms. In other rooms, flies were observed flying in the room, live gnats were present in the bathroom, and both dead and live roaches were seen on the floor. Interviews with five unidentified residents on 1/15/2026 revealed that flies, gnats, and roaches were consistently present in their rooms, and that although a pest control company treated the building, the pests continued to return. The Assistant Maintenance staff member reported that pest control had been in the facility a few days prior, treating for roaches, gnats, flies, and ants, and that they typically conducted morning walkthroughs, checked the maintenance log, and spoke with residents to address concerns. The Maintenance Supervisor stated he performed morning building walkthroughs several days a week and used a fly wipe that appeared to decrease flies. Record review of pest control receipts showed multiple treatment dates and indicated that rooms identified with roaches and gnats during the survey were not included on the list of rooms treated on 01/08/2026, despite an existing policy stating the facility shall maintain an effective pest control program to keep the building free of insects and rodents.
Failure to Revise Care Plan for Repeated Shower Refusals
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan to address ongoing refusals of showers. A male resident with diagnoses including hypertension, diabetes, Alzheimer’s disease, anxiety, depression, malnutrition, and diaper dermatitis was admitted in mid-January 2026. His quarterly MDS showed a BIMS score of 11, indicating moderately impaired decision-making, and documented no behaviors under the behavior section. Functionally, he required varying levels of assistance with ADLs, including maximal assistance for shower/bath and personal hygiene, and was incontinent of bladder with a colostomy. Despite these needs, his care plan dated late December 2025 did not include any problem, goal, or interventions related to shower or bathing refusals; it only reflected that he was to receive showers/bed baths at least twice per week as documented on shower sheets and CNA point-of-care tasks. Surveyor review of progress notes and shower sheets showed multiple instances where the resident refused showers and requested bed baths instead, with refusals documented on several specific dates in early January 2026. During observation, the resident was alert, oriented, able to make his needs known, and appeared groomed with no lingering odor. In interviews, he reported having problems getting a shower, stating that he usually received a bed bath but wanted a shower where staff could soap him up and wash him off, which he felt could not be done in bed. He also stated that he was bathed but not as often as he would like, that he had specific bathing days but did not always receive them when he wanted, and that he expected staff to know when he wanted a shower. Staff interviews confirmed awareness of the resident’s pattern of refusing showers. The MDS Coordinator acknowledged knowing that the resident often refused showers and stated it should have been addressed in the care plan, characterizing its omission as a human oversight. A CNA described that the resident would initially agree to a shower, be placed in the shower chair, then start screaming and yelling that he did not want a shower and preferred a bed bath, after which he would call his daughter and say he did not get a shower. ADONs reported they were aware the resident always refused showers and believed he was care planned for shower refusals, explaining that he would be placed on the shower bed, then refuse to go to the shower room and request a bed bath instead, and later call his daughter stating he needed a shower. The facility’s own care plan policy required ongoing assessment and revision of care plans as resident conditions or information changed, and for the IDT to develop a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not carried out for this resident’s shower refusal behavior.
Failure to Provide Timely Incontinent Care and Respond to Call Lights
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The resident, who had multiple medical diagnoses including congestive heart failure, hypertension, diabetes, stroke, COPD, and parkinsonism, was totally dependent on staff for most ADLs, including incontinent care. The care plan for this resident specified that call lights should be within reach and answered promptly, but this intervention was not consistently followed. Over a period of several months, the resident's call light was repeatedly ignored or not acknowledged by the 3rd shift nursing staff, particularly for incontinent care needs. Documentation and interviews revealed that the resident was left in soiled conditions for extended periods, sometimes for several hours, and that staff would enter the room, turn off the call light, and leave without providing care. The resident and her family member reported multiple instances of neglect, including verbal abuse and dismissive behavior from staff, and these concerns were corroborated by the resident's roommate and a CNA. Despite these ongoing issues, management staff and the administrator denied receiving complaints or being aware of the neglect, and incident reports did not reflect the call light concerns. The resident expressed feelings of neglect, belittlement, and shame as a result of the staff's actions and inactions. Interviews with other staff members confirmed that complaints about call lights not being answered, especially on the night shift, were known but not always reported or addressed. The facility's policy required staff to treat residents with kindness, respect, and dignity, but this was not upheld in the care provided to the resident during the period in question.
Failure to Supervise Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and safe storage of smoking materials for three residents with cognitive impairments and other medical conditions. On the morning of 12/18/2025, three residents were observed smoking unsupervised in the designated smoking area, outside of scheduled smoking times, and without the required use of smoke aprons. Interviews with the residents confirmed that they sometimes smoke on their own before the official smoking times, and that they occasionally obtain cigarettes from other residents. Staff interviews revealed that residents are not supposed to smoke unsupervised or keep their own smoking supplies, but these practices were not consistently enforced, particularly during night shifts when no designated smoking times were scheduled. The residents involved had significant medical histories, including dementia, cognitive communication deficits, schizoaffective disorder, hemiplegia, heart disease, diabetes, and neuropathy. Their care plans and smoking assessments indicated the need for supervision while smoking, the use of smoke aprons, and secure storage of smoking materials at the nurse's station. Despite these documented interventions, the residents were able to access cigarettes and lighters and smoke without staff supervision or protective equipment. Staff interviews confirmed awareness of the risks and the facility's policy, but also acknowledged that residents sometimes circumvented these rules, and that administration was aware of previous incidents of unsupervised smoking. Facility policy required that residents only smoke in designated areas under staff or family supervision, and that all smoking materials be stored securely at the nurse's station. However, observations and interviews demonstrated that these policies were not consistently followed, particularly during overnight hours. Staff reported redirecting residents when found smoking unsupervised and notifying management, but lapses in supervision and secure storage of smoking supplies persisted, resulting in residents being able to smoke unsupervised and without appropriate safety measures.
Failure to Follow Infection Control Procedures for Soiled Linens
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection control procedures for two residents who required enhanced barrier precautions due to their complex medical conditions. For one resident with a history of sepsis, quadriplegia, tracheostomy, stage 4 pressure ulcer, and gastrostomy, the CNA did not place the resident's soiled Hoyer transfer sling and bed sheets in the designated linen barrel after use. Instead, these items were found stuffed inside the resident's bedside rubbish bin, wet and saturated with liquid. The licensed vocational nurse (LVN) and director of nursing (DON) confirmed that these linens did not belong in the trash bin and that improper handling could be a source of infection, especially given the resident's vulnerability. In a separate incident, the same CNA was observed in another resident's room, where a navy-blue blanket was found bundled on the floor at the foot of the bed. The resident, who had diagnoses including acute and chronic respiratory failure, colostomy, tracheostomy, gastrostomy, and peripheral vascular disease, was dependent on staff for all activities of daily living and also required enhanced barrier precautions. The CNA picked up the blanket from the floor, shook it out, and attempted to place it back on the resident's bed before being stopped by the surveyor. When questioned, the CNA acknowledged that the blanket could be placed in the dirty linen barrel but initially attempted to reuse it. Both residents were on enhanced barrier precautions due to their wounds and indwelling medical devices, as indicated by physician orders and facility policy. The facility's infection control policies required that soiled linens be handled in a manner that prevents contamination and the transfer of microorganisms. The CNA's actions in both cases did not comply with these procedures, as confirmed by interviews and observations documented in the report.
Failure to Provide Functioning Call Light System at Bedside
Penalty
Summary
The facility failed to ensure that a resident had access to a functioning call light system at the bedside, as required for requesting staff assistance. During observation, it was noted that the call light device available to the resident was missing the push button component, leaving only the outer casing. The resident, who was nonverbal, dependent on staff for all activities of daily living, and had significant medical conditions including quadriplegia, tracheostomy, and a stage 4 pressure ulcer, was unable to use the call system to summon help. Interviews with facility staff, including the Administrator, DON, CNAs, LVN, HR/Payroll Director, and Maintenance Director, revealed that none were aware that the call light in the resident's room was nonfunctional prior to the surveyor's observation. Staff acknowledged that the expectation is to check call lights regularly and ensure they are within reach and operational for all residents. The Maintenance Director reported conducting weekly checks of call lights and keeping spare parts available, but there was no documentation of a broken call light for this resident in the maintenance binder. Record review confirmed that the facility's policy requires each resident to have a means to call staff for assistance from their bed, and that the call system must remain functional at all times. Despite these policies and routine checks, the deficiency occurred due to a lack of awareness and failure to identify and address the nonfunctional call light for a resident with severe impairments and high care needs.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Administer Phosphate Binder with Meals as Ordered
Penalty
Summary
A deficiency occurred when a medication aide (MA-B) failed to administer Sevelamer, a phosphate binder prescribed to control high phosphorus levels in a resident with end stage renal disease (ESRD) on dialysis, according to the pharmacy label instructions. The medication was ordered to be given with meals, but MA-B administered three tablets of Sevelamer to the resident without food during a morning medication pass. The medication administration record (MAR) and pharmacy label both specified that the medication should be taken with meals, yet this instruction was not followed. The resident involved was a male with a history of bilateral shin fractures, ESRD requiring dialysis, osteoarthritis, anxiety, and dependence on renal dialysis. At the time of the incident, the resident was observed with dry skin and was seen scratching his body, and he confirmed that he typically takes Sevelamer with meals. The nurse in charge was unaware that the medication had been given without food, and facility policy required verification of medication orders and adherence to label instructions. The failure to administer the medication as ordered constituted a lapse in pharmaceutical services for the resident.
Unattended and Unlocked Medication Cart
Penalty
Summary
A nurse failed to ensure that the medication cart on the 200 Hall was locked when left unattended. During an early morning observation, the medication cart was found in the hallway outside an open resident room, visibly unlocked and unattended. The cart contained various medications labeled for residents, including over-the-counter drugs, while controlled substances were secured within a separate locked compartment inside the cart. The nurse assigned to the cart stated she was called away and forgot to lock it, acknowledging that facility protocol requires the cart to be locked when unattended to prevent unauthorized access. The Director of Nursing confirmed that the assigned nurse or medication aide is responsible for securing the cart and restricting access to authorized personnel only.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Improper Storage and Disposal of Biohazard Waste Containers
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment by not properly disposing of waste in the appropriate receptacles. Observations revealed two red, cylindrical, 32-gallon containers labeled 'Infectious Waste: Biohazard' located outside the facility, one near the generator and another near a storage shed. Both containers were without lids and contained red bags of unknown origin, water, and various trash items. Some of the red bags were deteriorated, indicating prolonged exposure to the elements. The containers appeared to have been outside for an extended period, and the contents could not be clearly identified due to the condition of the bags. Interviews with facility staff, including the ADON/IP, Administrator, and Maintenance Director, revealed a lack of awareness regarding the presence and use of these biohazard containers outside the building. The ADON/IP stated that biohazard bags were only used for residents in isolation and were supposed to be stored and picked up from the Medical Waste room inside the facility. Neither the Administrator nor the Maintenance Director knew how long the containers had been outside or what they contained, with the Maintenance Director suggesting they may have been there for years. The containers were not part of the facility's approved waste disposal process.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by improper handling of soiled linen and patient care equipment. Observations revealed that CNAs were transporting dirty linen and soiled briefs across the hallway without using clear trash bags, which is against the facility's infection control policy. Personal care basins and bed pans were found on the bathroom floor without labels or protective plastic bags, posing a risk of cross-contamination between residents sharing the rooms. Interviews with CNAs and the Director of Nursing (DON) confirmed that staff were aware of the proper procedures but failed to implement them. CNA D admitted to not having clear plastic bags available during incontinent care, which could lead to contamination. The DON acknowledged that staff had been in-serviced on infection control measures, including the proper disposal of soiled items and labeling of personal care equipment, but these practices were not consistently followed. The facility's policies emphasize the importance of handling soiled items to prevent the spread of infections, yet these guidelines were not adhered to, potentially affecting all residents in the facility.
Environmental Deficiencies in Resident Halls
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents on two of the three halls reviewed for environmental concerns. Observations revealed several issues, including a non-illuminating overhead light in a bathroom, baseboards coming off the walls, broken sheet racks, peeling paint, and lifting floor tiles in various rooms. Additionally, there were strong urine and feces odors in some rooms, with visible brown stains and smears that resembled feces on the toilet and floor, contributing to an unsanitary environment. Interviews conducted during the survey indicated a lack of awareness and prompt action from the maintenance staff. A resident reported the bathroom light issue, and the Maintenance Supervisor, who was new to the position, was unaware of the problem. He mentioned plans to address the concerns and check the maintenance logs daily. The facility's policy emphasizes providing a safe, clean, and homelike environment, but the observed deficiencies suggest a failure to adhere to these standards, potentially affecting the residents' quality of life.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and gnats in two of the three halls reviewed. During the survey, live and dead roaches were observed in multiple rooms, including on residents' overbed tables and floors. Interviews with residents revealed that roaches were a persistent issue, with residents resorting to using their own spray to manage the problem. The facility's pest control company had been visiting monthly, but due to ongoing issues, the frequency was increased to weekly visits for four weeks before returning to a monthly schedule. The grievance log indicated a recent complaint about insects on a resident's plate, although the location was not specified. The pest control records showed treatments for various pests, including roaches, spiders, and ants, but the rooms identified with pest issues during the survey were not included in the recent treatment list. The facility's pest control policy stated an ongoing program to keep the building free of insects and rodents, but the observations and resident reports indicated that the program was not effectively implemented.
Medication Administration Error Due to Non-Adherence to Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident's medication, Metoprolol, was administered according to the physician's orders. The resident, who had a diagnosis of essential hypertension, was prescribed Metoprolol Tartrate 25mg to be taken orally every 12 hours, with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) was less than 70, or heart rate (HR) was less than 60. However, the medication was administered on multiple occasions when the resident's blood pressure readings were below the specified parameters, including instances where the SBP was 83/51 and 105/67. Interviews with the nursing staff revealed discrepancies in medication administration and documentation. One LVN stated that she was not responsible for administering the medication at the specified times and emphasized the importance of checking blood pressure before administering the medication. Another LVN acknowledged the possibility of incorrect documentation, despite being aware of the resident's tendency for low blood pressure. The Director of Nursing (DON) confirmed that the medication should not have been given when the blood pressure was below the parameters, as it could lead to adverse effects such as dizziness and potential falls.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, which could potentially place 89 residents at risk for foodborne illness. During an observation, it was noted that food items in the pantry were not properly sealed or dated. Specifically, a 16 oz bag of tortilla chips was found open, unsealed, and undated, while an 80 oz bag of instant oatmeal was dated but not sealed. Interviews with the Dietary Manager and staff revealed that all kitchen staff were responsible for ensuring food items were sealed and dated, and the Dietary Manager would double-check these items. The staff acknowledged that improperly sealed or dated food could lead to food poisoning for residents. Additionally, a dented can of apples was found stored with non-dented cans, contrary to safety protocols. The Dietary Manager confirmed that dented cans should be stored separately to prevent potential exposure to botulism. Staff interviews indicated that everyone in the kitchen was responsible for checking for dented cans, and shifts were expected to double-check each other's work. The facility's policy and FDA guidelines were reviewed, highlighting the importance of proper food storage and handling to prevent serious health hazards.
Medication Administration Error Due to Non-Adherence to Physician Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A medication aide (MA L) administered Doxazosin and Amiodarone to a resident with a blood pressure reading of 100/65, which was below the physician's recommended parameters of holding the medication if the systolic blood pressure (SBP) was less than 110 and diastolic blood pressure (DBP) was less than 60. Despite the resident's blood pressure being outside the safe range, MA L proceeded with the administration of the medications. Upon observation, MA L initially denied administering the medications and claimed to have discarded them in the resident's trash bin, which was not observed. The Assistant Director of Nursing (ADON) was informed of the situation and assessed the resident for adverse side effects. The ADON confirmed that the medications were not found in the trash bin, and MA L later admitted to administering them. The Director of Nursing (DON) reiterated that medications should be held if vitals are out of parameters and that the medication aide should have notified the nurse to inform the physician.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the first quarter of the fiscal year 2024. This deficiency was identified during a review of the facility's staff roster and the CMS PBJ Staffing Data Report, which indicated that no data was submitted for the quarter. The facility's policy required staffing information to be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. However, the facility did not meet this requirement for the specified period. Interviews revealed that an outside third-party HR company was responsible for submitting the payroll and PBJ data, but due to a lapse in submission, the contract with this company was terminated in February 2024. The Regional Director of Clinical Operations acknowledged the risk of not submitting the PBJ data, as it meant the facility was not accurately reporting staffing levels. The Administrator, who began working at the facility in March 2024, was unaware of the issue until it was brought up by the survey team. The failure to submit the PBJ data was recognized as a deficient practice, as it did not accurately reflect the staffing component necessary to meet residents' needs.
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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