Heritage Gardens Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Carrollton, Texas.
- Location
- 2135 N Denton Dr, Carrollton, Texas 75006
- CMS Provider Number
- 675111
- Inspections on file
- 40
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Heritage Gardens Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A cognitively impaired female resident with a history of cerebral infarction, bipolar disorder, memory deficit, and identified risk for psychosocial issues and re-traumatization was sexually touched over her clothing in the genital area by a cognitively impaired male resident with vascular dementia and other neurologic and mood disorders while they sat together in the dining room without staff present. Another resident witnessed the incident and reported it to the Administrator, and both the DON and Administrator later acknowledged being informed by an unidentified staff member of an allegation that the male resident touched the female resident’s private area. However, the female resident’s EMR contained no progress notes, incident reports, or witness statements about the allegation, demonstrating a failure to protect the resident from abuse and to document and address the reported incident.
The facility failed to report an allegation of sexual abuse between two cognitively impaired residents as required by regulation and its own abuse policy. A resident witness reported seeing one resident place a hand between another resident’s legs and touch the genital area in the dining room when no staff were present. The DON and Administrator acknowledged being informed of the allegation by staff but did not report it externally, citing both residents’ low BIMS scores, confusion, and their denials of the incident. No related progress notes, incident reports, or witness statements were found in the EMR, despite policy requiring immediate internal and external reporting of all abuse allegations.
The facility failed to investigate an allegation that a cognitively impaired male resident in the dining area touched a cognitively impaired female resident in her private area. Both residents had severe cognitive impairment and multiple neurologic and psychiatric diagnoses, and were care planned for significant ADL and cognitive deficits. The Administrator, acting as abuse coordinator, reported that the residents were separated and the male resident was placed on 1:1 and later discharged, but there was no documentation in either resident’s EMR of an abuse investigation or 1:1 monitoring. Interviews with leadership confirmed that no investigation had been completed, despite facility policy requiring immediate nursing examination, documentation, and prompt, thorough investigation of all abuse allegations.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A CNA did not change gloves or perform hand hygiene after providing incontinence care to a resident with dementia and mobility deficits. The CNA was aware of the required infection control procedures but did not follow them, as confirmed by both the Infection Preventionist and DON. This failure was observed and verified against the facility's handwashing policy.
Two nurse aides provided direct care to residents for several months without obtaining CNA certification, despite completing training and skills checkoffs. Facility staff were unclear about the 120-day certification requirement and responsibilities for tracking certification status, resulting in unqualified personnel performing resident care tasks beyond the permitted training period.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, on several occasions. The absence of an RN on these days, as confirmed by the DON, left residents at risk of inadequate medical care. The facility's procedure mandates daily RN services, which were not met.
The facility failed to ensure five residents could exercise their right to vote in the election cycle. Residents were not informed about voting options, and the Activity Director's efforts to obtain mail-in ballots were insufficient and undocumented. The Operations Manager also failed to document interactions and did not plan for in-person voting, leading to unmet mental and psychosocial needs.
The facility failed to prepare pureed meals to the required pudding consistency, resulting in pieces of pork and corn in the meals served to residents on pureed diets. The cook did not check the consistency before serving, and the Dietary Manager confirmed the error, which could pose a choking risk.
The facility failed to ensure five residents could exercise their voting rights in the current election cycle. Residents were not informed or assisted in voting, leading to dissatisfaction. The Activity Director and Operations Manager acknowledged inadequate efforts and lack of documentation. The facility's policy did not address voting rights, contributing to the oversight.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents involving residents. An LVN did not adhere to enhanced barrier precautions when administering medication to a resident with a gastrostomy tube, failing to wear a gown as required. Another LVN did not follow proper infection control protocols during wound care for a resident with a pressure ulcer, neglecting to change gloves and perform hand hygiene. Both incidents highlight lapses in infection control practices, despite training being provided.
A facility failed to change a piston syringe daily for a resident with a feeding tube, as required by physician orders and facility policy. The resident, who was cognitively impaired and had a history of dysphagia, was at risk due to the staff's failure to adhere to the protocol, as confirmed by observations and staff interviews.
A facility failed to include dialysis in the baseline care plan for a newly admitted resident with end-stage renal disease, despite physician orders for hemodialysis five times a week. The DON confirmed that the care plan worksheet did not have an option for dialysis, leading to a lack of necessary instructions for effective and person-centered care.
A resident with end-stage renal disease missed a scheduled dialysis session due to miscommunication between the facility and the dialysis provider. The resident was admitted late in the evening, and the facility failed to ensure she was on the dialysis schedule for the following day, contrary to physician orders.
The facility failed to store food properly, as observed by surveyors who found withered and spotted produce, open and undated items in the freezer, and exposed dry goods. The Dietary Supervisor confirmed daily checks were conducted but acknowledged the risk of foodborne illness due to improper storage. The facility's policy and FDA guidelines emphasize preventing food contamination.
The facility failed to maintain an effective pest control program in Hall 300, where fruit flies were observed in several residents' rooms. Residents reported flies around their food, leading to refusal to eat at times. Staff acknowledged the issue, which persisted despite regular pest control services. Maintenance confirmed monthly pest control visits, but no specific treatment for flies was recorded recently.
The facility failed to provide necessary supervision and assistance for two residents, leading to deficiencies in their grooming and personal care. A resident with dementia and a history of stroke was left unsupervised with a razor, contrary to her care plan. Another resident with Parkinson's disease and moderate cognitive impairment was observed using the bathroom without required staff supervision, increasing her fall risk. These actions were against the facility's policy to maintain residents' well-being.
A resident with an indwelling urinary catheter was observed with the drainage bag touching the floor and overfilled, contrary to the facility's care plan and policy. Staff interviews revealed that CNAs were responsible for maintaining the catheter bag, supervised by nurses, but the bag was not properly managed, posing an infection risk. Despite training, the deficiency persisted, indicating a failure in implementing catheter care procedures.
The facility failed to maintain a safe environment in Shower Room A, where a resident reported experiencing cold showers. Maintenance checks revealed the water temperature did not exceed 77 degrees, below the required 100 to 110 degrees. Despite weekly checks showing compliant temperatures, no complaints were reported to the DON or Administrator. The maintenance director or designee is responsible for overseeing water temperature checks.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to recognize, document, and respond appropriately to an allegation of sexual abuse between residents. On 01/25/2026, video evidence showed a male resident (Resident #2), who had severe cognitive impairment and diagnoses including vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit, placing his hand between a female resident’s (Resident #1) legs and touching her private area over her pants while they were in the dining room. Resident #1 also had severe cognitive impairment with diagnoses including cerebral infarction, bipolar disorder, and memory deficit, and her care plan identified risks related to impaired cognitive function, psychosocial well-being, and re-traumatization due to a history of trauma from other resident violence. At the time of the incident, no staff were present in the dining room, as confirmed by another resident (Resident #3) who witnessed the event. Despite the allegation being reported to the Administrator by a resident witness and to the DON and Administrator by an unidentified staff member around the end of January 2026, the facility’s records for Resident #1 contained no progress notes, incident reports, or witness statements regarding the abuse allegation. The Administrator, who served as the abuse coordinator, and the DON both acknowledged being informed of an incident in which Resident #2 attempted or was alleged to have touched Resident #1 in her private area, but neither could recall which staff member reported it. When interviewed, Resident #1, who was alert and willing to speak but severely cognitively impaired, denied remembering anyone touching her inappropriately. The lack of documentation and investigation in the EMR, combined with the absence of staff supervision at the time of the incident, formed the basis of the cited failure to ensure the resident’s right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse between residents to the State Agency and other required authorities, as mandated by regulation and facility policy. Resident #1 was a cognitively severely impaired female with a history of cerebral infarction, bipolar disorder, memory deficit, left-sided paralysis, TIA, depression, fall risk, social isolation, and a documented care plan entry indicating risk for re‑traumatization related to prior trauma from other resident violence. Resident #2 was a cognitively severely impaired male with vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit. Both residents had care plans reflecting significant cognitive and functional impairments. A third resident (Resident #3) reported witnessing Resident #2 place his hand between Resident #1’s legs and touch her private area while they were seated together in the dining room, with no staff present at the time. The DON stated she was informed toward the end of January that Resident #2 attempted to touch Resident #1 while they were in the dining room. She reported that the incident was reported by a staff member, though she could not recall who, and that she did not consider the allegation valid because both involved residents denied the incident when questioned. Based on this, she did not report the allegation to the State. The Administrator, who served as the abuse coordinator, stated he was informed by a staff member (whom he could not identify) that Resident #2 touched Resident #1 in her private area while they were in the dining room. He confirmed that the residents were separated and that Resident #2 was placed on 1:1 and later transferred, but he did not report the allegation to the State Agency, citing both residents’ low BIMS scores, confusion, and the fact that Resident #2 was in the process of being transferred. When interviewed, Resident #1 denied being touched or hurt and was unable to recall any inappropriate touching. Review of Resident #1’s EMR revealed no progress notes, incident reports, or witness statements regarding the allegation, despite the facility’s written abuse policy requiring that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate State or Federal agencies within applicable timeframes.
Failure to Investigate Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving one cognitively impaired female resident and one cognitively impaired male resident. The female resident had severe cognitive impairment and diagnoses including cerebral infarction, bipolar disorder, memory deficit, TIA, depression, left-sided paralysis, and a history of falls and psychosocial well-being problems. The male resident also had severe cognitive impairment and diagnoses including vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit, and was care planned for risks related to altered neurological status, depression, and impaired cognitive function. The Administrator, who served as the abuse coordinator, reported being informed by an unidentified staff member that the male resident touched the female resident in her private area while they were in the dining area. He stated that the residents were separated, the male resident was placed on 1:1 monitoring, and then discharged and transferred to another facility the following day. Despite the Administrator’s statement that he completed an investigation, there was no documentation of any abuse investigation or 1:1 monitoring in either resident’s EMR. The DON indicated that the Administrator should have a copy of the investigation, but none was available in the records reviewed. The corporate Administrator later confirmed that an investigation had not been completed and that work on an investigation would begin at that time. Review of the facility’s abuse policy showed that all allegations of abuse were to be promptly and thoroughly investigated by the Administrator or designee, that a licensed nurse was to immediately examine the resident and document findings in the medical record, and that all identified events were to be reported to the Administrator immediately. Record review and interviews showed that these required investigative steps and documentation were not carried out for the alleged sexual abuse incident involving these two residents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before applying a clean brief. This action was observed while the resident, who was in bed, awake, alert, and confused, received care. The CNA acknowledged awareness of the required procedures but chose not to follow them due to concerns about the resident playing with water in the sink. The resident involved had a history of stroke, non-Alzheimer's dementia, and was occasionally incontinent of bowel and bladder. The resident was severely cognitively impaired and had a self-care performance deficit related to dementia and decreased mobility. Both the Infection Preventionist and the Director of Nursing confirmed that staff are required to change gloves and perform hand hygiene after cleaning a resident, as outlined in the facility's handwashing policy. The failure to adhere to these procedures was identified through observation, interviews, and record review.
Failure to Ensure Nurse Aide Certification and Competency
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) demonstrated competency in the skills and techniques necessary to care for residents, as required by resident assessments and care plans. Specifically, two nurse aides, NA A and NA B, were employed and provided resident care for more than four months without obtaining certification as Certified Nurse Assistants (CNAs). Both NAs completed their training and skills checkoffs, but there was no documentation of CNA certification, and their status remained 'Prospective' on the state portal. Timesheet reviews confirmed that both NAs worked regular shifts and provided direct care to residents beyond the allowed 120-day period for certification. Interviews with staff revealed a lack of clarity and oversight regarding the certification process and the 120-day requirement. NA A reported technical difficulties in registering for the CNA test and was unaware of the exact timeframe for certification. The DON and Operations Manager both indicated they had only recently become aware of the 120-day requirement, and there was confusion about who was responsible for tracking certification deadlines. The staffing coordinator and HR Director also expressed uncertainty about their roles in ensuring timely certification, and the corporate CNA trainer stated that while she tracked training start dates, the facility was responsible for monitoring certification deadlines. Facility documentation, including the employee handbook and job descriptions, outlined the responsibility of maintaining current credentials and described the NA position as a training role leading to CNA certification. Despite this, both NA A and NA B worked independently and performed resident care tasks similar to those of certified CNAs, with the only noted restriction being documentation. The lack of proper certification and oversight resulted in unqualified staff providing care to residents, as identified through interviews and record reviews.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified for 7 specific days within a 61-day review period. The facility was unable to provide evidence of RN coverage on these dates, which included several Sundays and a Saturday. The absence of an RN on these days placed all residents at risk of not receiving adequate medical care and supervision. Interviews and record reviews revealed that the Director of Nursing (DON) acknowledged the lack of RN coverage on the specified dates. The DON indicated that typically an RN is scheduled for at least 8 hours each day, but on these occasions, only Licensed Vocational Nurses (LVNs) were working. The DON was uncertain about the oversight that led to the absence of RNs on these days, suggesting a lapse in communication or scheduling with the staffing coordinator. The facility's procedure and guidance require RN services to be provided daily, which was not adhered to during the identified dates.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility failed to provide medically related social services to ensure that five residents could exercise their right to vote in the current election cycle. During a confidential group interview, the residents revealed that they were not asked if they wanted to vote or informed about how they could vote while living in the facility. They expressed their desire to vote and their disappointment at not being able to participate in the election. The Activity Director attempted to obtain mail-in ballots and communicated with residents about voting during a bingo activity, but lacked documentation of these efforts and did not follow up adequately. The Operations Manager acknowledged that the responsibility for ensuring residents could vote was assigned to the Activity Director. However, the Operations Manager also failed to document interactions with residents regarding voting and did not make plans for in-person voting. The Operations Manager admitted that only initial attempts were made to facilitate voting and recognized the need for better follow-up. The facility's Resident Rights and Responsibilities policy did not address residents' voting rights, contributing to the deficiency in meeting the residents' mental and psychosocial needs.
Failure to Prepare Pureed Meals Correctly
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of residents requiring pureed diets. During the lunch service, pureed rosemary roast pork and pureed corn were not prepared to a pudding consistency as required. Observations revealed that the pureed roasted pork contained pieces of pork, and the pureed corn contained pieces of corn and corn skin, indicating that the food was not fully blended to the necessary smooth consistency. Interviews with the staff involved revealed that the cook responsible for preparing the pureed meals did not check the consistency of the food before serving. The cook admitted to using a hand blender and sometimes a robot blender, but on this occasion, she did not ensure the food was fully pureed before serving. The Dietary Manager confirmed that the expectation was for pureed food to have a smooth, pudding-like consistency and acknowledged that the cook had mistakenly used gravy from the regular texture menu, which contributed to the presence of chunks in the pureed meal.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility failed to ensure that five residents were able to exercise their right to vote in the current election cycle. During a confidential group interview, the residents expressed that they were not asked if they wanted to vote or informed about how they could vote while living in the facility. They emphasized the importance of voting and expressed dissatisfaction with not being able to participate. The Activity Director attempted to facilitate mail-in voting but lacked documentation and follow-up, and the Operations Manager acknowledged the lack of adequate efforts to assist residents in voting. The Activity Director mentioned voting during a bingo activity but did not document the details or follow up with residents. The Operations Manager also failed to document interactions with residents regarding voting and did not make arrangements for in-person voting. The facility's Resident Rights and Responsibilities policy did not address voting rights, contributing to the oversight. Both the Activity Director and Operations Manager recognized their shortcomings in ensuring residents could exercise their voting rights.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not adhere to enhanced barrier precautions when administering medication to a resident with a gastrostomy tube. Despite a sign indicating the need for gown and gloves, the LVN only donned gloves and not a gown, which was required for high-contact care activities. The LVN admitted to being unaware of the need for such precautions for residents with a gastrostomy tube, despite having received training on enhanced barrier precautions. In the second incident, another LVN did not follow proper infection control protocols during wound care for a resident with a pressure ulcer. The LVN failed to change gloves and perform hand hygiene after removing the old dressing and before cleansing the wound. This oversight was acknowledged by the LVN, who attributed it to nervousness and a lack of specific training on wound care, despite having attended infection control training. The Assistant Director of Nursing (ADON) confirmed that the expected procedure was not followed, which could lead to cross-contamination and infection. Both incidents highlight lapses in the facility's infection control practices, particularly in the use of personal protective equipment and adherence to hand hygiene protocols. The Director of Nursing (DON) and ADON both expressed expectations for staff to follow these protocols to prevent the spread of infection, indicating that training had been provided, but the practices were not consistently implemented by the staff involved.
Failure to Change Piston Syringe Daily for Tube Feeding
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. Specifically, the facility did not ensure that the piston syringe used for flushing the resident's G-tube was changed daily as required. Observations revealed that the piston syringe on the resident's bedside table was dated two days prior, indicating it had not been changed as per the physician's orders and facility policy. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Licensed Vocational Nurse (LVN) confirmed that the piston syringe should be changed every shift to prevent infections, but this protocol was not followed in this instance. The resident in question was a cognitively impaired male with a history of dysphagia following a cerebral infarction, necessitating the use of a feeding tube. The resident's care plan and physician orders explicitly stated that the piston syringe should be changed every shift and rinsed after each use. Despite these directives, the facility staff failed to adhere to the protocol, as evidenced by the undated syringe observed during the survey. Interviews with the nursing staff revealed a lack of consistent monitoring and adherence to the policy, which could lead to unsanitized treatment and potential infections for the resident.
Failure to Include Dialysis in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included necessary instructions for dialysis, which is crucial for effective and person-centered care. The resident, a [AGE] year-old female with multiple diagnoses including end-stage renal disease, was admitted to the facility and required hemodialysis five times a week. However, the baseline care plan and the initial care plan did not include any focus area for dialysis, despite physician orders indicating the need for this treatment. The Director of Nursing (DON) confirmed that the care plan worksheet used by the facility did not have an option for dialysis and did not allow for additional information to be added. The DON acknowledged the importance of including specialized services like dialysis in the baseline care plan to ensure a true reflection of the care and services required by the resident. The facility's policy on Comprehensive Person-Centered Care Planning mandates that a baseline care plan be developed within 48 hours of admission, including minimum healthcare information necessary to properly care for each resident. The omission of dialysis from the baseline care plan indicates a failure to meet these professional standards of quality care, potentially affecting the continuity of care and communication among nursing home staff.
Failure to Provide Scheduled Dialysis Treatment
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received the treatment as ordered by the physician. The resident, a female with multiple diagnoses including end-stage renal disease, was admitted to the facility late in the evening. Despite the physician's order for dialysis five times a week from Monday to Friday, the resident missed her scheduled dialysis on Friday due to miscommunication between the facility and the dialysis provider. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the resident was not on the dialysis schedule for Friday, and the hospital paperwork did not specify when the last dialysis session was conducted. The resident's admission was delayed, and the night shift nurse reported that the resident had received dialysis on the day of admission, leading to the missed treatment the following day. Interviews with the DON, ADON, and the dialysis provider's RN revealed that the resident's late admission and the lack of clear communication about her last dialysis session contributed to the oversight. The Administrator acknowledged the miscommunication and confirmed that the resident missed her dialysis session on Friday, which was against the physician's orders. The facility's policy on dialysis care emphasized the importance of maintaining homeostasis and ongoing communication with the dialysis provider, which was not adhered to in this case.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage of food items in the kitchen. During an inspection, surveyors observed several issues in the facility's refrigerator, freezer, prep table, and dry storage areas. Specifically, the refrigerator contained withered tomatoes and tomatoes with white spots, as well as heads of cabbage with black spots. In the freezer, a box of country fried beef steak was found open and exposed to air, along with undated bags of chicken and fries. Additionally, the prep table had a white onion with black spots, and the dry storage area contained an open container of corn flakes exposed to air. The Dietary Supervisor, during an interview, stated that both he and the dietary staff were responsible for daily checks to ensure proper food storage, using a first in, first out system. He acknowledged that improper food storage could lead to residents being exposed to foodborne illnesses. The facility's policy on infection control in dietary services, dated October 2022, emphasized the prevention of food contamination to avoid foodborne illnesses. The Food and Drug Administration Food Code of 2017 was also referenced, highlighting the requirement for food to be stored in a clean, dry location, protected from contamination.
Ineffective Pest Control in Hall 300
Penalty
Summary
The facility failed to maintain an effective pest control program, specifically in Hall 300, where fruit flies were observed in multiple residents' rooms. During observations and interviews, residents reported the presence of fruit flies, which were seen around their food and personal items. One resident mentioned that the flies were so pervasive that they would sometimes refuse to eat. Staff members, including an LVN and a housekeeper, acknowledged the issue, noting that the flies had been present for several weeks. The facility's pest control service agreement indicated regular pest control services, but there was no record of treatment specifically targeting flies in the past month. Despite a recent inspection report stating no pest activity in common areas, the issue persisted in Hall 300. Maintenance staff confirmed that a pest control company visited monthly, but residents continued to report problems with flies in their living areas.
Deficiencies in Resident Supervision and Assistance
Penalty
Summary
The facility failed to provide necessary supervision and assistance for two residents, leading to deficiencies in their grooming and personal care. Resident #34, a female with dementia, depression, schizophrenia, and a history of stroke, required supervision for activities of daily living (ADLs) due to her cognitive and physical impairments. Despite this, she was observed handling a razor unsupervised, which she was not supposed to have due to safety concerns. The Activity Director, unaware of the risk, provided her with a razor, and she was left alone in the bathroom, contrary to her care plan that required supervision to prevent self-harm. Resident #54, a female with hypertension, Parkinson's disease, and moderate cognitive impairment, required extensive assistance with toileting. However, she was observed using the bathroom without staff supervision, which was against her care plan that mandated one-person assistance due to her fall risk. Interviews revealed inconsistencies in the staff's understanding of her supervision needs, with some staff leaving her unattended based on her perceived condition at different times of the day. This lack of consistent supervision led to her toileting herself when staff did not respond to her call light, increasing her risk of falls. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain their well-being. However, the failure to adhere to care plans and provide adequate supervision for Residents #34 and #54 demonstrated a lapse in following this policy. The Director of Nursing acknowledged the need for supervision and assistance for both residents, highlighting the risk of injury due to inadequate care.
Inadequate Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency in preventing urinary tract infections. The resident, an elderly male with multiple diagnoses including a stage 4 pressure ulcer, mild cognitive impairment, and urinary retention, was observed with his Foley catheter drainage bag touching the floor and filled beyond capacity. This was noted on multiple occasions, indicating a lack of adherence to the care plan and facility policy, which required the catheter bag to be kept off the floor and emptied regularly. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN), revealed that the responsibility for ensuring the catheter bag was not overfilled and off the floor was assigned to Certified Nursing Assistants (CNAs) and supervised by nurses. However, the staff acknowledged that the catheter bag was not maintained properly, which was not acceptable and posed an infection control issue. The ADON and LVN admitted to having received training on catheter care, but the LVN was unsure about attending recent in-service training sessions. The Director of Nursing (DON), who had recently assumed the position, confirmed the observations and acknowledged the deficiency. The DON stated that the expectation was for staff to monitor catheter bags throughout their shifts to prevent them from touching the floor or becoming too full. Despite monthly in-service training on catheter care, the deficiency persisted, highlighting a gap in the implementation of the facility's policies and procedures regarding catheter management.
Facility Fails to Maintain Safe Water Temperature in Shower Room
Penalty
Summary
The facility failed to maintain a safe environment for residents using Shower Room A, as the water temperature was not at a comfortable level. During a confidential resident council meeting, a resident reported experiencing cold showers and had informed staff, although they could not recall the specific staff members. The resident mentioned having three cold showers in the month and expressed unwillingness to continue with cold showers. On inspection, Maintenance L checked the water temperature in Shower Room A and found it did not exceed 77 degrees, which is below the required range of 100 to 110 degrees for resident areas. Maintenance L stated that water temperatures were checked weekly and could be adjusted, although no complaints had been received since the summer. The facility's policy requires weekly water temperature checks, and records showed temperatures ranging from 103 to 110 degrees. Interviews with the DON and Administrator revealed no resident complaints had been reported to them, and the Administrator confirmed that the maintenance director or designee was responsible for overseeing water temperature checks.
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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