Highland Pines Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Longview, Texas.
- Location
- 1100 N 4th St, Longview, Texas 75601
- CMS Provider Number
- 675133
- Inspections on file
- 35
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Highland Pines Nursing Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was allegedly slapped by an LVN during feeding, as witnessed by a CNA. The LVN denied hitting the resident, claiming she only moved his hands to prevent interference with his feeding tube. The incident was reported, and the resident showed no signs of distress or trauma. The LVN was terminated following an investigation.
A facility failed to provide adequate pressure ulcer care for three residents, leading to deficiencies in treatment. One resident's mattress was set incorrectly at 360 lbs, despite her actual weight being 240.3 lbs. Another resident, weighing 78 lbs, was found on a mattress set at 210 lbs. A third resident with multiple stage 4 pressure ulcers did not receive documented wound care on several occasions, and his mattress was set at 490 lbs, much higher than his actual weight of 134.6 lbs. Staff interviews revealed confusion about responsibility for mattress settings and wound care.
The facility failed to ensure proper catheter care for three residents, as catheter securement devices were not used, and a catheter bag was improperly placed on a bed during wound care. These actions could lead to urinary tract infections due to improper catheter management and infection control practices.
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in their care. A resident with chronic respiratory issues did not have a physician's order for oxygen therapy until surveyor intervention, and their oxygen concentrator filter was dirty. Another resident's CPAP mask was improperly stored, and their oxygen concentrator lacked a filter. A third resident's oxygen concentrator filter was not cleaned as required. Staff interviews revealed a lack of clarity on responsibilities for maintaining respiratory equipment, contributing to the deficiencies.
The facility failed to ensure safe and sanitary storage of food in residents' personal refrigerators, with one resident's fridge containing moldy meat and others lacking consistent temperature checks. Staff interviews revealed confusion over responsibilities, leading to potential health risks.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in infection control practices. Staff did not change gloves or perform hand hygiene during incontinent care for a resident, and enhanced barrier precautions were not implemented for residents with medical devices. Observations showed staff not wearing PPE during care, despite signs indicating the need for enhanced precautions. These lapses placed residents at risk of infection.
A facility failed to protect residents from abuse, resulting in deficiencies in care. A resident with moderate cognitive impairment reported feeling abused during bed baths by a CNA, who was described as rough and unwilling to assist. Another resident was slapped by a fellow resident with a history of aggression, and a third resident experienced unwanted touching by a roommate with a history of inappropriate behavior. The facility did not adequately address these incidents, leading to deficiencies in abuse prevention measures.
The facility failed to provide two residents with a SNF ABN upon discharge from Medicare Part A services, as required by regulation. Both residents, who had intact cognition, were not informed of potential out-of-pocket costs after their covered days ended. Interviews revealed a lack of awareness about the requirement to issue the SNF ABN, which is crucial for informing residents about their financial liability.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect coding of medications and diagnoses. One resident was misclassified as being on an antipsychotic and having bipolar disorder, while another's PASRR positive status was omitted. These errors were due to data entry mistakes and a lack of available coding options, highlighting the need for accurate assessments to ensure proper care.
A resident with schizophrenia was inaccurately marked as not having a mental illness in their PASRR Level I screening, despite having an active diagnosis and requiring psychotropic medication. The error was attributed to the hospital's incorrect marking, and facility staff displayed a lack of clarity regarding PASRR responsibilities. The facility's policy mandates screening for mental illness or intellectual disability before admission, which was not followed in this case.
A facility failed to notify the State Mental Health Authority of a significant change in a resident's mental condition after a PTSD diagnosis, neglecting to conduct a new PASRR Level 1 screening. Staff interviews revealed a lack of awareness that PTSD could necessitate a PASRR evaluation, contrary to facility policy requiring screenings for significant condition changes.
A facility failed to develop a comprehensive care plan for a resident requiring oxygen therapy, despite the resident's chronic respiratory conditions. The care plan did not address oxygen use, and a physician's order was missing until a state surveyor pointed it out. Staff interviews confirmed the oversight, highlighting the risk of unfamiliar staff being unaware of the resident's oxygen needs.
Two residents in a facility did not receive necessary care for personal hygiene and mobility. One resident experienced delayed incontinent care, leading to leakage, while another had inadequate oral hygiene and was not offered the chance to get out of bed. Staffing challenges were cited as a reason for these deficiencies.
A resident was found with Lidocaine patches in their personal refrigerator, which were not prescribed and should have been stored on the nurse's cart. Observations and staff interviews revealed confusion about who was responsible for checking and cleaning residents' refrigerators, leading to a failure in adhering to the facility's medication storage policy.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications due to missing documented diagnoses for several prescribed drugs. Interviews with staff revealed confusion over responsibility for documenting diagnoses, with the MDS Coordinator and nurse managers identified as responsible. The absence of documented diagnoses could lead to unnecessary medication use and inaccurate assessments.
A resident with moderate cognitive impairment and on hospice care had a PRN order for Lorazepam that exceeded the 14-day limit without physician re-evaluation. The facility staff, including the DON, were unaware of this oversight, which contradicts the facility's policy and regulatory requirements.
A long-term care facility reported a medication error rate of 14.81%, involving two residents who did not receive their prescribed medications. One resident missed their vitamin B-complex and received an incorrect dose of Vitamin D3, while another did not receive Oxybutynin and Protonix. The errors were due to miscommunication and unclear responsibilities between nursing staff and central supply regarding medication reordering.
A resident with severe cognitive impairment and chronic pain did not receive scheduled doses of Acetaminophen-Codeine due to a misunderstanding by a newly employed MA. The MA believed there was a discrepancy between the medication blister pack and the EMR order and did not notify a nurse for clarification. This resulted in the resident missing three doses, potentially increasing her anxiety and behaviors.
Two residents had medications improperly stored in their rooms, with Santyl, Mupirocin, and Triamcinolone ointments found unsecured on bedside tables. Staff interviews confirmed that medications should be stored on medication carts, not in resident rooms, as per facility policy. The deficiency highlights a failure to adhere to proper medication storage protocols.
The facility failed to report the results of an investigation into an alleged abuse incident between two residents to the state survey agency within the required 5 working days. The incident involved a resident alleging being hit by another resident, but both were confused and unable to recall details. The report was submitted one day late, and the facility lacked a specific policy for timely submission.
A facility failed to document foley catheter changes for a resident with obstructive and reflux uropathy, COPD, and benign prostatic hyperplasia. Despite having a care plan and physician's orders for monthly catheter changes, there was no documentation of changes from January to September 2024. Staff interviews revealed inconsistencies in documentation practices, with catheter changes only recorded if abnormalities were present. This lack of documentation could lead to staff being unaware of completed tasks, potentially risking urinary tract issues.
A resident with a history of traumatic brain injury and dementia, identified as high fall risk, was not adequately supervised, resulting in a fall. Despite interventions in her care plan, such as keeping the call light within reach, the resident was found on the floor, indicating these measures were not effectively implemented. Staff interviews revealed inconsistencies in fall prevention practices, contributing to the incident.
A resident with cognitive impairment and a history of wandering eloped from a facility and was found on a busy street in a wheelchair. The staff were unaware of the resident's absence and did not know how he left. The resident's care plan and elopement risk evaluations were not updated to reflect his increased risk, and the facility failed to implement adequate interventions to prevent his elopement.
A resident with severe cognitive impairment and a history of wandering was found in traffic after leaving the facility unnoticed. Despite increased confusion due to a UTI, the resident was not monitored closely, and the incident was not reported to the state agency as required. The facility believed the resident did not intend to elope, leading to a failure in reporting the incident.
Resident Abuse Incident Involving LVN
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) and a resident. On the morning of the incident, a Certified Nursing Assistant (CNA) heard the LVN being loud in the resident's room and subsequently witnessed the LVN slap the top of the resident's hands. The CNA reported that the slap was not a light tap but a hard hit, which was confirmed by another CNA who heard the skin-on-skin contact. The LVN claimed that she only moved the resident's hands to prevent him from interfering with his feeding tube, denying any hitting or slapping. The resident involved was an elderly male with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. He had a history of interfering with his feeding tube and was being fed by the LVN at the time of the incident. Despite the alleged abuse, the resident did not show signs of distress or recall the incident when questioned later. The facility's records indicated that the resident was assessed for physical injury and trauma following the incident, with no impairments or trauma found. The incident was reported to the Texas Health and Human Services Commission, and an investigation was conducted. Interviews with staff revealed that they were aware of the facility's abuse and neglect policies, including the requirement to report any suspected abuse and ensure the resident's safety. The LVN involved was terminated following the investigation, and the facility conducted in-service training on abuse and neglect for its staff.
Inadequate Pressure Ulcer Care and Mattress Setting Management
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their treatment. Resident #21, a 69-year-old female with multiple health issues including diabetes and chronic kidney disease, was observed lying on a pressure-relieving mattress set incorrectly at 360 lbs, despite her actual weight being 240.3 lbs. This discrepancy was noted during multiple observations, indicating a failure to adjust the mattress settings according to the resident's weight, as per the physician's orders. Resident #51, a 60-year-old female with severe cognitive impairment and weighing 78 lbs, was also found lying on a low air loss mattress set at 210 lbs. This incorrect setting was observed over several days, suggesting a lack of adherence to the physician's directive to check mattress settings every shift. The resident's care plan highlighted her risk for pressure ulcers due to fragile skin, yet the facility did not ensure the mattress settings were within the therapeutic range. Resident #79, a 55-year-old male with paraplegia and multiple stage 4 pressure ulcers, did not receive documented wound care on several occasions. His mattress was set at 490 lbs, significantly higher than his actual weight of 134.6 lbs. Interviews with staff revealed confusion and lack of responsibility regarding who should ensure correct mattress settings and perform wound care. The failure to perform wound care as ordered and document it properly could lead to delayed healing and increased risk of infection, as noted by the staff during interviews.
Failure to Ensure Proper Catheter Care and Securement
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, which could lead to urinary tract infections. Specifically, three residents with catheters did not have catheter securement devices to anchor the catheters to their legs over several days. This lack of securement was observed during multiple instances, where the catheter tubing was not anchored to the residents' thighs, increasing the risk of catheter movement and potential injury. Additionally, during a wound care session, a treatment nurse placed a resident's catheter bag on the bed, which is against infection control practices. The catheter bag should have been kept below the level of the bladder to prevent urine backflow, which can cause infections. The nurse acknowledged the mistake and the potential risks associated with improper catheter bag placement. Interviews with various staff members, including nurses and the interim administrator, revealed a lack of consistent practice in ensuring catheter securement devices were used. Staff members recognized the importance of these devices in preventing catheter-related injuries and infections but admitted to lapses in their application. The facility's catheter care policy emphasizes the need for securement devices and proper catheter bag placement, yet these guidelines were not consistently followed.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in their care. Resident #25, a male with chronic respiratory failure, heart failure, chronic obstructive pulmonary disease, and chronic pulmonary edema, did not have a physician's order for oxygen therapy until it was pointed out by a surveyor. Observations revealed that his oxygen concentrator filter was dirty, covered with gray and black debris, which was not addressed by the staff until after surveyor intervention. The Assistant Director of Nursing (ADON) admitted to not being aware of the dirty filter and acknowledged the risk of potential infection due to this oversight. Resident #15, a 96-year-old female with respiratory disorders, shortness of breath, chronic obstructive pulmonary disease, and obstructive sleep apnea, was found to have her CPAP mask improperly stored on the machine instead of in a bag, and her oxygen concentrator lacked a filter. These issues persisted over multiple observations, indicating a lack of adherence to proper storage and maintenance protocols for respiratory equipment. Interviews with staff revealed a lack of clarity on responsibilities for storing and maintaining the equipment, further contributing to the deficiency. Resident #16, a 71-year-old female with shortness of breath and congestive heart failure, had an oxygen concentrator filter with gray, fuzzy material on it, indicating it had not been cleaned as required. Despite having orders to change and clean respiratory equipment weekly, observations and interviews with staff showed that these tasks were not consistently performed. The staff acknowledged the importance of cleaning and storing equipment properly for infection control but admitted to lapses in following these protocols, which could affect the residents' oxygenation and increase the risk of infection.
Deficiency in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents' food items in personal refrigerators, affecting five residents. Specifically, Resident #72's refrigerator was found to be cluttered, unclean, and contained meat with green mold. Observations revealed ice build-up in the refrigerator, and interviews with staff indicated a lack of clarity regarding responsibility for checking and cleaning the refrigerators. Staff members acknowledged the potential health risks associated with the presence of moldy food, including the possibility of the resident becoming ill. Additionally, the facility did not consistently check and log the temperatures of personal refrigerators for Residents #42, #49, #51, and #81. Temperature logs were incomplete or missing for these residents, and interviews with staff revealed confusion about who was responsible for maintaining these logs. Housekeeping staff admitted to not always recording temperatures on the log sheets, and there was a lack of oversight to ensure that temperature checks were performed daily. The facility's policies required daily temperature checks and weekly cleanliness checks of personal refrigerators, but these procedures were not followed. Interviews with various staff members, including housekeeping, nursing, and administrative personnel, highlighted a lack of adherence to these policies, resulting in the potential for food spoilage and health risks to residents. The failure to maintain proper food storage practices could lead to foodborne illnesses among residents.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple deficiencies related to infection control practices. Specifically, the facility did not ensure that staff members changed gloves and performed hand hygiene appropriately during incontinent care for a resident with cognitive impairments and incontinence issues. Observations revealed that a CNA did not change gloves after cleaning the resident's front area before touching other items, which posed a risk of cross-contamination and infection. Interviews with staff confirmed that the CNA was aware of the proper procedure but failed to follow it due to nervousness. Additionally, the facility did not implement enhanced barrier precautions for several residents with medical devices such as feeding tubes, Foley catheters, and IV therapy. For instance, a resident with a feeding tube did not have an enhanced barrier precautions sign posted on the door, and staff were observed not wearing the required PPE during care. Another resident with a Foley catheter and a history of infections did not have proper PPE storage outside the room, and staff were not consistently using PPE during care. These lapses in infection control practices were acknowledged by staff, who cited a lack of awareness or understanding of the enhanced barrier precautions requirements. The facility's infection control program was further compromised by the absence of PPE usage during catheter care for a resident on enhanced barrier precautions. Staff members were observed performing catheter care without donning the necessary PPE, despite the presence of a sign indicating the need for enhanced precautions. Interviews with staff revealed a lack of adherence to the facility's infection control policies, with some staff members forgetting to wear PPE or being unaware of the updated protocols. The facility's failure to ensure consistent implementation of infection control measures placed residents at risk of exposure to communicable diseases and infections.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, resulting in deficiencies in care. Resident #21, a 69-year-old female with moderate cognitive impairment, reported feeling abused during bed baths by a CNA. She described the CNA as rough and unwilling to assist her, causing her pain and emotional distress. Despite informing a nurse about the situation, no action was taken, and the CNA continued to provide care in a manner that Resident #21 perceived as abusive. Resident #50, a 68-year-old male with moderate cognitive impairment, was involved in an altercation with another resident, Resident #70. Resident #70, who also had moderate cognitive impairment, slapped Resident #50 in the face after perceiving him as being mean to the staff. The incident occurred in the dining room and was witnessed by a nurse. Despite Resident #70's history of aggressive behavior, the facility failed to prevent the altercation, resulting in physical abuse of Resident #50. Resident #74, a female with intact cognition, experienced unwanted touching by her roommate, Resident #77, who was moderately cognitively impaired. Resident #77, who had a history of sexually inappropriate behavior, approached Resident #74 while naked and attempted to touch her. Although the incident was reported, the facility did not adequately address the situation, allowing Resident #77 to remain in the same room as Resident #74. This failure to separate the residents and prevent further incidents constituted a deficiency in the facility's abuse prevention measures.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to ensure that residents were informed of their Medicare/Medicaid coverage and potential liability for services not covered. Specifically, two residents were not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when they were discharged from skilled services before their covered days were exhausted. This notice is crucial as it informs residents that Medicare will no longer pay for skilled services, allowing them to understand potential out-of-pocket costs. The absence of this notice was confirmed through interviews and record reviews, indicating a lapse in the facility's adherence to regulatory requirements. Resident #274, a female with intact cognition, was admitted with conditions including embolism and thrombosis of arteries of the upper extremities and type 2 diabetes. She received Medicare Part A skilled services, but the facility did not provide her with a SNF ABN upon discharge. Similarly, Resident #275, also with intact cognition, was admitted with metabolic encephalopathy and chronic obstructive pulmonary disease. She too was not given a SNF ABN when her Medicare Part A services ended. Interviews with the social worker and interim administrator revealed a lack of awareness and understanding of the requirement to issue the SNF ABN, which is mandated by the facility's policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. For Resident #49, the MDS assessment inaccurately coded the resident as being on an antipsychotic medication and having a diagnosis of bipolar disorder. The resident was actually prescribed Depakote, an anticonvulsant, for a mood disorder, not an antipsychotic. The MDS Coordinator, who was new to the facility, misclassified the medication due to a lack of available coding options at the time and incorrectly coded the mood disorder as bipolar without supporting documentation. Resident #88's MDS assessment failed to reflect the resident's PASRR positive status for developmental disability, which was crucial for ensuring the resident received appropriate services. The MDS Coordinator responsible for this assessment admitted to a data entry error, acknowledging that the resident's PASRR status should have been included in the MDS to ensure the resident's needs were met. The oversight was identified during interviews with the MDS Coordinators and the Regional MDS Coordinator, who emphasized the importance of accurate MDS assessments. The report highlights the responsibility of the MDS Coordinators and the RN who signs off on the assessments to ensure accuracy. The facility's policy mandates adherence to RAI guidelines for MDS coding, but the errors in these cases suggest a lapse in following these procedures. The inaccuracies in the MDS assessments could potentially lead to residents not receiving the care they require, as the assessments are integral to planning and delivering appropriate care.
Inaccurate PASRR Level I Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident diagnosed with schizophrenia. The resident's PASRR Level I screening inaccurately indicated that the resident did not have a mental illness, despite having an active diagnosis of schizophrenia and requiring psychotropic medication. This discrepancy was identified during a review of the resident's records, which included a face sheet, quarterly MDS, and care plan. The MDS Coordinator acknowledged that the hospital had incorrectly marked the mental illness section as 'no' and had since completed the necessary form to rectify the error. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process. The social worker was unaware of which residents were receiving PASRR services, and the ADON expressed uncertainty about PASRR procedures. The MDS Coordinator and Regional Nurse indicated that the MDS nurse was responsible for ensuring PASRR forms were completed accurately. The facility's policy stated that all applicants should be screened for mental illness or intellectual disability before admission, but this was not adhered to in the case of the resident with schizophrenia.
Failure to Notify SMHA of Significant Change in Condition
Penalty
Summary
The facility failed to notify the State Mental Health Authority (SMHA) of a significant change in mental condition for a resident, specifically regarding the diagnosis of post-traumatic stress disorder (PTSD). This oversight was identified during a review of the resident's records, which showed that the resident was diagnosed with PTSD on a specific date, but the facility did not conduct a new Preadmissions Screening and Annual Resident Review (PASRR) Level 1 screening following this diagnosis. The resident's initial PASRR Level 1 screening, conducted upon admission, indicated no mental illness, intellectual disability, or developmental disability, and no subsequent screening was performed after the PTSD diagnosis. Interviews with facility staff revealed a lack of awareness that PTSD could necessitate a positive PASRR evaluation. The Regional MDS Coordinator and MDS Coordinator both indicated that they were unaware PTSD alone could trigger a PASRR requirement. The facility's policy requires a Level 1 screening for residents experiencing a significant change in condition, but this was not adhered to in this case. The failure to conduct a new PASRR evaluation could potentially affect the resident's access to necessary services, such as counseling, that could benefit their daily life.
Failure to Implement Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with chronic respiratory failure, heart failure, chronic obstructive pulmonary disease, and chronic pulmonary edema. Despite the resident's need for oxygen therapy, the care plan did not address his oxygen use. The resident was observed using oxygen via nasal cannula on multiple occasions, yet there was no physician's order for oxygen until it was pointed out by a state surveyor. The Assistant Director of Nursing (ADON) acknowledged the oversight and obtained the necessary order only after the surveyor's intervention. Interviews with facility staff, including the ADON, Director of Nursing (DON), Interim Administrator, and MDS Coordinator, revealed a consensus that the resident should have had a care plan for oxygen. The lack of a care plan posed a risk that unfamiliar staff might not be aware of the resident's need for oxygen, as it was not documented in the care plan. The facility's policy on care planning emphasized the importance of developing a comprehensive care plan based on individual assessed needs, which was not adhered to in this case.
Deficiencies in Personal Hygiene and Mobility Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for two residents, leading to deficiencies in care. Resident #81, a 75-year-old female with chronic respiratory failure and a need for assistance with personal care, did not receive timely incontinent care. On 10/15/24, she reported not being changed from 10 a.m. until 4 p.m., resulting in her brief leaking through her clothes and sheets. She mentioned that the CNA responsible for her care cited short staffing as the reason for the delay. Resident #88, a 59-year-old male with Asperger's syndrome and severe cognitive impairment, was observed with a yellow substance on his gum line and teeth on multiple occasions. Despite requiring substantial assistance for oral hygiene, the facility failed to ensure his oral care was adequately provided. Additionally, Resident #88 was not offered the opportunity to get out of bed throughout October 2024, despite expressing a desire to do so. The CNA responsible for his care admitted to not asking him if he wanted to get out of bed and cited staffing challenges as a barrier to providing the necessary assistance. Interviews with various staff members, including CNAs, LVNs, and the acting DON, revealed a lack of adherence to the facility's policies regarding incontinent care, oral hygiene, and encouraging residents to get out of bed. Staff acknowledged the importance of these care practices in preventing skin breakdown, maintaining oral health, and promoting socialization and physical activity. However, the facility's failure to implement these practices consistently resulted in deficiencies in the care provided to Residents #81 and #88.
Improper Medication Storage and Monitoring
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of drugs for one resident. Specifically, Resident #72 was found to have Lidocaine patches 5% strength stored in his personal refrigerator, which were not prescribed by a physician. The presence of these patches in the resident's possession was against the facility's policy, which mandates that medications should be stored securely and only accessible to authorized personnel. Observations over several days revealed that the Lidocaine patches remained in the resident's refrigerator, indicating a lack of monitoring and adherence to medication storage policies. Interviews with various staff members, including licensed vocational nurses (LVNs), restorative aides, assistant directors of nursing (ADONs), and housekeeping staff, highlighted confusion and inconsistency regarding the responsibility for checking and cleaning residents' refrigerators. Staff members acknowledged that residents should not have medications in their possession and that the patches should have been stored on the nurse's cart. The facility's policy on medication storage, revised in August 2020, clearly states that medications should be stored safely and only accessible to licensed personnel. However, the lack of clarity among staff about their roles in monitoring and cleaning refrigerators contributed to the oversight. The administrator and ADONs admitted to the need for a change in the monitoring process to prevent such incidents from occurring in the future.
Failure to Document Diagnoses for Medications
Penalty
Summary
The facility failed to ensure that Resident #21's drug regimen was free from unnecessary medications, as there were no documented diagnoses for several medications prescribed to the resident. These medications included Atorvastatin for hyperlipidemia, Furosemide and Lasix for heart failure, Gabapentin for neuropathy, Melatonin for insomnia, and Allopurinol for gout. The absence of documented diagnoses in the resident's medical records could lead to the resident receiving unnecessary medications. Interviews with facility staff revealed a lack of clarity and responsibility regarding the documentation of diagnoses for medications. Licensed Vocational Nurse (LVN) K mentioned that the MDS Coordinator was responsible for adding diagnoses to the resident's medical record, but there was no clear process for ensuring that all medications had appropriate diagnoses. The Assistant Director of Nursing (ADON) and the MDS Coordinator both acknowledged the importance of having accurate diagnoses linked to medications to prevent unnecessary medication use. The facility's failure to document appropriate diagnoses for Resident #21's medications was further highlighted by the Regional RN and the Interim Administrator, who both stated that the MDS Coordinator and nurse managers were responsible for ensuring that medications had appropriate diagnoses. The lack of documented diagnoses could lead to inaccurate assessments and the potential for unnecessary medication use, as noted by the staff during interviews.
Failure to Limit PRN Psychotropic Medication Order to 14 Days
Penalty
Summary
The facility failed to ensure that a resident's PRN order for the psychotropic medication Lorazepam was limited to fourteen days, as required by regulations. The resident, a male with moderate cognitive impairment and on hospice care, had a PRN order for Lorazepam to manage anxiety and restlessness. This order, initiated on August 29, 2024, did not have an end date and was not re-evaluated by a physician to determine if it should continue as a PRN or become a scheduled medication. The medication was administered twice in September 2024, but there was no documentation of a physician's rationale for extending the PRN order beyond the 14-day limit. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed a lack of awareness regarding the resident's PRN order for Lorazepam exceeding the 14-day limit. The DON acknowledged that PRN orders for psychotropic drugs should not exceed 14 days without a physician's documented rationale. The facility's Psychotherapeutic Drug Management Policy also stipulates that PRN orders for psychotropic drugs are limited to 14 days unless extended with documented justification. This oversight could place residents at risk of receiving unnecessary medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 14.81% due to four errors out of 27 opportunities. These errors involved two residents, one of whom did not receive their prescribed vitamin B-complex and was given an incorrect dose of Vitamin D3. The other resident did not receive their prescribed medications, Oxybutynin and Protonix, as ordered. These deficiencies were identified through observation, interviews, and record reviews. Resident #39, an elderly female with multiple diagnoses including cerebral infarction and type II diabetes, was not administered her prescribed vitamin B-complex and received an incorrect dose of Vitamin D3. The nurse responsible for her care noted that the vitamin was out of stock and had not been reordered. This oversight was attributed to a lack of clarity regarding who was responsible for restocking the vitamins, as well as a failure in communication between nursing staff and central supply. Resident #90, a male with a history of traumatic brain injury and intellectual disabilities, did not receive his prescribed medications for overactive bladder and GERD. Interviews with nursing staff and the administration revealed that there was confusion over the responsibility for reordering medications, with central supply handling over-the-counter and supplements, while nurses were expected to reorder prescription medications. This miscommunication and lack of timely ordering led to the medication errors observed.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Acetaminophen-Codeine Oral Tablet 300-60mg. The resident, a female with severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and chronic pain, was supposed to receive this medication three times a day for pain management. However, the medication was not administered as scheduled on three occasions due to a misunderstanding by a medication aide (MA) who thought there was a discrepancy between the medication blister pack and the electronic medical record (EMR) order. The MA, who had been employed at the facility for only a week, did not administer the medication on the specified dates because she believed the blister pack labeled Tylenol #4 did not match the EMR order for Tylenol #3. Despite being aware of the issue, the MA did not notify a nurse immediately to clarify the order, resulting in the resident missing three doses of her pain medication. This oversight was noted to have potentially increased the resident's anxiety and behaviors, as she exhibited signs of distress such as cussing and throwing water. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the acting Director of Nursing (DON), revealed that the MA did not report the missed doses to the appropriate personnel. The acting DON emphasized that the MA should have sought clarification from a licensed nurse and that the nursing staff is expected to administer medications as scheduled. The facility's medication administration policy requires resolving any discrepancies before administering medication, which was not adhered to in this case.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, allowing only authorized personnel access to the keys. This deficiency was observed in the cases of two residents. For one resident, Santyl and Mupirocin ointment 2% were found on the bedside table, not properly stored or locked as per professional standards. The resident, who was moderately cognitively impaired, did not recall where the medications came from and had a history of bringing outdated ointments from home to self-apply, against medical advice. In the case of the second resident, Triamcinolone Acetonide Ointment 1% was found on the bedside table without a prescription. The resident was cognitively intact but was not present in the room at the time of observation. Staff interviews revealed that medications should not be in resident rooms and should be stored on medication carts. However, the ointment was left unsecured, posing a risk of misuse by other residents or visitors. Interviews with various staff members, including CNAs, LVNs, and the ADON, confirmed that medications should be stored securely and not left in resident rooms. The facility's policy mandates that medications be stored safely and securely, accessible only to authorized personnel. Despite these policies, the medications were found unsecured, indicating a lapse in adherence to the facility's procedures for medication storage and security.
Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an investigation regarding an alleged abuse incident involving two residents to the state survey agency within the required 5 working days. The incident involved a resident who alleged that another resident hit her on the back after an argument. Both residents were confused and unable to recall the details or timing of the incident. A head-to-toe assessment revealed no injuries to the resident who made the allegation, and the investigation concluded that the allegation was inconclusive. The facility's administrator acknowledged that the provider investigation report was submitted to the state survey agency one day late, on the sixth day instead of within the required five days. The facility did not have a specific policy for submitting the provider investigation report within the required timeframe, other than the general abuse policy. The administrator, who was new to the position, confirmed that the report should have been submitted within the specified timeframe.
Failure to Document Foley Catheter Changes
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically by not documenting foley catheter changes. The resident, who was admitted with diagnoses including obstructive and reflux uropathy, COPD, and benign prostatic hyperplasia, used a foley catheter as indicated in their medical records. However, the care plan did not specify the frequency of catheter changes, and there was no documentation of catheter changes from January to September 2024. This lack of documentation was confirmed during interviews with facility staff, who acknowledged that catheter changes were not consistently recorded unless there were abnormalities. The facility's policy required documentation of catheter changes, including details such as the type and size of the catheter, urine characteristics, and any difficulties encountered. Despite this policy, the staff failed to document the catheter changes, which could lead to other staff being unaware of whether the task had been completed. Interviews with the Director of Nursing and the Administrator confirmed that it was the responsibility of the nursing staff to ensure catheter changes were documented, and the failure to do so could place residents at risk for urinary tract problems.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as high fall risk. The resident, a female with a history of traumatic subdural hemorrhage, dementia, depression, seizures, muscle wasting, and reduced mobility, was admitted to the facility with a severely impaired cognitive status. Her care plan indicated she was at high risk for falls due to confusion and required substantial assistance with self-care and mobility. Despite these assessments, the resident was not monitored closely enough, leading to a fall incident. The resident's care plan included interventions such as keeping the call light within reach, providing a safe environment, and educating the resident and family about safety. However, during an incident, the resident was found on the floor by LVN E, indicating that these interventions were not effectively implemented. The resident complained of head pain after the fall, suggesting a potential injury. Interviews with staff revealed that the resident did not have a fall mat next to her bed, and there was uncertainty about whether the call light was within reach at the time of the fall. The facility's policy on fall prevention emphasizes evaluating residents for fall risk upon admission and developing appropriate interventions. However, the staff interviews indicated inconsistencies in the implementation of these policies. The DON and other staff members expressed differing opinions on the use of fall mats and the placement of high-risk residents, which may have contributed to the inadequate supervision and subsequent fall of the resident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident identified as confused and a wanderer. This resident, who had a history of cognitive impairment and was at risk for elopement, was found on a high-traffic street in a wheelchair. The facility staff were unaware of the resident's elopement and did not know how he left the facility. The resident had a history of wandering into other residents' rooms and had been recently confused due to a urinary tract infection (UTI). The resident's care plan and elopement risk evaluations were not adequately updated to reflect his increased risk of elopement. Despite being identified as having an imminent risk for elopement, the facility did not implement sufficient interventions to prevent the resident from leaving the premises. The staff failed to monitor the resident closely, and there was a lack of communication and coordination among the staff regarding the resident's whereabouts and condition. Interviews with staff revealed that there was confusion about how the resident managed to leave the facility. It was suggested that the resident might have exited with a family that was moving another resident's belongings, but no alarms were heard, and no staff witnessed the resident leaving. The facility's investigation into the incident was incomplete, and the administrator did not initially report the incident to the state agency, believing the resident did not intend to elope.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a resident who was found in traffic on a busy street, which was a violation of the requirement to report alleged violations involving abuse, neglect, exploitation, or mistreatment immediately. The resident, who was severely cognitively impaired and identified as a wanderer, was not monitored closely despite increased confusion. The facility did not report the incident to the Health and Human Services Commission (HHSC) when the resident was discovered in traffic, placing the resident at risk for harm. The resident, an elderly male with a history of cognitive communication deficit, muscle weakness, unsteadiness on feet, lack of coordination, and stroke, was admitted to the facility with a BIMS score indicating severe cognitive impairment. Despite being identified as a wanderer and having a wander guard in place, the resident was able to leave the facility unnoticed. The facility's records indicated that the resident had a history of wandering into other residents' rooms and using their bathrooms, but there was no indication of an increased risk for elopement until the incident occurred. On the day of the incident, the resident was seen self-propelling in his wheelchair around the facility, and staff noted his increased confusion due to a urinary tract infection. However, the facility failed to monitor him adequately, and he was able to leave the building, possibly unnoticed by staff due to a family moving another resident's belongings. The police found the resident in the street and returned him to the facility, but the facility did not report the incident to the state agency as required, as they did not believe the resident intended to elope.
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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