Hilltop Village Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Kerrville, Texas.
- Location
- 1400 Hilltop Rd, Kerrville, Texas 78028
- CMS Provider Number
- 455628
- Inspections on file
- 31
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Hilltop Village Nursing And Rehabilitation during CMS and state inspections, most recent first.
A CNA removed towels and briefs from a resident's room without informing or seeking permission, despite the resident's cognitive intactness and care plan interventions for hoarding behavior. The resident became upset and expressed that the CNA did not communicate or explain the removal of her belongings. Nursing staff confirmed that there was no directive to remove these items and that such actions were not in line with resident rights or facility policy.
A resident's family reported to staff that an agency CNA provided rough care during toileting, leaving the resident visibly upset. The DON was informed but did not report the incident to the Administrator or state agency, interpreting it as rudeness rather than potential abuse. The incident was not documented or investigated as required by policy, and the Administrator only learned of the event after surveyor intervention.
A facility failed to investigate and document an allegation of rough care after a resident's family reported that an agency CNA was rough during toileting. The DON did not interview the resident or CNA, did not document the incident, and did not report it to the Administrator, contrary to facility policy. The Administrator only learned of the incident after surveyor intervention, and no investigation was initiated until that point.
A CNA failed to use a gait belt while transferring a resident who required maximum assistance, instead pulling the resident up by her pants during a transfer from the commode to a wheelchair. The resident, who had muscle weakness and urge incontinence, became upset, and family members reported the incident to staff. The facility did not have a policy for one-person or gait belt transfers, contributing to the deficiency.
Four residents with physician orders to self-administer medications were not properly assessed or care planned for this practice, and their ability to safely self-administer was not consistently evaluated by the interdisciplinary team. Medications were stored in unsecured locations, and some residents had medications not ordered for self-administration. Staff interviews revealed a lack of verification and documentation regarding whether self-administered medications were actually taken as ordered, and the DON was unaware of these lapses.
Four residents with physician orders for self-administration of medications were found storing their medications in unsecured locations such as unlocked drawers and on top of bedside tables. Interviews confirmed this was their usual practice, and the facility's policy did not address secure storage for these medications. The DON acknowledged the issue, and the deficiency was identified through observation, interviews, and record review.
A female resident with intact cognition and a history of anxiety and depression was subjected to unwanted sexual exposure by a male resident with severe dementia and chronic wandering. The incident was reported by the resident to multiple staff, but an LVN dismissed the allegations and failed to notify leadership or initiate an investigation. The event only came to the attention of facility leadership after a third-party review, revealing a breakdown in abuse reporting and protection protocols.
A resident with intact cognition reported to staff that another resident exposed himself and masturbated at her doorway on multiple occasions. Despite these allegations being communicated to a CNA and an LVN, the incidents were not promptly reported to facility leadership or the State Survey Agency as required. The LVN dismissed the reports, and the administrator only became aware of the situation through a third-party, leading to a delayed investigation and lack of timely documentation or external reporting.
A resident with respiratory and mobility issues who required partial assistance for showering was left unsupervised by a CNA, resulting in the resident independently exiting the bathroom after waiting for help that did not arrive. The CNA admitted to leaving residents alone during showers, contrary to facility policy, and the incident was confirmed by an LVN and the DON.
A resident with asthma, COPD, and sleep apnea regularly used both oxygen and CPAP therapy, but the facility did not have active physician's orders or care plan interventions for CPAP therapy, and lacked orders for oxygen use while in the facility. Nursing staff and the DON confirmed these omissions, and facility policy requires such orders and care planning for respiratory care.
A resident with cognitive communication deficit was not served her lunch meal while others at her table were eating, leading to feelings of being left out. Despite previous training, staff failed to serve meals table by table, as acknowledged by the Administrator and ADON.
Several residents in a long-term care facility did not receive their scheduled showers due to staffing shortages. These residents, who required assistance with bathing, were left without care, leading to discomfort and a loss of dignity. The facility was short-staffed, with some staff members not showing up for their shifts, which resulted in missed showers and inadequate documentation.
A resident with cognitive and physical impairments was unable to reach their call light during a meal because it was wedged between the wall and mattress. This deficiency was observed when the resident attempted to call for assistance and was confirmed by a CNA who had to retrieve the call light. Interviews with staff, including the DON, highlighted the expectation that call lights should be within reach at all times, as per the facility's policy on assistive devices.
The facility failed to maintain a clean and homelike environment for a resident who had food residue on her wall, and in a hallway where a large barrel was used to contain a ceiling leak. The resident, with moderate cognitive impairment, was observed in a room with a dirty wall, and the hallway setup obstructed residents' movement, causing dissatisfaction.
Two residents in a LTC facility were found to have inaccurate MDS assessments. One resident was incorrectly documented as receiving an anticoagulant instead of an antiplatelet, while another resident's range of motion limitations were not accurately reflected, despite having contractures. These inaccuracies were confirmed by staff and could lead to inadequate care.
The facility failed to coordinate assessments with the PASRR program for two residents. One resident's PASRR Level 1 Screening did not reflect a developmental disability related to Multiple Sclerosis, and another resident's screening did not accurately reflect their mental illness. These discrepancies were confirmed by the MDS nurse, indicating a lack of adherence to the facility's policy requiring prompt referral for Level II resident reviews.
A resident with dysphagia was served a regular diet instead of a mechanically soft diet, and her preference against gravy was not accommodated, leading to decreased food intake. The CDM was unaware of the preference, and the dietary department was not informed of updated diet orders following the resident's hospital stay. This oversight in communication resulted in the resident receiving an incorrect diet.
A resident was prescribed a regular diet but was served a mechanical soft diet with gravy, which she disliked. Despite voicing her preference, the meal ticket was not updated, and the dietary department was not informed of the correct diet order. The DON confirmed the oversight in communication between nursing and dietary staff.
The facility failed to provide necessary special eating equipment for two residents during meal service, affecting their dignity and feeding independence. One resident, with severe cognitive impairment, was observed eating without a plate guard, resulting in food spillage. Another resident, with moderate cognitive impairment, struggled to eat without a divided plate. Staff interviews revealed that the required equipment was on back order, and the facility did not have enough available to meet residents' needs.
A LTC facility failed to maintain an effective infection control program, as evidenced by two incidents. A Medication Aide did not sanitize a blood pressure cuff between two residents, and a CNA failed to change gloves or wash hands while providing incontinent care. Both staff members acknowledged their oversights, despite having received infection control training. The DON confirmed the lapses in adherence to the facility's infection control policies.
The facility failed to meet the required square footage per resident in 15 rooms, with each room measuring between 72.4 and 76.4 square feet instead of the required 80 square feet for multiple resident rooms. The deficiency was confirmed during a survey, and the DON noted that some rooms were intended for single occupancy despite being certified for two residents.
The facility failed to protect residents from verbal abuse by staff, involving an RN and an OT. The RN was reported to have verbally abused two residents, making inappropriate comments about medication and personal hygiene. An OT called a resident a liar and contacted their previous employer, upsetting the resident. These incidents were witnessed by other staff members, and the facility's administrator stated that abuse is not tolerated.
A resident in an LTC facility missed 25 doses of Doxycycline due to a transcription error by an LVN, who entered the medication order incorrectly. The MAR confirmed the absence of administration, and a doctor's note suggested the resident's symptoms were likely neurological. The DON verified the error after a change in facility ownership.
Failure to Respect Resident's Personal Space and Belongings
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident's room, supplies, and personal space with respect, contrary to the resident's rights to dignity and self-determination. The resident, a cognitively intact female with chronic obstructive pulmonary disease, major depressive disorder, and generalized anxiety disorder, was known to require supervision for showering and set-up assistance for dressing. The care plan also noted a history of hoarding towels and linens, with interventions focused on positive interaction and calm communication. The incident began when the CNA removed approximately ten towels from the resident's room without informing or seeking permission from the resident, who was outside on a smoke break at the time. The CNA stated that towels were removed due to facility shortages and that this was a routine practice when supplies were low. The CNA also admitted to previously removing briefs from the resident's room, leaving only a small supply, and did not notify or seek direction from nursing staff before doing so. The CNA acknowledged being trained on resident rights and the importance of seeking permission before entering a resident's room or taking belongings but did not follow this protocol in this instance. The resident expressed distress and frustration over the removal of her towels and briefs, stating that the CNA did not ask before taking the items and that it made her feel upset and unsure of the CNA's intentions. Interviews with nursing staff confirmed that there was no directive to remove towels or briefs from resident rooms and that such actions were not appropriate. The facility's policy emphasized treating residents with kindness, respect, and dignity, and staff interviews reiterated that residents have the right to their belongings and to be asked before items are removed from their rooms.
Failure to Timely Report Allegation of Rough Care and Potential Abuse
Penalty
Summary
The facility failed to report an allegation of rough care and possible abuse involving a resident, as required by federal and state regulations. The incident involved a cognitively intact female resident who required maximum assistance with transfers and was being assisted by an agency CNA. The resident's family reported to staff that the CNA had provided rough care during toileting, specifically stating that the CNA pushed the resident down onto the toilet and wiped her roughly, which left the resident visibly upset. The family initially reported the incident to another CNA (who was also the facility scheduler), who then informed the DON. The DON did not speak directly to the resident and did not report the incident to the Administrator or the state survey agency, as required by policy and regulation. The DON interpreted the family's complaint as an issue of rudeness and improper use of a gait belt, rather than as a potential abuse allegation. The DON removed the CNA from caring for the resident but did not initiate a formal report or investigation as required. The CNA involved was allowed to continue working in the facility for at least one additional day before being sent home. The incident was not documented in the facility's self-reported incidents system, and there was no evidence that the Administrator was informed until surveyors intervened and began asking questions. Interviews with staff and the Administrator revealed confusion and inconsistency regarding what was reported and how it was handled. The Administrator only became aware of the incident after surveyor intervention and stated that she would have expected the DON to report the incident if it had been described as abuse. The facility's abuse policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation of resident property, but this policy was not followed in this case. The failure to report the allegation in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate and Document Allegation of Rough Care
Penalty
Summary
The facility failed to thoroughly investigate and document an allegation of rough care and treatment for one resident. The incident involved a cognitively intact female resident who required maximum assistance with transfers and had a care plan indicating the need for one staff member to assist with toileting and transfers. The resident's family reported concerns that an agency CNA provided rough care during toileting, specifically stating the CNA pushed the resident down onto the toilet and was rough when wiping. The family reported the incident to a staff member, who then informed the DON. However, there was no documentation of a formal investigation, and the facility's grievance records did not reflect the complaint. Interviews revealed inconsistencies in staff responses and actions. The CNA scheduler, who was informed of the incident by the family, reported the matter to the DON but did not directly notify the Administrator. The DON stated she did not consider the incident to be abuse, did not interview the resident or the CNA involved, and was unable to produce any documentation or notes regarding the incident, stating that any notes had been shredded. The DON also did not report the incident to the Administrator, as required by facility policy. The Administrator only became aware of the incident after being questioned by a surveyor and confirmed that no investigation had been initiated prior to surveyor intervention. The facility's policy requires all reports of abuse, neglect, or mistreatment to be thoroughly investigated and documented, with findings reported to appropriate agencies. In this case, the facility did not follow its own policy, as there was no evidence of a thorough investigation or documentation of the incident involving the resident. The lack of investigation and documentation could place residents at risk by failing to address and resolve allegations of abuse or neglect.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA), identified as agency staff, failed to use a gait belt while transferring a resident who required maximum assistance with transfers. The resident, a cognitively intact female with diagnoses including generalized muscle weakness and urge incontinence, was care planned to require one-person assistance and the use of a gait belt for transfers and toileting. Despite this, the CNA assisted the resident from the commode to a wheelchair without a gait belt, instead pulling the resident up by her pants, which caused distress to the resident and concern from her family members. Family members reported that the CNA was rough during the transfer and did not use the gait belt that was available in the room. The resident was visibly upset after the incident, and family members relayed their concerns to facility staff. The facility scheduler and the Director of Nursing (DON) were both informed of the incident, with the DON confirming that a gait belt should have been used for safety during transfers. The CNA admitted to not using a gait belt and described assisting the resident by pulling her up by her pants due to the resident's foot getting stuck and her knee locking during the transfer. Further review revealed that the facility did not have a policy in place for one-person or gait belt transfers. The DON acknowledged that agency staff were not provided with additional training and that the facility relied on removing agency staff who did not meet expectations. The lack of a clear policy and failure to ensure the use of appropriate transfer techniques led to the deficiency in providing adequate supervision and assistance devices to prevent accidents.
Failure to Assess, Monitor, and Care Plan for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents with physician orders for self-administration of medications were properly assessed, monitored, and care planned for this practice. Four residents with orders to self-administer medications were not consistently evaluated by the interdisciplinary team for their ability to safely self-administer, and their care plans did not include interventions or focus areas related to medication self-administration. In several cases, documentation of assessments was missing, outdated, or not present in the residents' electronic medical records, and care plan meetings did not reflect discussion or planning for self-administration. Observations revealed that residents were storing medications in unsecured locations, such as unlocked dresser drawers or on top of bedside tables, and in some cases, residents possessed medications that were not ordered for self-administration. For example, one resident had two medications in his possession without physician orders for self-administration and reported difficulty applying a topical medication to an area not specified in the physician's order. Another resident was found with over-the-counter eye drops not prescribed by the facility physician and was unable to articulate the appropriate use of the medication. Interviews with staff, including the DON and nursing staff, indicated a lack of consistent verification and documentation regarding whether self-administered medications were actually being taken as ordered. Staff reported that there was no process for documenting self-administration on the MAR, and verification of administration was not routinely performed. The DON was unaware of these gaps in practice and acknowledged that care plans should include planning for self-administration of medications. The facility's policy required that the interdisciplinary team and physician determine a resident's capacity for self-administration, but this was not consistently implemented.
Failure to Secure Self-Administered Medications in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used by residents with physician orders for self-administration were stored in locked compartments, as required by regulation. Four residents with intact cognition and various medical conditions, including neuralgia, neuropathy, asthma, glaucoma, and chronic pain, were observed storing their self-administered medications in unsecured locations within their rooms. Specifically, medications were found in unlocked dresser drawers, unlocked nightstand drawers, and on top of bedside tables and nightstands, making them accessible to others. Interviews with the residents confirmed that these unsecured storage methods were their usual practice. The Director of Nursing (DON) acknowledged that four residents had physician orders to self-administer medications and stated that staff believed medications were safely stored by keeping them out of reach. However, the DON also indicated that residents were instructed not to keep medications in visible or easily accessible places, which was inconsistent with the observed practices. A review of the facility's policy on self-administration of medications revealed that it did not address the storage of medications in residents' rooms. The lack of secure storage for self-administered medications was identified through direct observation, resident interviews, and record review, demonstrating a failure to prevent unintended access to medications by other residents.
Failure to Protect Resident from Sexual Abuse and Inadequate Reporting
Penalty
Summary
A deficiency occurred when the facility failed to protect a female resident with a history of anxiety disorder, depression, and recent joint replacement from abuse, specifically unwanted sexual exposure by another male resident with severe cognitive impairment and a history of wandering. The female resident reported that the male resident entered her room in a wheelchair and masturbated in front of her. She disclosed the incident to multiple staff members, expressing distress and fear. Documentation in her progress notes confirmed her reports of the male resident's behavior on two consecutive nights. Despite the resident's reports, the staff response was inadequate. A CNA who received the allegations reported them to an LVN on at least two occasions, but the LVN dismissed the concerns, attributing them to confusion and did not escalate the report to facility leadership as required. The LVN did not speak to the resident about the allegations or initiate any investigation, and there was no immediate notification to the administrator or abuse coordinator. The incident only came to the attention of facility leadership after a third-party professional discovered documentation of the event during a chart review, significantly delaying the facility's awareness and response. The male resident involved had a documented history of chronic wandering and was previously observed engaging in sexually inappropriate behavior in a communal area. However, there was no evidence that the facility implemented additional behavioral interventions or supervision in response to these behaviors prior to the incident. The facility's policies required prompt investigation and reporting of abuse allegations, but these procedures were not followed, resulting in a failure to ensure the resident was free from abuse and to report the incident in accordance with federal guidelines.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported within the required two-hour timeframe to the administrator and State Survey Agency (SSA), as mandated by federal and state regulations. Specifically, a female resident with a history of anxiety disorder, depression, and recent joint replacement surgery reported to staff that a neighboring male resident had exposed himself and masturbated at her doorway on multiple occasions. The resident was cognitively intact at the time, as indicated by a recent BIMS score of 15. Despite the resident reporting these incidents to multiple staff members, including a CNA and an LVN, the allegations were not promptly reported to facility leadership or the SSA. The CNA who received the initial reports from the resident stated that she informed the LVN on at least two separate occasions, but the LVN was dismissive and attributed the allegations to resident confusion. The LVN did not report the allegations to the administrator or initiate an investigation, believing the matter was already known or not credible. The social worker only became aware of the incident through a third-party professional and subsequently notified the administrator and initiated an assessment. The administrator confirmed that she was not notified by staff and only began an investigation after being informed by the social worker, well after the initial allegations were made. The facility's internal investigation confirmed the identity of the alleged perpetrator, a male resident with severe cognitive impairment and a history of wandering and inappropriate behavior. However, the incident was not documented in the facility's incident report log for the relevant month, and there was no evidence that the incident was reported to the SSA as required. Interviews with facility leadership revealed uncertainty about reporting requirements and a lack of immediate notification procedures, despite existing policies mandating prompt reporting of abuse allegations.
Resident Left Unsupervised During Shower
Penalty
Summary
A deficiency occurred when a resident with diagnoses including asthma, COPD, lack of coordination, muscle weakness, and unsteadiness on feet, who required partial assistance for showering, was left unsupervised in the shower by a CNA. The resident reported being assisted into the shower and then left alone, after which he used the call light for help but did not receive a response. The resident experienced difficulty breathing due to the heat and humidity and, after waiting approximately 20 minutes, independently ambulated to his wheelchair and exited the restroom without assistance. Interviews confirmed that the CNA left the resident unsupervised to assist another resident or obtain supplies, despite facility policy requiring supervision during showers. The resident reported the incident to an LVN, who confirmed the resident's account. The CNA acknowledged leaving residents unsupervised at times and recognized the potential for harm, such as slipping. The DON confirmed awareness of the incident and facility policy against leaving residents unsupervised during bathing.
Failure to Ensure Physician Orders and Care Planning for Respiratory Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with multiple respiratory diagnoses, including asthma, COPD, and obstructive sleep apnea. The resident was observed to use both an oxygen concentrator and a CPAP device, and confirmed using the CPAP every night and oxygen as needed. However, a review of the resident's medical record revealed there were no active physician's orders for CPAP therapy or for oxygen use while at the facility, despite evidence of regular use. The care plan only addressed PRN oxygen use and did not mention CPAP therapy or its maintenance. Interviews with nursing staff and the DON confirmed that the resident should have had signed physician's orders and care planning for CPAP therapy, and that staff should be monitoring the application of respiratory devices. Facility policy also requires verification of physician's orders and review of the care plan prior to oxygen administration. The lack of appropriate orders and care planning for the resident's respiratory therapies constituted a failure to provide care consistent with professional standards and the resident's comprehensive care plan.
Resident Not Served Lunch Promptly
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not serving her lunch meal while other residents at her table were eating. On the specified date, Resident #94, who had a cognitive communication deficit and required setup assistance for eating, was observed without her lunch meal while two other residents at her table were already eating. A fellow resident had to signal the nursing staff to indicate that Resident #94 had not been served. Resident #94 expressed that this situation occurred frequently, although she could not specify how often, and stated that she felt left out when it happened. The facility's Administrator and Assistant Director of Nursing (ADON) acknowledged during an interview that serving residents table by table was important for quality of care. They admitted that this issue had been a problem in the past, and staff had been trained to serve all residents at a table before moving to the next. However, they speculated that the nursing staff might have been nervous due to the presence of the state agency, despite knowing the correct procedure. The facility's policy on dignity, revised in February 2021, emphasized that residents should be treated with dignity and respect at all times.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary services to maintain good personal hygiene. Specifically, five residents did not receive their scheduled showers on a particular day due to staffing issues. These residents were dependent on staff for assistance with bathing, and the failure to provide this care could lead to a loss of dignity and diminished quality of life. Resident #9, a male with intact cognition but incontinent of bowel and urine, did not receive a shower on the scheduled day. His care plan required extensive assistance with bathing three times a week. Similarly, Resident #36, a female with quadriplegia and intact cognition, was scheduled for showers three times a week but missed her scheduled shower due to short staffing. She expressed discomfort and sadness due to the lack of care. Other residents, including Resident #19, who had osteoarthritis and diabetes, and Resident #13, with multiple sclerosis and dementia, also missed their scheduled showers. The facility was short-staffed on the day in question, with several staff members not showing up for their shifts. This led to a situation where the available staff could not meet the residents' needs, resulting in missed showers and inadequate documentation of care provided.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to communicate their needs to the staff. During an observation, the resident was found sitting up in bed with their lunch meal, and when asked by the surveyor how they would normally get staff's attention, the resident attempted to reach for the call light. However, the call light was wedged between the wall and the mattress, making it inaccessible to the resident. This situation was confirmed when a CNA entered the room and had to pull the call light out from its wedged position. The resident in question had been admitted with diagnoses including Hemiplegia and Hemiparesis following a cerebral infarction affecting the right dominant side, and vascular dementia. The resident's care plan indicated a communication problem, requiring staff to anticipate their needs. Interviews with facility staff, including a CNA and the DON, confirmed that the call light should always be within the resident's reach, and it was the nursing staff's responsibility to ensure this. The facility's policy on assistive devices and equipment also supports the need for such devices to be accessible to residents to aid in their mobility, safety, and independence.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident #17, who was observed with food residue on the wall next to her bed. Despite the resident's habit of wiping her hands on the wall, the housekeeping staff did not adequately clean the area, as confirmed by observations and interviews with staff members. The resident, who has moderate cognitive impairment and requires assistance with personal hygiene, was found in a room with a dirty wall on multiple occasions. The housekeeping supervisor was informed of the issue, but improvements were minimal. Additionally, the facility did not ensure a homelike environment in the D-wing hallway, where a large industrial barrel was placed to contain a ceiling water leak. This setup obstructed the hallway and affected residents' ability to move freely, as noted by residents and staff. The barrel, positioned under a dripping ceiling, was a temporary solution that had been in place for about two weeks, causing inconvenience and dissatisfaction among residents. The maintenance director acknowledged the issue and considered using a smaller container to minimize obstruction.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks for inadequate care. Resident #7's quarterly Minimum Data Set (MDS) inaccurately documented the resident as receiving an anticoagulant medication, when in fact, the resident was receiving Clopidogrel, an antiplatelet medication. This error was confirmed by the MDS nurse, who acknowledged that Clopidogrel should not have been coded as an anticoagulant. The MDS nurse had access to the Resident Assessment Instrument (RAI) for reference but did not utilize it correctly in this instance. Resident #51's quarterly MDS inaccurately reflected that the resident did not have upper or lower range of motion limitations, despite having contractures in both upper and lower extremities. This inaccuracy was confirmed through observation and interviews, where the resident expressed limited mobility in his limbs. The MDS Coordinator acknowledged the inaccuracy and emphasized the importance of accurate MDS assessments to ensure residents receive the necessary assistance, as the MDS drives the care plan. The Director of Nursing stated that a review of the MDS and care plans would be conducted.
Failure to Coordinate PASRR Assessments
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program under Medicaid, specifically for two residents reviewed for PASRR. Resident #29's PASRR Level 1 Screening did not accurately reflect a diagnosis of developmental disability related to Multiple Sclerosis, despite the resident having been diagnosed with Multiple Sclerosis on 01/29/2022. The care plan for Resident #29 indicated a physical functioning deficit related to Multiple Sclerosis, but the PASRR Level 1 Screening showed no evidence of mental illness, intellectual disability, or developmental disability. This discrepancy was confirmed during an interview with the MDS nurse, who was unaware if the PASRR 1 had been updated after the resident's admission. Similarly, Resident #13's PASRR Level 1 Screening did not accurately reflect the resident's mental illness, despite a diagnosis of schizoaffective disorder, bipolar type, and Multiple Sclerosis. The PASRR Level 1 Screening for Resident #13 was positive for mental illness but did not include evidence of intellectual or developmental disability. The MDS nurse confirmed that Resident #13 had a Mental Illness/Dementia Review, despite the diagnosis of mental illness and Multiple Sclerosis. The facility's policy requires prompt referral for a Level II resident review for any resident with a newly evident or possible intellectual disability or related condition, which was not adhered to in these cases.
Failure to Provide Correct Diet and Accommodate Food Preferences
Penalty
Summary
The facility failed to provide a mechanically soft diet to a resident who required it due to oropharyngeal phase dysphagia, instead serving a regular diet during a lunch meal. Additionally, the resident had expressed a preference against gravy, which was not accommodated, leading to decreased food intake. The resident, who was cognitively intact, had previously communicated this preference to staff, but it was not reflected in her meal ticket. The Certified Dietary Manager (CDM) was unaware of the resident's preference and stated that gravy was part of the mechanical soft diet recipe, which was believed to prevent choking hazards. The Director of Nursing (DON) and the CDM acknowledged that the resident should have been on a regular diet following a hospital stay, but the dietary department had not been informed of the updated diet orders. The facility's policy on therapeutic diets emphasizes that diets should align with residents' informed choices and preferences, but this was not adhered to in this case. The oversight in communication between nursing staff and the dietary department resulted in the resident being served an incorrect diet, which could potentially affect other residents with specific diet orders.
Failure to Provide Prescribed Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was prescribed and provided to a resident as ordered by the attending physician. Specifically, a resident who was prescribed a regular diet was instead provided with a mechanical soft diet during lunch on 07/09/24. This discrepancy was observed when the resident expressed dissatisfaction with the meal, particularly due to the presence of gravy, which was not to her preference. The resident had previously communicated her dislike for gravy to the staff, but no action was taken to adjust her meal preferences accordingly. The resident's meal ticket incorrectly reflected a mechanical soft diet, which included gravy, contrary to the doctor's order for a regular diet. The issue was further compounded by a lack of communication between the nursing staff and the dietary department. The Director of Nursing (DON) confirmed that the nursing staff failed to provide the necessary communication form to update the dietary department about the resident's prescribed regular diet. The Certified Dietary Manager (CDM) was unaware of the resident's diet change until after the incident, indicating a breakdown in communication and adherence to the facility's policy on therapeutic diets. The facility's policy requires that diets be determined in accordance with the resident's informed choices and physician's orders, which was not followed in this case.
Failure to Provide Special Eating Equipment for Residents
Penalty
Summary
The facility failed to provide necessary special eating equipment and utensils for two residents during meal service, which could affect their dignity and feeding independence. Resident #21, who has severe cognitive impairment and dysphagia, was observed eating without a plate guard, resulting in food spilling onto her clothes. Despite her care plan and meal ticket indicating the need for a plate guard, staff did not provide one, and it was noted that the dietary manager mentioned they were on back order. Similarly, Resident #63, with moderate cognitive impairment and a history of stroke, was observed struggling to eat without a divided plate, which was part of her dietary requirements. Staff interviews revealed that the facility did not have enough divided plates available, and they were also on back order. The deficiency was further highlighted by staff interviews, where it was revealed that the dietary manager had ordered the necessary equipment weeks prior, but they were still awaiting delivery. The facility's policy on assistive devices and equipment, which mandates the provision and supervision of such devices for resident independence and safety, was not adhered to. The lack of available equipment and the failure to ensure residents had the necessary tools for eating compromised the residents' ability to eat independently and maintain their dignity.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving improper care practices. In the first incident, a Medication Aide did not sanitize a blood pressure cuff between using it on two residents. This oversight was confirmed by the Medication Aide, who acknowledged forgetting to disinfect the cuff, despite having received infection control training within the year. The Director of Nursing (DON) also confirmed that the cuff should have been sanitized between uses to prevent cross-contamination. In the second incident, a Certified Nursing Assistant (CNA) failed to change gloves or wash hands while providing incontinent care to a resident. The CNA touched a bed remote with gloved hands and then proceeded to provide care without changing gloves or sanitizing hands. Additionally, the CNA handled both soiled and clean incontinent pads with the same gloves. The CNA admitted to realizing the mistake after the fact and confirmed having received infection control training within the year. The DON confirmed that the CNA should have changed gloves and sanitized hands after touching contaminated surfaces. Both incidents highlight lapses in adherence to the facility's infection control policies, which require cleaning and disinfecting reusable items between residents and proper hand hygiene practices. The facility's policies, dated 2001 and 2019, respectively, emphasize the importance of these practices to prevent the transmission of infections.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide bedrooms that met the required square footage per resident, as specified by regulations. Specifically, 15 out of 99 rooms were found to be deficient in size, with each room measuring between 72.4 and 76.4 square feet per resident, instead of the required 80 square feet for multiple resident rooms. This deficiency was identified during a survey conducted on July 20, 2024, where measurements were taken and confirmed by the Maintenance Director. The rooms in question were certified for two beds each, yet they did not meet the necessary space requirements. During an interview, the Director of Nursing (DON) mentioned that certain rooms were designated as small and were intended for single occupancy, although they were certified for two residents. The DON was unable to clarify the meaning of the acronym SCU, which was used to label these rooms. A review of the facility's documentation, including Form 3740 and an undated list of rooms with insufficient square footage, confirmed the deficiency. This failure could potentially impact the quality of life for residents by limiting space for personal effects and movement within their rooms.
Verbal Abuse Incidents Involving Staff and Residents
Penalty
Summary
The facility failed to ensure residents' right to be free from verbal abuse, affecting three of the seven residents reviewed for abuse. Specifically, RN A was reported to have verbally abused two residents. In one incident, RN A was witnessed telling a resident that they wanted to spray them with Ativan spray because they were getting on their nerves. In another instance, RN A told a different resident that they couldn't get clean because the staff were busy feeding others. These incidents were corroborated by a CNA who witnessed RN A's behavior. Additionally, the facility failed to protect another resident from verbal abuse by an occupational therapist (OT). The OT was reported to have called the resident a liar and proceeded to verify the resident's past employment by contacting their previous employer, which upset the resident. This incident was witnessed by a physical therapy assistant (PTA) staff member. The facility's administrator, who was not familiar with these incidents due to a recent change in ownership, stated that abuse is not tolerated. The facility's abuse and neglect policy prohibits any form of abuse, including verbal abuse.
Medication Transcription Error Leads to Missed Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the error involved the transcription of a medication order for Doxycycline, an anti-infective prescribed for epididymitis. The Licensed Vocational Nurse (LVN) responsible for transcribing the order incorrectly entered it to be administered every 21 days instead of for 21 days. As a result, the resident missed 25 doses of the medication over a period from early to mid-April. A review of the Medication Administration Record (MAR) confirmed the absence of Doxycycline administration during this time frame. Additionally, a doctor's note from mid-April indicated a trial of Doxycycline for possible epididymitis, although the physician noted that the resident's symptoms were likely neurological and not related to any physical abnormalities. The Director of Nursing (DON), who was not in the position at the time of the incident, verified the missing medication doses upon review.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
