Hollymead
Inspection history, citations, penalties and survey trends for this long-term care facility in Flower Mound, Texas.
- Location
- 4101 Long Prairie Road, Flower Mound, Texas 75028
- CMS Provider Number
- 676369
- Inspections on file
- 32
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hollymead during CMS and state inspections, most recent first.
Multiple residents did not have comprehensive, person-centered care plans addressing their specific medical, nursing, and psychosocial needs, including conditions such as ADHD, diabetes with insulin dependence, ADL dependence, and fall risk. Staff interviews and record reviews confirmed that care plans were missing, incomplete, or not updated in a timely manner, resulting in the potential for unmet care needs.
Several residents dependent on staff for ADL care were found with excessively long, dirty, and untrimmed fingernails, despite facility policies and care plans requiring regular nail care. Staff interviews revealed inconsistent understanding of responsibilities, and some staff admitted to not noticing or addressing the issue. Care plans often lacked specific interventions for personal hygiene, resulting in unmet needs for grooming and hygiene among residents.
A resident with a history of stroke and hemiplegia, who had a contracture in her left hand, did not receive consistent application of prescribed splints or range of motion interventions. Staff were unaware of the care plan requirements, and necessary tasks were not included on CNA task lists. Documentation of splint use and restorative care was lacking, resulting in a failure to provide appropriate treatment and services to prevent further decline in the resident's range of motion.
Nursing staff failed to ensure the secure storage and proper handling of controlled medications, as multiple blister packs containing tramadol tablets were found with broken seals and pills still inside, including one instance where a broken blister was taped over. Staff did not consistently check blister pack integrity during narcotic counts, and the facility's policy requiring the discarding of medications from broken blisters was not followed.
Surveyors found that a packet of frozen pork and vegetable eggrolls was stored in the kitchen freezer without proper covering, labeling, or dating, contrary to facility policy and FDA Food Code. Staff interviews confirmed that all kitchen staff were responsible for ensuring food items were covered and labeled, and acknowledged the risks of cross-contamination and foodborne illness from such lapses.
Two residents did not have required physician orders for immediate care needs, including oxygen therapy and colostomy care, despite receiving these treatments. Staff interviews and record reviews confirmed that orders were missing from the medical record, and facility policy requires such orders for all treatments.
Two residents did not have their current conditions and diagnoses accurately reflected in their MDS assessments, including a missing colostomy status and an omitted ADHD diagnosis, despite supporting documentation and staff awareness. Staff interviews revealed the omissions were not identified during assessment completion, and a transition to a new electronic health record system may have contributed to the errors.
A CNA failed to use a gait belt while transferring a resident with severe cognitive impairment and mobility issues, instead lifting the resident by her clothes and under her arms, causing the resident pain. This action was not in accordance with the resident's care plan or facility policy, both of which required the use of a gait belt for transfers.
A resident with a suprapubic catheter and bowel incontinence did not receive proper perineal and catheter care, as a CNA failed to clean under skin folds, separate the labia, or clean around the catheter site, and an RN did not maintain sterile technique during catheter reinsertion, allowing urine to drain onto the resident's side. These actions did not follow facility policies and increased the risk of infection.
Staff failed to follow infection control protocols for two residents, including not wearing required PPE during catheter care for a resident with an indwelling device and not performing proper glove changes and hand hygiene during incontinence care for another resident. These lapses were observed during direct care and confirmed through staff interviews and policy review.
A resident with multiple health conditions was administered the wrong G-tube formula, Fibersource HN 1.2, instead of the prescribed Isosource 1.5, due to a nurse's failure to verify the physician's order. This error could lead to inadequate nutrition as the resident is NPO and fully dependent on the G-tube for nutrition.
A resident with a G-tube under Enhanced Barrier Precautions (EBP) did not receive proper infection control measures when an LVN failed to don a gown while administering G-tube feeding. Despite EBP signage and facility policy requiring gowns and gloves for high-contact care, the LVN only wore gloves. The DON confirmed the policy and the necessity of PPE to prevent infections.
A resident with a history of metabolic encephalopathy, vascular dementia, and multiple fractures experienced severe pain during repositioning, which was not adequately managed by the facility. Despite having a care plan for pain management, there were gaps in documentation and assessment, leading to unrelieved pain. Staff interviews revealed inconsistent communication and documentation, resulting in the resident's pain being unaddressed until a hospital evaluation identified a right subcapital hip fracture.
A facility failed to maintain a resident's dignity by allowing a caregiver to stand over the resident while assisting with a meal. The resident, who had multiple medical conditions and required extensive assistance, was observed being fed by a caregiver standing at her bedside. The DON and Administrator were unaware of this practice, and the facility lacked a specific policy on feeding residents, despite having a policy on treating residents with respect and dignity.
A resident requiring extensive assistance with personal hygiene was found with unclean and untrimmed fingernails, despite facility policies stating that nail care is part of the bathing process. Interviews revealed that CNAs were responsible for nail care unless the resident was diabetic, highlighting a lapse in adherence to care protocols.
A resident with COPD was found with unlabeled and undated nasal cannula tubing, contrary to physician orders and care plan requirements. An LVN admitted to changing the tubing without labeling it due to time constraints and did not document the change in the MAR. The DON and Nursing Manager acknowledged the risk of infection control issues due to the lack of proper labeling, although no formal policy was in place.
A resident with moderately impaired cognition and wrist concerns was not provided a divided plate as ordered, affecting her ability to eat independently. Despite the physician's order and the resident's expressed need, the facility failed to ensure the adaptive device was available, leading to the resident consuming only a portion of her meal. Staff interviews revealed a lack of communication and adherence to the facility's policy on providing necessary adaptive equipment.
A facility failed to maintain an infection control program when two CNAs did not perform proper hand hygiene while providing care to a resident with severe cognitive impairment and hemiplegia. The CNAs did not change gloves or perform hand hygiene between tasks, despite being aware of the protocols. The DON confirmed the expectation for hand hygiene to prevent infection spread.
A resident in an LTC facility missed two doses of Hydromorphone due to the facility's failure to have the medication available. Despite the resident's multiple diagnoses and need for pain management, the medication was not administered as scheduled. Staff interviews revealed communication issues and a lack of a medication refill policy, contributing to the oversight.
The facility failed to maintain the personal hygiene of a resident who required maximal assistance with ADLs. The resident was observed with long, dirty fingernails, and staff interviews revealed a lack of awareness and communication regarding nail care responsibilities.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. For one resident with a diagnosis of attention deficit hyperactivity disorder (ADHD), the care plan did not address this diagnosis, despite it being documented in psychological assessments and confirmed by both the resident and staff. Interviews with the Social Services Director, LVN, MDS Coordinator, and DON confirmed that the ADHD diagnosis was not included in the care plan due to a lack of entry in the electronic system and oversight during MDS look-back periods. Staff acknowledged the importance of care planning for all diagnoses to ensure resident needs are met. Another resident, who was dependent on staff for activities of daily living (ADLs) including personal hygiene, did not have a care plan addressing ADL assistance or fingernail care. Observation revealed the resident's fingernails were excessively long, and the resident expressed a desire for staff assistance with nail care, which had not been provided. Staff interviews confirmed the resident's dependence and the absence of a care plan for these needs. Similarly, a resident with diabetes and insulin dependence did not have a care plan addressing these conditions, despite physician orders for insulin administration and severe cognitive impairment. Staff interviews highlighted the lack of tailored care planning for this resident's specific needs. Additionally, a resident with a history of multiple falls did not have timely updates to the care plan reflecting fall interventions after each incident. Although interventions were discussed and implemented immediately, the care plan was not updated promptly, particularly when falls occurred on weekends. Another resident with multiple complex diagnoses, including severe cognitive impairment and heart failure, had no comprehensive care plan initiated at all. Staff interviews consistently indicated that care plans are essential for guiding care and that the absence or delay in care planning could result in unmet resident needs.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for four residents who were unable to perform these tasks independently. Observations and interviews revealed that multiple residents had excessively long, dirty, and untrimmed fingernails, despite being dependent on staff for personal hygiene. In several cases, residents expressed dissatisfaction with the state of their nails and reported that staff had not offered or provided nail care. For example, one resident with hemiplegia and a history of stroke was found with nails up to 1.5 inches long and a brown/black substance under her nails, and she stated that her sister, not staff, last trimmed her nails. Staff interviews indicated confusion or lack of awareness regarding responsibility for nail care. Certified Nursing Assistants (CNAs) and nurses gave inconsistent accounts of who was responsible for trimming nails, with some stating it was done on shower days or as needed, and others indicating that restorative aides or the staffing coordinator were also responsible. In some cases, staff admitted they had not noticed the residents' nail conditions or had not reported refusals or missed care to supervisors. One staff member stated she assumed others would take care of nail trimming if she was unable to do so. Record reviews showed that care plans for some residents did not include specific interventions for personal hygiene or nail care, despite documentation of self-care deficits and the need for assistance. Facility policy required daily cleaning and regular trimming of nails to prevent infection, but this was not consistently implemented. The Director of Nursing and other staff acknowledged that assigned individuals were responsible for ensuring nails were kept clean and trimmed, but residents were still found with long, dirty nails during the survey.
Failure to Implement and Document Range of Motion Interventions for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in her condition. The resident, a cognitively intact female with a history of stroke, hemiplegia, and diabetes, had a contracture in her left hand. Her care plan indicated the use of supportive devices such as splints as recommended by occupational therapy (OT), but there was no evidence that these interventions were consistently implemented. Documentation showed that the carrot splint was to be applied daily, yet there was no record of its application or refusal for a period of several days. Observations and interviews revealed that the resident's left hand was drawn up in a fist, and she was unable to open it. The splints intended for her use were found in her room but not in use, and the resident reported not having seen the splint in a while. Certified Nursing Assistants (CNAs) were unaware of the need to apply the splint or perform ROM exercises, and these tasks were not included on their task lists. The restorative aide also confirmed that the resident was not on her list for restorative care and had not documented any refusals or issues due to lack of access to the new electronic system. Further interviews with facility staff, including the MDS nurse, restorative aide, and Director of Rehabilitation (DOR), confirmed a lack of communication and documentation regarding the resident's restorative needs. The facility did not have a formal restorative program, and there was no specific restorative care plan in place for the resident. The failure to implement and document the prescribed interventions for the resident's contracture led to a deficiency in providing appropriate care to maintain or improve her range of motion.
Failure to Secure and Properly Handle Controlled Medications
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the secure storage and handling of controlled medications on three medication carts. During observations, surveyors found that blister packs containing tramadol 50 mg tablets for three different residents had broken seals, with the pills still inside the damaged blisters. In one instance, a broken blister was taped over rather than properly discarded. Nursing staff, including LVNs and an RN, reported that while narcotic counts were performed at shift changes, they did not check the integrity of the blister packs during these counts and were unaware of when or how the seals were broken. The staff acknowledged that the correct procedure would be to discard any pills from broken blisters with another nurse present, but this was not consistently followed. The Director of Nursing (DON) confirmed that the facility's expectation was for any medication with a broken seal to be discarded and that it was unacceptable to keep pills in opened blister packs. The DON also stated that nurses were responsible for checking blister packs for broken seals during shift changes, and that the ADON and DON were to check carts weekly, with the pharmacy consultant auditing monthly. Facility policy required all drugs to be stored in a safe, secure, and orderly manner, and not to use deteriorated drugs, but these procedures were not adhered to in the cases observed.
Failure to Properly Store and Cover Food Items in Kitchen Freezer
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. Specifically, a packet of frozen pork and vegetable eggrolls was found loosely wrapped in a plastic bag and kept in an open cardboard box inside the walk-in freezer. This food item was not properly covered, labeled, or dated, as required by both facility policy and the Food and Drug Administration Food Code. Multiple staff interviews confirmed that it was the expectation and responsibility of all kitchen staff, including cooks, dietary aides, and the dietary manager, to ensure all food items were appropriately covered, labeled, and dated at all times. The facility's policy on food storage and the FDA Food Code both require that frozen foods be covered, labeled, and dated to prevent cross-contamination and maintain food safety. Staff interviews revealed a consistent understanding of these requirements and the risks associated with non-compliance, such as cross-contamination, freezer burn, and potential foodborne illness. The deficiency was identified through direct observation and confirmed by staff acknowledgment that the uncovered food item was not in compliance with established standards.
Failure to Obtain Physician Orders for Immediate Care Needs
Penalty
Summary
The facility failed to ensure that two residents had physician's orders for their immediate care needs upon admission, specifically regarding oxygen therapy and colostomy care. One resident, a female with diagnoses including morbid obesity, heart failure, acute and chronic respiratory failure with hypoxia, and pneumonia, was admitted with a need for oxygen. Despite being on 4 liters of oxygen via nasal cannula, there was no physician order for continuous or as-needed oxygen supplementation, nor for related care such as changing the cannula, tubing, or humidifier, or for assessing the resident’s nares. Multiple staff interviews confirmed that an order should have been present and that the absence of such orders was a deviation from facility policy and standard practice. Another resident, a male with heart failure, chronic kidney disease, and acute respiratory failure, had a colostomy appliance but did not have an active physician order for colostomy care upon readmission. Although the care plan noted the presence of a colostomy and staff reported changing the pouch daily, there was no corresponding physician order in the treatment administration record after a certain date. Staff interviews revealed that the omission was not noticed during the readmission process, and the DON acknowledged that a physician order for colostomy care should have been present and care planned. Facility policy reviews confirmed that all treatments, including oxygen administration and colostomy care, require a physician's order to be recorded in the medical record. The lack of such orders for these two residents was identified through observation, record review, and staff interviews, and was not in accordance with the facility’s own procedures for ensuring safe and appropriate care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status and diagnoses of two residents. For one resident, the quarterly MDS completed after readmission did not indicate the presence of a colostomy, despite documentation in the care plan and previous MDS, as well as confirmation from the resident and staff that the colostomy appliance was in place and being managed. The MDS Coordinator acknowledged that the ostomy status should have been selected and was unsure why it was missed. For another resident, the quarterly MDS did not include a diagnosis of attention deficit hyperactivity disorder (ADHD), even though this diagnosis was documented in psychological assessments, the care plan, and confirmed by the resident, the Social Services Director, and the DON. The Social Services Director noted that the diagnosis should have been added to the electronic health record, and the MDS Coordinator confirmed it was not included in the MDS. The DON indicated that the omission may have occurred during a transition to a new electronic health record system and emphasized the responsibility of nursing and the MDS Coordinator to ensure accurate and updated diagnoses during admission and readmission. Interviews with staff and review of facility policy confirmed that comprehensive and accurate assessments are required at specified intervals. The failure to accurately code the colostomy and include the ADHD diagnosis in the MDS assessments resulted in incomplete documentation of the residents' needs and conditions.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a gait belt while transferring a resident from her bed to a wheelchair. The resident, who had severe cognitive impairment and required maximal assistance with transfers due to weakness and abnormal gait, was instead lifted by her clothes and under her arms. During the transfer, the resident expressed pain, stating it hurt under her breasts. The resident's care plan specifically required the use of a gait belt and assistance of one staff member for all transfers to prevent injury. Observation confirmed that the CNA did not follow the care plan or facility policy, which mandates the use of a transfer belt for any patient needing assistance with transfers or ambulation. The CNA acknowledged awareness of the requirement and had received training on gait belt use. The facility's policy and the resident's care plan both documented the necessity of a gait belt for safe transfers, but this protocol was not followed during the observed incident.
Deficient Catheter and Perineal Care Leading to Infection Risk
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate catheter and perineal care to a female resident with a suprapubic catheter and frequent bowel incontinence. During incontinence care, the CNA did not separate the labia or clean under the resident's skin folds, nor did she clean around the suprapubic catheter insertion site, despite visible leakage and redness. The resident was found with a strong urine odor, saturated brief, and a large bowel movement, but the required cleaning steps to prevent infection were not followed. Additionally, a registered nurse (RN) did not maintain sterile technique while re-inserting the resident's suprapubic catheter. The RN failed to set up a sterile field before donning sterile gloves, removed the sterile gloves after cleaning the stoma, and then continued the catheter insertion using utility gloves. The catheter was inserted and connected to the drainage bag, but urine was allowed to drain onto the resident's side, requiring further cleaning. The resident involved was cognitively intact, dependent on staff for toileting, and had diagnoses including multiple sclerosis and neurogenic bladder. Physician orders and care plans required regular catheter care and monitoring for infection, but the observed care did not adhere to facility policies for perineal and catheter care, as confirmed by staff interviews and policy review.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program for two residents observed for infection control. For one resident with multiple sclerosis and a neurogenic bladder, who had an indwelling urinary catheter and was on Enhanced Barrier Precautions, a registered nurse did not use the required personal protective equipment (PPE) while changing the suprapubic catheter. Specifically, the nurse wore gloves but did not don a gown as required by the facility's Enhanced Barrier Precautions policy, despite signage and available PPE in the resident's room. The nurse acknowledged the oversight and confirmed understanding of the required precautions for residents with indwelling medical devices. In a separate incident, a certified nursing assistant (CNA) did not follow proper glove and hand hygiene protocols while providing incontinence care to another resident. The CNA changed gloves without performing hand hygiene and, at one point, used soiled gloves to place a clean brief under the resident. The CNA also assisted the resident with dressing and transferring without changing gloves or performing hand hygiene between tasks. The CNA later stated awareness of the correct procedures but did not realize the lapse during care. Both incidents were observed directly by surveyors and confirmed through interviews with the involved staff and the Director of Nursing. Facility policies on Enhanced Barrier Precautions, perineal care, and hand hygiene were reviewed and found to require the use of gowns and gloves for certain care activities and hand hygiene between glove changes, which were not followed in these cases.
Incorrect G-tube Formula Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was administered the correct G-tube feeding as ordered by the physician. The resident, an elderly male with a history of stroke, hypertension, diabetes, hyperlipidemia, anxiety disorder, depression, and malnutrition, was observed to have been given a different enteral formula than prescribed. The physician had ordered Isosource 1.5 Cal Oral Liquid to be administered via G-tube, but the nurse administered Fibersource HN 1.2 instead. This discrepancy was noted during an observation, and the nurse admitted to not verifying the physician's order before administering the formula. The nurse acknowledged that the incorrect formula was less calorically dense than the prescribed one, which could lead to inadequate nutrition for the resident, who was NPO and reliant on the G-tube for all nutritional needs. The Assistant Director of Nursing and the Director of Nursing both emphasized the importance of following physician orders to prevent complications such as weight loss and decreased nutrition. The facility had the correct formula in stock, indicating that the error was due to a failure in following protocol rather than a supply issue.
Infection Control Deficiency Due to Inadequate PPE Use
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of LVN A during the care of a resident requiring Enhanced Barrier Precautions (EBP). The resident, an elderly male with a history of stroke, hypertension, diabetes, hyperlipidemia, anxiety disorder, depression, and malnutrition, was observed to have a G-tube and was under EBP. Despite the presence of EBP signage on the resident's door, LVN A did not don the appropriate personal protective equipment (PPE) required for EBP, specifically a gown, while administering G-tube feeding. This oversight occurred despite LVN A's acknowledgment of the necessity of gowns and gloves for EBP to prevent infections. The Director of Nursing (DON) confirmed that the facility's policy required all direct care staff to follow EBP, which includes wearing gowns and gloves during high-contact resident care activities. The facility's policy on Enhanced Barrier Precautions, dated August 2020, specifies that gloves and gowns are to be applied prior to performing high-contact resident care activities, such as device care. The failure to adhere to these precautions was noted during the survey, and the facility was unable to provide competency skill checks for LVN A regarding EBP by the time of the survey exit.
Inadequate Pain Management for Resident with Multiple Fractures
Penalty
Summary
The facility failed to provide adequate pain management for a resident, leading to unnecessary pain and discomfort. The resident, a female with a history of metabolic encephalopathy, vascular dementia, and multiple fractures, was observed to be in severe pain during repositioning. Despite having a care plan that required staff to assess and manage her pain, the facility did not consistently document or address her pain levels, particularly during episodes of breakthrough pain. The resident's care plan included interventions for pain management, such as observing for behaviors indicating pain and administering scheduled pain medications. However, there were gaps in documentation and assessment, as evidenced by missing nurse notes on specific dates and inconsistent pain assessments. The resident was observed yelling in pain during repositioning, yet there was no documentation of PRN pain medication being administered on those occasions. Interviews with staff revealed a lack of consistent communication and documentation regarding the resident's pain. Caregivers reported the resident's pain to nurses, but there was no follow-up documentation or assessment noted. The Director of Nursing acknowledged the missing pain assessments and the lack of PRN medication documentation, indicating a failure to adhere to the facility's pain management policy. This oversight resulted in the resident experiencing unrelieved pain, which was later identified as a right subcapital hip fracture upon hospital evaluation.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring that staff did not stand over the resident while assisting with her meal. This incident involved a female resident with a diagnosis of metabolic encephalopathy, vascular dementia, low back pain, anorexia, fractures in the upper arm and forearm, and anxiety disorder. Despite having an intact cognition as indicated by a BIMS score of 13, the resident required extensive assistance with activities of daily living, including meals, due to impaired mobility and weight loss. On the date of the incident, a video observation showed a caregiver standing at the resident's bedside with one hand on her hip while feeding the resident. The Director of Nursing (DON) was unaware of this practice and acknowledged that the resident and staff should be at eye level during feeding. The facility's administrator also stated that there was no policy on feeding residents and expressed no major concerns about the caregiver's actions. The facility's policy on resident rights emphasized treating all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The deficiency was identified for a male resident who required extensive assistance with personal hygiene due to medical conditions including cerebral infarction and hemiplegia. Despite having an intact cognition as indicated by a BIMS score of 15, the resident's fingernails were observed to be unclean and untrimmed, with nails extending approximately 0.6 centimeters from the fingertips and discolored with dark brown residue underneath. Interviews with facility staff revealed that Certified Nursing Assistants (CNAs) were responsible for nail care unless the resident was diabetic, in which case licensed nurses would perform the task. The Director of Nursing (DON) stated that nail care should be provided as needed, particularly during shower times, and emphasized the resident's right to have clean and trimmed fingernails. The facility's policy indicated that nail care is part of the bathing process, yet this was not adhered to in the case of the resident, leading to the identified deficiency.
Failure to Label and Date Oxygen Tubing
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy. The resident, a female with a history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, hyperlipidemia, and hypertension, was observed with nasal cannula tubing that was not labeled or dated. This oversight was contrary to the physician's order, which specified that oxygen tubing should be changed weekly and dated accordingly. The resident's comprehensive care plan also indicated the need for oxygen therapy to manage episodes of shortness of breath and prevent respiratory distress. Interviews with facility staff revealed that the nasal cannula tubing was changed by an LVN, who admitted to not labeling or dating the tubing due to being in a hurry. The LVN also failed to document the tubing change in the Medication Administration Record (MAR) because of uncertainty on how to do so. The Director of Nursing (DON) and the Nursing Manager both acknowledged the importance of dating the tubing to prevent infection control issues, although there was no formal facility policy in place for this procedure. The lack of proper labeling and documentation of the oxygen tubing change posed a risk of respiratory infections for the resident.
Failure to Provide Assistive Eating Device
Penalty
Summary
The facility failed to provide a resident with a divided plate, which was necessary for her to eat independently. The resident, a female with a history of hypertension, hyperlipidemia, hemiplegia, chronic obstructive pulmonary disorder, and respiratory failure, had a BIMS score indicating moderately impaired cognition. Despite being independent with suitable utensils, her physician had ordered a divided plate to be used every day, every shift. On a specific day, the resident was observed eating from a regular plate, which led to her consuming only a quarter of her meal before leaving the dining room. The resident expressed her preference and need for a divided plate due to wrist concerns, which had been in place for about a year. Interviews with facility staff revealed a breakdown in communication and procedure. The Regional Director of Nutrition Services expected kitchen staff to provide assistive devices as indicated on meal tickets, but was unaware of the specific needs of the resident. A cook acknowledged the divided plate was broken and replaced, but was not informed of the replacement. The Regional Director of Rehabilitation and the DON confirmed the necessity of the divided plate for the resident's independent feeding and dignity, noting the order was initiated by the nursing team. The facility's policy required adaptive equipment to be provided as ordered, but this was not adhered to in this instance.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of two CNAs during the care of a resident. The resident, a female with severe cognitive impairment and hemiplegia following a cerebral infarction, required extensive assistance with personal hygiene. During an observation, it was noted that the CNAs did not perform proper hand hygiene while providing incontinence care. Specifically, CNA D applied skin barrier cream and then handled a clean brief without changing gloves, while CNA E discarded soiled linen and assisted with dressing the resident without changing gloves. Both CNAs failed to perform hand hygiene between glove changes, which is a critical step in preventing the spread of infection. Interviews with the CNAs revealed that they were aware of the hand hygiene protocols but failed to adhere to them due to nervousness and forgetfulness. The Director of Nursing confirmed that the expectation was for staff to perform hand hygiene before and after care, and between glove changes, to prevent infection transmission. The facility's policy on hand hygiene, reviewed in August 2015, emphasized the importance of using an alcohol-based hand rub before moving from a contaminated body site to a clean one and after removing gloves.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in ensuring the availability of Hydromorphone, a medication used for pain management. The resident, a cognitively intact female with multiple diagnoses including pain, schizoaffective disorder, and heart failure, missed two doses of Hydromorphone due to the facility not having the medication available. The resident's medication administration record indicated that the doses scheduled for 12:00 AM and 8:00 AM on a specific date were not administered, as the medication was not available until later that evening. Interviews with facility staff revealed a lack of communication and coordination in managing the resident's medication needs. The Director of Nursing (DON) was unaware of the medication issue until the resident reported it. The Licensed Vocational Nurse (LVN) on duty during the missed doses was informed by the resident about the lack of medication and notified the physician, but the medication was not available until the evening. The Regional Nurse and the Vice President of Pharmacy Operations highlighted challenges with insurance restrictions and the need for timely reordering, but the facility did not have a policy in place to manage medication refills effectively. The physician confirmed that the prescription for Hydromorphone could not be refilled before a certain date due to insurance restrictions, and the medication was reordered as soon as possible. Despite the missed doses, the resident did not exhibit withdrawal symptoms or report severe pain, as she had access to OxyContin for pain management. The facility's lack of a medication ordering/refill policy contributed to the oversight, and staff interviews indicated a misunderstanding of responsibilities regarding medication reordering.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The resident, an 89-year-old male with multiple diagnoses including cognitive communication deficit, heart failure, and dementia, required maximal assistance with personal hygiene, dressing, bathing, and toileting. Despite this, the resident was observed with fingernails that were roughly a quarter of an inch or longer, with dried brown and yellow matter under each nail. The resident could not recall when his nails were last trimmed and mentioned that he had scratched his scalp due to their length. Interviews with the resident's day shift nurse and aide revealed a lack of awareness and communication regarding the resident's nail care needs. The nurse stated that the aides were able to cut the resident's nails as he was not diabetic, while the aide believed that only the nurse was responsible for trimming the nails due to the resident's diabetic status. The Director of Nursing (DON) and the Executive Director (ED) both stated that it was the responsibility of the nursing staff to ensure residents' nails were clean, dry, and trimmed. The facility's policy on activities of daily living also emphasized the importance of providing appropriate care and services to maintain good grooming and personal hygiene for residents unable to carry out ADLs independently.
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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