Interlochen Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Texas.
- Location
- 2645 West Randol Mill Rd, Arlington, Texas 76012
- CMS Provider Number
- 455835
- Inspections on file
- 42
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Interlochen Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors observed multiple gnats in various locations on one hall, including at both ends of the corridor, at the nurse’s station, and in a resident room where several gnats were seen around the resident and the sink despite the area being clean. The resident reported that gnats had long been a problem, had worsened, and were bothersome, and stated she had informed staff. Nursing staff acknowledged seeing gnats in rooms and on meal trays and described notifying housekeeping or the administrator, while the administrator admitted the gnat issue was known. When documentation was requested, the facility could only provide an insect and rodent control policy limited to the food service department and did not produce a facility-wide pest control policy or pest control log, supporting a deficiency for failure to maintain an effective pest control program.
A resident with dementia, anxiety, chronic pain, and metabolic encephalopathy was admitted with documented needs including poor memory, wheelchair use, two-person assist for transfers and ADLs, and multiple skin issues. Although admission notes and subsequent progress notes described falls, fall risk, skin tears, hospice involvement, agitation, and confusion, no baseline care plan or comprehensive care plan was documented in the EMR within 48 hours of admission. Staff interviews revealed that the admitting LVN did not know where baseline care plans were kept, the Regional RN confirmed there were no care plans in the system, and the ADON acknowledged only a verbal plan of care discussion with the family and admitted he failed to document the baseline care plan, despite facility policy requiring a written baseline care plan and summary within 48 hours.
A resident with severe cognitive impairment and multiple complex diagnoses, including prior cerebral infarction and acute kidney failure, was receiving Eliquis (apixaban) twice daily for clot prevention without a corresponding anticoagulant-focused care plan. Review of the care plan showed no measurable objectives or interventions related to anticoagulant use, despite an active medication order and a facility policy requiring comprehensive, person-centered care plans for all identified medical and nursing needs. Staff interviews confirmed that a care plan for anticoagulants should have included monitoring for bruising, bleeding, and other adverse reactions, but this was not documented or implemented for the resident.
A resident with dementia, metabolic encephalopathy, high fall risk, and extensive ADL assistance needs was found on the floor in front of a wheelchair. After an LVN assessed the resident and found no obvious injury, two CNAs manually lifted the resident from the floor to the wheelchair using a gait belt while placing their forearms under the resident’s arm pits, even though the resident did not assist and was effectively non–weight-bearing. Staff interviews showed that therapy and nursing leadership had instructed that residents should never be lifted under the arm pits and that a mechanical lift should be used when a resident cannot safely assist, but the CNAs proceeded with the manual lift based on their judgment and expectation that the resident would help. Facility policies addressed gait belt use and two-person transfers but did not specify procedures for non–weight-bearing residents during floor transfers, contributing to the failure to provide adequate supervision and appropriate assistance devices to prevent accidents.
A resident with chronic respiratory failure, hypoxia, and a tracheostomy was receiving oxygen therapy, but the facility did not post required oxygen use signage outside the room. Staff interviews confirmed there was no designated person responsible for ensuring the signage was in place, and facility policy requiring such signs was not followed.
A resident with severe cognitive impairment and a recent wrist injury did not receive timely pain management or appropriate monitoring, as staff failed to document pain assessments and the effectiveness of pain medications according to facility policy. Delays in diagnostic imaging and inadequate follow-up contributed to a delay in identifying a wrist fracture, resulting in unmanaged pain until the resident was sent to the hospital.
A resident with severe cognitive impairment and multiple health conditions experienced swelling and bruising of the wrist after a fall. Although a stat x-ray was ordered, it was not completed within the required timeframe, and the imaging was performed on the wrong body part. The correct diagnosis of a wrist fracture was delayed until the resident was sent to the hospital for further evaluation.
A resident with multiple medical conditions, who was cognitively intact and required assistance with daily living, experienced unauthorized withdrawals totaling over $11,000 from her bank account after her debit card was accessed by a caregiver. The facility did not inform the resident about available lock boxes or offer protection for valuables, and staff were unaware the card was kept in the resident's room until after the theft occurred. The resident suffered emotional distress and loss of trust as a result.
A facility failed to prevent a CNA, previously suspended due to an abuse allegation, from providing care to a resident with severe cognitive and physical impairments. Despite the suspension, the CNA continued to be assigned to the resident, highlighting a lack of effective policies and procedures to prohibit and prevent abuse and neglect.
A nurse failed to properly review and interpret an abnormal X-ray result for a resident with a recent fall and ongoing pain, resulting in a two-day delay in recognizing and treating a hip fracture. The X-ray report, which showed a pelvic fracture, was misread as negative and this incorrect information was communicated to other staff and the NP. The resident continued to experience pain and impaired mobility until being sent to the hospital, where the fracture was confirmed and treatment was provided.
A nurse failed to fully review and accurately report an abnormal X-ray result showing a hip fracture for a resident with dementia and ongoing pain. The nurse only read part of the report and incorrectly informed the NP that the result was negative, leading to a two-day delay in appropriate medical evaluation and treatment until the resident was hospitalized.
A resident on Enhanced Barrier Precaution due to feeding tube status was not properly protected when an LVN administered medication without wearing a gown, contrary to facility policy. The LVN admitted to forgetting the gown, acknowledging the risk of infection spread. The DON emphasized the importance of adhering to infection control policies, which require gown and gloves during high-contact care activities.
A resident with COPD and pulmonary hypertension experienced shortness of breath and required oxygen therapy, but the facility failed to notify the physician of the condition change. Despite multiple episodes of respiratory distress, there was no documented attempt to contact the physician until the resident's condition worsened, leading to hospitalization and eventual death.
A resident with COPD and pulmonary hypertension experienced shortness of breath and required respiratory care, but the facility failed to conduct proper assessments or notify medical personnel of the resident's condition change. Despite low oxygen saturation levels and breathing treatments, staff did not document vital signs or communicate with the physician, leading to the resident's transfer to the ER and subsequent death.
Two residents with severe cognitive impairment were not provided a dignified dining experience when staff stood over them while assisting with meals, contrary to the facility's policy of promoting dignity by sitting at eye level. Interviews confirmed that staff should sit next to residents during meals to respect their dignity, highlighting a deficiency in maintaining residents' quality of life.
A resident with cerebral palsy and other conditions required total assistance for transfers, but the facility failed to include the use of a mechanical lift in the care plan. Staff used unsafe manual lifting methods, contrary to facility policy, posing a risk of injury. The deficiency was due to the care plan not being updated to reflect the resident's needs.
A resident with severe cognitive impairment and a history of fractures suffered a new fracture when his hand and wrist became stuck in his wheelchair wheel. The incident was not reported to the state agency within the required two-hour timeframe, as the facility's administrator admitted to possibly sending the report to the wrong number and forgetting to send it immediately. This delay in reporting violated the facility's abuse policy and placed residents at risk of ongoing neglect.
A facility failed to implement a comprehensive care plan for a resident with cognitive decline and fall risk, resulting in the resident falling from an elevated bed and sustaining a head injury. The care plan interventions were not followed, and the resident was left unattended during incontinence care, leading to the incident.
A resident with cognitive decline and a history of falls fell and sustained a head injury requiring sixteen staples after a CNA failed to follow the care plan for incontinence care, which required lowering the bed. The care plan was later revised to require two staff members for incontinence care.
Failure to Maintain Effective Pest Control for Gnats on One Hall
Penalty
Summary
The facility failed to maintain an effective pest control program to keep Hall 200 free of gnats. On multiple observations on Hall 200, surveyors saw gnats in various locations, including one gnat at the south end of the hall, one gnat at the north end of the hall, and one gnat at the nurse’s station. In one resident room at the south end of Hall 200, a surveyor counted three gnats around the resident and five gnats around the sink, despite the sink being clean and without foul odors. The resident in that room reported that gnats had always been an issue, stated the gnats were worse than in the past, and said the gnats bothered her. She indicated she had informed staff about the gnats and that the room had been sprayed. During interviews, LVNs reported seeing gnats in resident rooms and on meal trays, and one LVN stated she was supposed to notify housekeeping when gnats were present. Staff described removing meal trays when gnats were seen and suggested that food in resident rooms might be contributing to the issue. The administrator acknowledged that gnats were a known issue on the hall. When surveyors requested documentation, the facility did not provide a pest control policy for the entire facility or a pest control log, but only produced a 2012 food service department policy on insect and rodent control that applied specifically to the food service area. This lack of a facility-wide pest control policy and documentation, combined with ongoing observations of gnats on Hall 200 and in a resident room, formed the basis of the deficiency.
Failure to Develop and Implement Timely Baseline Care Plan on Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission, or to have a comprehensive care plan in place within that same timeframe, for one resident. The resident was an adult male admitted with dementia, anxiety disorder, chronic pain, and metabolic encephalopathy, conditions associated with confusion, memory issues, and personality changes. On admission, an LVN documented that the resident was admitted to a secured unit from another nursing facility, arrived on a stretcher, had poor memory, used a wheelchair, and required two-person assistance for transfers, hygiene, and bathing. A skin assessment at admission identified bruising and small scabs on his body. Record review on a later date showed that the resident’s electronic medical record contained no care plans on the care plan page, and the admission MDS was still being edited. Progress notes from admission through several days afterward documented multiple care concerns, including fall risk and actual falls, skin tears, hospice services, agitation, and confusion, but there was no corresponding baseline care plan in the EMR during that period. A Baseline Care Plan Acknowledgment form indicated that the resident and his representative were given a copy of a baseline care plan several days after admission, yet the EMR still showed no care plans until a later date, when multiple care plans (ADLs, medications, skin, cognition/dementia, communication, falls, and behaviors) were all initiated on the same day. Interviews with staff further clarified the lack of a documented baseline care plan. The admitting LVN stated she did not know where baseline care plans were kept, though she entered admission information in her note. The Regional RN explained that baseline care plans were created in the same section as regular care plans and acknowledged that there were no care plans visible for this resident at the time of review. The ADON reported that he had provided a baseline care plan acknowledgment to the resident’s responsible party after a verbal discussion of the plan of care but admitted there was no documented baseline care plan, stating he must have forgotten to enter it. The facility’s own baseline care plan policy required completion and implementation of a baseline care plan within 48 hours of admission, including initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations, and required documentation that a written summary was provided to the resident and representative, which was not met in this case.
Failure to Care Plan Anticoagulant Therapy for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and interventions for a resident receiving anticoagulant therapy. Record review showed that the resident, an elderly female admitted with a primary diagnosis of cerebral infarction and additional diagnoses including dementia, sepsis, obstructive and reflux uropathy, and acute kidney failure, had a BIMs score of 3 indicating severe cognitive impairment. Medication orders reflected an active prescription for Eliquis (apixaban) 2.5 mg twice daily for clot prevention, started several months prior. However, review of the resident’s care plan, last revised on 12/20/2025, did not show any care plan addressing anticoagulant use. Interviews with facility staff confirmed that a care plan for anticoagulant medication should have been in place. The Regional RN stated there should be a care plan for anticoagulants to help staff identify adverse reactions, with interventions such as daily monitoring and CNA observation of the resident’s skin. The ADON reported she was responsible for parts of the care plan related to acute care, antibiotics, and falls, and described that staff were expected to monitor for bruising and bleeding in residents on anticoagulants as part of their tasks and morning rounds. The Administrator acknowledged that not care planning for medications like anticoagulants posed a risk that residents could receive medications they should not be getting or experience medication interactions. The facility’s Comprehensive Care Planning Policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ identified medical, nursing, mental, and psychosocial needs, but this was not carried out for the resident’s anticoagulant therapy.
Improper Manual Floor-to-Wheelchair Transfer Without Mechanical Lift
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe transfer techniques for a newly admitted resident with significant cognitive and functional impairments. The resident was an elderly male with dementia, anxiety disorder, chronic pain, and metabolic encephalopathy, admitted via EMS on a stretcher and requiring extensive assistance with ADLs. Admission and nursing notes documented that he needed two-person assistance for bed mobility, transfers, dressing, bathing, and hygiene, used a wheelchair most of the time, was unable to use devices or comprehend instructions due to poor cognition, and had poor decision-making ability requiring reminders, cues, and supervision. A fall risk assessment identified him as high risk for falls due to recent fall history, intermittent confusion, chair-bound status, inability to stand, and multiple medications contributing to fall risk. His care plan included two-person assistance for transfers but did not specify assistive devices. On the day of the incident, the resident was observed sitting on the floor in the dining area in front of his wheelchair. An LVN ran to assist, assessed the resident on the floor, and found no evidence of injury. The LVN then directed two CNAs to transfer the resident back to his wheelchair. The CNAs placed a gait belt around the resident’s waist, positioned themselves on either side of him facing him, grasped the gait belt in the back, and simultaneously placed their forearms directly under his arm pits to lift him from the floor into the wheelchair. During this maneuver, the gait belt slid up the resident’s back, and the resident did not appear to assist in the transfer, resulting in the CNAs performing the full lift. The resident was then positioned near the nurses’ station, where he intermittently leaned forward as if attempting to stand, and staff verbally redirected him to remain seated. Interviews with staff revealed uncertainty and inconsistency regarding appropriate transfer methods for this resident, particularly when he was unable to bear weight or assist. The LVN who responded to the fall believed the CNAs were supposed to “cup their arms under his” to lift him. Therapy and nursing leadership, including the OT, DOR, ADONs, and Regional RN, stated that residents should not be lifted under the arm pits and that a mechanical lift should be used when a resident cannot safely assist or when staff cannot safely lift with a gait belt alone. The OT specifically stated she would never go under a resident’s arms to lift and described alternative methods that avoid stress on the shoulders. Both CNAs acknowledged that lifting under the arm pits could injure a resident’s shoulders and that a mechanical lift is normally used when a resident cannot stand or bear weight, but they proceeded with the manual lift because they expected the resident to help and he did not. Review of CNA proficiency audits showed both CNAs had previously been deemed satisfactory in various transfer techniques, and review of the facility’s transfer policy showed it addressed gait belt use and two-person transfers but did not address procedures when a resident is unable to assist or bear weight. Additional documentation and interviews indicated that the resident had a prior unwitnessed fall in the facility, was combative and agitated at times, did not call for assistance, and resisted redirection, leading to additional fall precautions such as a low bed, air mattress, and fall mat. The ADON reported that at admission he believed the resident was unable to bear weight and that the resident had not noticeably changed since admission. Multiple staff, including the DOR, ADON, and Regional RN, confirmed that staff were trained not to lift under the arm pits and that mechanical lifts should be used when manual lifting exceeded the capabilities of the resident or staff. Despite this, the CNAs manually lifted the resident from the floor using their forearms under his arm pits in combination with a gait belt, rather than using a mechanical lift, which constituted the failure to provide adequate supervision and appropriate assistance devices to prevent accidents. The facility’s fall policy stated that staff must be trained in safe transfer techniques and proper body mechanics, and the transfer procedure referenced the use of a gait belt and two-person assistance but did not specify what to do when a resident could not assist or bear weight. Staff interviews also referenced that an ice storm had interfered with therapy’s timely evaluation of new residents, including this resident, which contributed to the lack of a therapy assessment at the time of the incident. Nonetheless, the existing nursing assessments and fall risk evaluation already documented the resident’s high fall risk, cognitive impairment, and extensive assistance needs. In this context, the decision by CNAs to lift the resident from the floor by supporting him under the arm pits, combined with the absence of clear policy guidance for non–weight-bearing residents in floor transfers, led to the cited deficiency for failure to ensure the resident received adequate supervision and appropriate assistance devices to prevent accidents.
Failure to Post Oxygen Use Signage for Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy and tracheostomy management. Specifically, the facility did not ensure that cautionary and safety signs indicating oxygen use were posted outside the resident's room, despite the resident receiving oxygen via nasal cannula connected to an oxygen concentrator at 2 LPM with a capped tracheostomy. Observations confirmed the absence of required signage, and interviews with staff revealed there was no designated individual responsible for ensuring oxygen signage was posted. The resident involved was admitted with a primary diagnosis of cerebral infarction and secondary diagnoses including chronic respiratory failure with hypoxia and tracheostomy status. Facility policy required "No Smoking" signs to be placed in areas where oxygen was administered or stored, but this was not followed. Both the ADON and DON acknowledged their responsibility for ensuring proper signage and recognized the risks associated with the lack of oxygen use indicators, such as the potential for staff to inadvertently use flammable substances or electrical appliances near the oxygen source.
Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with severe cognitive impairment and a history of type 2 diabetes and dementia. The resident developed swelling and bruising on her right wrist, which was reported to nursing staff and the nurse practitioner (NP). Orders were given for a stat x-ray and ice pack application, but the x-ray was not completed within the expected four-hour window, and the imaging performed was of the forearm rather than the wrist. Despite ongoing swelling and bruising, the resident remained in the facility without timely escalation or reassessment, and the stat x-ray order was not properly followed up as required by facility policy. Throughout the incident, pain management was inconsistent and not documented according to professional standards or the facility's own pain management policy. The resident was administered Tylenol routinely, but there was no documentation of pain assessments or follow-up on the effectiveness of pain medication in the treatment administration record (TAR). Staff interviews revealed that pain assessments were not consistently performed or recorded, especially for residents unable to verbalize pain, and that documentation of pain and medication effectiveness was lacking. The facility's policy required monitoring and recording of pain medication effectiveness, but this was not done for the resident in question. The deficiency was further compounded by communication issues among staff, delays in obtaining appropriate diagnostic imaging, and a lack of timely escalation to higher levels of care when the stat x-ray was not completed. The resident was eventually sent to the hospital at the request of her responsible party, where a wrist fracture was diagnosed. The failure to follow the facility's pain management policy and to document pain assessments and medication effectiveness placed the resident at risk of uncontrolled pain.
Failure to Provide Timely and Correct Radiology Services
Penalty
Summary
A deficiency occurred when the facility failed to provide or obtain timely and appropriate radiology services for a resident with severe cognitive impairment and multiple comorbidities, including type 2 diabetes and dementia. The resident was observed with swelling, bruising, and discoloration on the right wrist, which was possibly related to a prior fall. A nurse practitioner assessed the resident and ordered a stat x-ray of the right hand and wrist, along with ice pack application. The stat x-ray order was not fulfilled within the expected four-hour window, and the x-ray provider was unresponsive to follow-up calls from nursing staff. The x-ray was eventually performed more than 24 hours after the initial order, but it was conducted on the resident's right leg (tibia/fibula) instead of the wrist as ordered. The radiology report for the leg was negative for fracture, and the resident continued to experience swelling and bruising of the right hand. Despite ongoing monitoring and communication with the resident's responsible party, the correct imaging of the wrist was not obtained in a timely manner, and the resident's pain was managed with ice packs and Tylenol. Subsequently, the resident was sent to the emergency room for further evaluation due to persistent swelling and bruising of the right hand. Hospital imaging revealed a nondisplaced fracture of the distal radius (wrist), which had not been identified by the initial, incorrect x-ray. Interviews with facility staff and administration confirmed that the stat x-ray order was not properly processed, follow-up was inadequate, and communication breakdowns occurred. The facility did not provide a policy on x-ray services during the survey.
Failure to Protect Resident Property from Misappropriation
Penalty
Summary
The facility failed to protect a resident's property from misappropriation, resulting in unauthorized use of the resident's debit card for 25 ATM withdrawals totaling $11,735. The resident, a cognitively intact female with multiple medical conditions including gram-negative sepsis, morbid obesity, hypokalemia, muscle atrophy, and kidney failure, was admitted to the facility and required assistance with activities of daily living. The resident kept her debit card in her room and had allowed one or two staff members to use it for vending machine purchases, but did not recall who they were. She reported that the card was never removed from her room by her, and the unauthorized withdrawals were only discovered after the bank and police became involved. The facility's admission policy did not offer protection for residents' property or valuables, and the availability of lock boxes for securing valuables was not communicated to residents in the admission packet. The resident was not informed by the facility that her bank card could be protected or stored securely. The social worker and administrator were made aware of the missing funds after the resident reported the issue, but the facility was unaware that the resident was keeping her debit card in her room until after the theft occurred. The administrator acknowledged that it was his responsibility to ensure the safety of residents' valuables, including bank and credit cards, but this was not effectively communicated or implemented prior to the incident. Interviews and record reviews confirmed that a caregiver employed at the facility was identified by the bank's fraud investigator as the individual making the unauthorized withdrawals, as evidenced by video footage. The resident expressed emotional distress and a loss of trust following the incident. The facility's abuse and neglect policy stated that residents have the right to be free from misappropriation of property, but the necessary measures to protect residents' belongings were not in place or communicated to the resident prior to the theft.
Failure to Prevent Suspended CNA from Providing Care After Abuse Allegation
Penalty
Summary
The facility failed to develop and implement written policies and procedures that effectively prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Specifically, the facility did not ensure that a certified nursing assistant (CNA) who had been suspended following an allegation of verbal abuse by a resident was restricted from providing care to that resident upon returning to work. Documentation revealed that the CNA continued to provide care to the resident after the suspension, contrary to the intended protective measures. The resident involved was an older female with multiple complex medical and psychiatric diagnoses, including Multiple Sclerosis, incomplete paraplegia, and severe bipolar disorder with psychotic features. She had significant memory impairment, exhibited both physical and verbal behaviors, and required extensive assistance with activities of daily living. The resident was unable to complete cognitive interviews and was noted to have difficulty recalling the incident in question during subsequent interviews. The facility's investigation into the alleged abuse was inconclusive, but the lack of clear and enforced policies allowed the suspended CNA to resume care duties for the resident. Interviews with staff confirmed that the CNA had continued to provide care, and that room assignments were made by the charge nurse without adequate safeguards to prevent the CNA from being assigned to the resident. The facility's existing policy on abuse and neglect did not provide sufficient guidance or enforcement to prevent this lapse.
Failure to Review and Report Abnormal X-ray Result Led to Delay in Fracture Care
Penalty
Summary
A deficiency occurred when a nurse failed to properly review and interpret an abnormal X-ray result for a resident who had a recent fall and was experiencing pain. The resident, an elderly female with a history of muscle weakness, dementia, and hypertension, was assessed as having low cognitive function and a high risk for falls. After reporting pain following a fall, the resident was evaluated and an X-ray was ordered. The X-ray, which showed a stable acute nondisplaced fracture of the left pubic rami, was misread by the nurse as negative, and this incorrect information was verbally relayed to other staff and the nurse practitioner. The resident continued to experience pain and showed signs of impaired mobility, such as dragging her left leg. Despite ongoing complaints and ineffective pain management, the abnormal X-ray findings were not recognized or acted upon for two days. The nurse who received the X-ray result only reviewed the first page, which did not indicate a fracture, and failed to read the subsequent page that documented the fracture. This led to a delay in appropriate medical evaluation and treatment for the resident, who was eventually sent to the hospital where the fracture was confirmed and pain management was initiated. Interviews with staff revealed that the process for reviewing and reporting diagnostic results was not consistently followed, and that communication breakdowns contributed to the delay in care. The nurse practitioner did not receive the faxed X-ray result and relied on a verbal report from the nurse, which was inaccurate. The deficiency was identified as Immediate Jeopardy due to the risk of harm from delayed treatment, and the facility's investigation confirmed that the failure to review and report the X-ray findings in a timely manner constituted neglect.
Failure to Promptly Notify Practitioner of Abnormal X-ray Result
Penalty
Summary
A deficiency occurred when a nurse failed to properly review and communicate the results of an abnormal X-ray for a resident with muscle weakness, dementia, and hypertension. The resident, who had a low cognitive function as indicated by a BIMS score of 4 out of 15, experienced pain in her left hip and waist. After a stat X-ray was ordered due to ongoing pain, the result, which showed a stable acute nondisplaced fracture of the left pubic rami, was not correctly read by the nurse on duty. The nurse misinterpreted the report, only reviewing the first page and reporting a negative result to the nurse practitioner, which led to a delay in appropriate medical intervention. The resident continued to experience pain and was observed dragging her left leg, with routine pain management proving ineffective. Despite ongoing complaints and visible symptoms, the abnormal X-ray findings were not communicated to the practitioner or acted upon for two days. The error was discovered only after the resident was sent to the hospital, where a hip fracture was confirmed and pain management was initiated. Interviews with staff revealed that the nurse responsible for reviewing the X-ray result failed to read the entire report and provided incorrect information to both the nurse practitioner and the next shift nurse. The facility's policy required immediate notification of abnormal diagnostic results to the practitioner, but this protocol was not followed, resulting in a delay in care for the resident.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a resident on Enhanced Barrier Precaution (EBP) due to feeding tube status. The resident, an elderly female with multiple diagnoses including spondylosis, chronic obstructive pulmonary disorder, and muscle weakness, was observed to have an EBP sign on her door. Despite this, LVN A administered medication via the resident's feeding tube without donning the required gown, although gloves were worn after hand hygiene. Interviews revealed that LVN A acknowledged forgetting to put on a gown, understanding the risk of infection spread to staff and residents. The Director of Nursing (DON) confirmed that staff should be aware of which residents require EBP and adhere to the infection control policy. The facility's policy, dated April 2024, mandates the use of gown and gloves during high-contact care activities, such as feeding tube care, to prevent the transmission of infections.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform the resident's physician and notify the resident's representative when there was a significant change in the resident's condition. Specifically, a resident experienced shortness of breath and required breathing treatments and oxygen therapy over several days. Despite these changes, there was no documented evidence that the facility attempted to notify the physician during this period. The resident was eventually transferred to the emergency room, where he was intubated and subsequently passed away. The resident, an elderly male with a history of COPD and pulmonary hypertension, was admitted to the facility with a recent diagnosis of a displaced comminuted fracture of the right femur. His care plan included monitoring for signs of respiratory distress and administering oxygen therapy as needed. However, the facility's records showed inconsistencies in documenting vital signs and the administration of treatments. Nursing progress notes indicated that the resident experienced episodes of shortness of breath, but there were no attempts to contact the physician or nurse practitioner until the resident's condition significantly worsened. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's deteriorating condition. Several staff members, including LVNs and CNAs, noted the resident's difficulty breathing and elevated temperature but failed to ensure timely notification of the physician. The facility's policy required immediate notification of the physician for significant changes in a resident's condition, but this protocol was not followed, contributing to the resident's decline and eventual death.
Removal Plan
- All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses. No additional issues were found.
- DON, ADON will audit all resident nursing notes for a change of condition to ensure notification of changes to the attending physician/nurse practitioner. Going forward the DON/ADON/designee will monitor progress notes for a change in condition and notification to the attending physician/nurse practitioner daily during the morning clinical meeting.
- All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained by the DON/ADON. No additional issues were found.
- LVN A and LVN B were immediately suspended pending investigation.
- LVN A and LVN B will not be permitted to return to work or provide care to residents until the following 1:1 in-services have been completed by the DON or Compliance Nurse.
- Abuse and Neglect-failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect.
- Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress.
- Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified.
- The medical director was notified by the administrator of this plan.
- An Ad Hoc QAPI meeting to include the Director and IDT team was held.
- All charge nurses will be in-serviced by the DON/ ADON regarding the following and all nurses not in-serviced will not be allowed to work their assigned position until completion of these in-services. All PRN staff, new hires, and agency staff will be in-serviced prior to start of their shift. The Administrator, DON and ADON were in-serviced 1:1 by Compliance Nurse.
- Abuse and Neglect- failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect.
- Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident non pharmacological or pharmacological. Notification of the MD and RP.
- Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified.
- The medical director was notified by the administrator of this plan.
- An Ad Hoc QAPI meeting to include the Director and IDT team was held.
- The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure than an assessment was completed for any new or worsened shortness of breath and is communicated to the NP, Attending MD, or Medical Director immediately. Monitoring began and will continue x 4 weeks.
Failure to Provide Adequate Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required such care, leading to a significant deficiency. The resident, an elderly male with a history of COPD and pulmonary hypertension, experienced shortness of breath and required breathing treatments and oxygen therapy. Despite these needs, the facility did not conduct a proper respiratory assessment or notify the necessary medical personnel when the resident's condition changed. This lack of action resulted in the resident being transferred to the emergency room, where he was intubated and subsequently passed away. The report highlights several instances where the facility's staff did not perform necessary assessments or document vital signs and respiratory conditions. On multiple occasions, the resident's oxygen saturation levels were low, and breathing treatments were administered, but there was no follow-up or communication with the resident's physician or nurse practitioner. The staff failed to document full sets of vital signs and did not consistently monitor the resident's condition, despite clear signs of respiratory distress and a significant change in the resident's health status. Interviews with facility staff revealed a lack of communication and understanding of the procedures required for handling a resident's change in condition. Staff members, including LVNs and CNAs, did not adequately assess the resident's respiratory status or notify medical personnel of the resident's deteriorating condition. The facility's policy on responding to significant changes in a resident's condition was not followed, contributing to the resident's decline and eventual death.
Removal Plan
- All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses. No additional issues were found.
- DON, ADON will audit all resident nursing notes for a change of condition to ensure notification of changes to the attending physician/nurse practitioner. Going forward the DON/ADON/designee will monitor progress notes for a change in condition and notification to the attending physician/nurse practitioner daily during the morning clinical meeting.
- All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained by the DON/ADON. No additional issues were found.
- LVN A and LVN B were immediately suspended pending investigation.
- LVN A and LVN B will not be permitted to return to work or provide care to residents until the following 1:1 in-services have been completed by the DON or Compliance Nurse.
- Abuse and Neglect-failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect.
- Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident nonpharmacological or pharmacological. Notification of the MD and RP.
- Notifications of changes of conditions test, to include components of a focused respiratory assessment.
- Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified.
- The medical director was notified by the administrator of this plan.
- An Ad Hoc QAPI meeting to include the Director and IDT team was held.
- All charge nurses will be in-serviced by the DON/ ADON regarding the following and all nurses not in-serviced will not be allowed to work their assigned position until completion of these in-services. All PRN staff, new hires, and agency staff will be in-serviced prior to start of their shift. The Administrator, DON and ADON were in-serviced 1:1 by Compliance Nurse.
- The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure than an assessment was completed for any new or worsened shortness of breath and is communicated to the NP, Attending MD, or Medical Director immediately. Monitoring began and will continue x 4 weeks.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, leading to a deficiency in maintaining their dignity and quality of life. Resident #2, a female with severe cognitive impairment and dependent on staff for eating, was assisted by a staff member who stood over her while feeding, rather than sitting at eye level. Similarly, Resident #3, also with severe cognitive impairment and requiring supervision while eating, was assisted by a CNA who stood over her during the meal. Both residents were observed in their geri chairs with food trays in front of them, and the staff's actions did not align with the facility's policy of promoting dignity during dining. Interviews with the CNA, personnel staff, and the Director of Nursing (DON) confirmed that staff should sit next to residents when assisting them with meals to respect their dignity. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, promoting a respectful environment, and ensuring a dignified dining experience. Despite in-service training on resident rights and dignity, the staff's actions during the dining service did not adhere to these standards, resulting in a deficiency report.
Failure to Implement Comprehensive Care Plan for Resident Transfer
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. The resident, a male with cerebral palsy, scoliosis, muscle weakness, and other conditions, required total assistance for transfers and bed mobility. However, the care plan did not specify the use of a mechanical lift for transfers, leading to staff using unsafe manual lifting methods. Observations and interviews revealed that the resident was transferred by staff using a method where one person held his shoulders and another held his legs, without the use of a mechanical lift. This practice was observed by a CNA who had been employed for one month and was following what she had seen other staff do. The resident expressed that he was accustomed to being lifted manually, as his brothers used to do, but this method was not safe according to facility policy and posed a risk of injury. The facility's policy required the use of a mechanical lift for residents who were totally dependent on staff for mobility. Interviews with the DON and other staff confirmed that the use of manual lifting was against policy and unsafe. The deficiency was identified as a failure to update the care plan to include the use of a mechanical lift, which could lead to inadequate interventions and potential injuries for the resident.
Failure to Timely Report Alleged Neglect Incident
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident to the State Agency within the required timeframes. The incident involved a male resident with severe cognitive impairment, who required modified to total assistance for daily care. The resident, who had a history of acute hairline fractures and peripheral vascular disease, suffered a fracture when his left hand and wrist became stuck in the wheel of his wheelchair. The incident occurred on April 17, 2024, but was not reported to the state agency until April 30, 2024, which was beyond the two-hour reporting requirement for incidents resulting in serious bodily injury. The facility's administrator admitted to possibly sending the Provider Investigation Report to the wrong number and acknowledged forgetting to send it to the correct CII provider immediately after the incident. The facility's abuse policy, revised in March 2028, mandates immediate reporting of all alleged violations to the appropriate authorities. However, the administrator failed to adhere to these guidelines, resulting in a delay in reporting the incident. This oversight placed residents at risk of ongoing neglect, as the facility did not comply with the required reporting timeframes outlined in Provider Letter PL 19-17.
Failure to Implement Comprehensive Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, which included measurable objectives and time frames to meet the resident's mental and psychosocial needs. The resident, an elderly female with a history of cognitive decline, falls, and lack of coordination, was dependent on staff for all activities. Despite these needs, the care plan did not adequately address the necessary interventions to prevent falls and ensure proper supervision and incontinence care. This deficiency was highlighted by an incident where the resident fell from her bed and sustained a head injury requiring sixteen staples. The care plan had listed interventions such as keeping the bed in the lowest position and ensuring the call light was within reach, but these were not effectively implemented or followed by the staff, leading to the resident's fall and injury. The incident occurred when a CNA left the resident unattended on an elevated bed while retrieving an item, resulting in the resident sliding off the bed and hitting her head on the floor. The CNA admitted to not lowering the bed and turning her back on the resident, which directly contributed to the fall. The facility's failure to ensure that staff followed the care plan interventions for proper supervision and incontinence care placed the resident at risk for injuries. The report also noted that the facility's policy on fall prevention strategies was not adequately followed, as individualized nursing care plans were not effectively implemented to prevent falls. The resident's care plan was not updated to reflect the need for two staff members to be present during incontinence care until after the incident occurred.
Failure to Follow Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that Resident #1's environment remained as free of accident hazards as possible and that the resident received adequate supervision and assistance devices to prevent accidents. Resident #1, an elderly female with age-related cognitive decline, a history of falling, and other coordination issues, was dependent on staff for all activities. Despite these needs, the care plan interventions for proper supervision and incontinence care were not followed by CNA-J, leading to a fall incident where the resident sustained a head injury requiring sixteen staples. On the day of the incident, CNA-J was providing incontinence care to Resident #1 but did not lower the bed as required by the care plan. When CNA-J turned her back to retrieve a brief from the nightstand, Resident #1 slid out of the bed and hit her head on the floor, resulting in a 10 cm laceration. Immediate first aid was administered, and the resident was sent to the hospital for further evaluation. The hospital performed a CT scan, which was negative for fractures, and treated the laceration with sixteen staples. The resident was also diagnosed with a urinary tract infection and prescribed antibiotics. Interviews with facility staff revealed that the initial care plan required only one person for incontinence care based on a fall assessment score indicating low risk. However, following the incident, the care plan was revised to require two staff members for incontinence care to prevent future falls. The facility's policy on fall prevention and care planning was not adequately followed, leading to the incident and subsequent injury to Resident #1.
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.
