Kingwood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingwood, Texas.
- Location
- 23775 Kingwood Place, Kingwood, Texas 77339
- CMS Provider Number
- 676160
- Inspections on file
- 34
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 10 (3 serious)
Citation history
Health deficiencies cited at Kingwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents were exposed to harm due to inadequate supervision and environmental safety. One resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unnoticed and was later found by a bystander after experiencing falls. The resident's care plan did not address elopement risk, and staff were not consistently aware of or monitoring for such behaviors. Additionally, an unsecured oxygen tank was found in another resident's room, presenting an accident hazard.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions, as observed in the care planning documentation.
A resident was not provided with the necessary assistance to access vision and hearing services, resulting in unmet care needs in these areas.
Staff failed to properly secure and label medications on a medication cart, leaving a resident's medications unattended and the cart unlocked during administration. Multiple opened topical medications were found on the cart without dates or resident names, and staff confirmed there was no consistent policy for dating opened medications.
Staff did not immediately inform a resident, the resident's doctor, and a family member about incidents such as injury, decline, or room changes that affected the resident, as required by policy.
A nurse failed to fully administer prescribed doses of carvedilol, misoprostol, and famotidine via G-tube to a resident with multiple complex conditions, resulting in a medication error rate of 8%. The nurse did not properly rinse the medication cup, leaving residue and nearly discarding part of the dose before being corrected by a surveyor.
An LVN failed to disinfect a glucometer between uses on two residents with diabetes and other chronic conditions, using the same device without cleaning it and storing it improperly, contrary to facility infection control policy.
A resident with paraplegia and multiple wounds did not receive prescribed wound care, turning, or assistance with transfers, leading to wound deterioration, severe sepsis, and hospitalization. Staff interviews and observations revealed missed wound care, lack of accountability, and failure to follow care plans. Additionally, another resident was not protected from alleged staff abuse, with the accused staff member continuing to provide care after the allegation. These failures placed residents at risk for harm and were identified as Immediate Jeopardy situations.
A resident with Parkinson's disease, requiring significant assistance and with intact cognition, reported to the DON and administrator that an LVN physically and verbally abused him, including jabbing him with a needle and hitting him in the face. Despite these allegations, the facility did not notify the abuse coordinator, did not investigate, and allowed the LVN continued access to the resident. Both the DON and administrator failed to follow required reporting and investigation procedures, resulting in a lack of protection for the resident.
A resident with Parkinson's disease reported being stabbed with an insulin needle and scratched by an LVN, expressing fear and discomfort with the nurse's care. Despite these allegations, the facility did not promptly investigate, report, or remove the LVN from providing care, and the required notifications and assessments were not completed. The resident continued to receive care from the LVN after the report, and the incident was not immediately reported to the state or fully investigated as required by facility policy.
Three residents did not receive consistent wound care as ordered, including missed dressing changes, inadequate turning and repositioning, and failure to follow wound care specialist instructions. One resident with paraplegia and multiple wounds experienced deterioration leading to hospitalization for severe sepsis and surgical debridement. Staff interviews and observations confirmed lapses in daily wound care for two other residents, with soiled dressings left unchanged. Residents and families reported ongoing concerns about missed care and poor communication, and staff shortages contributed to the deficiencies.
A resident with severe cognitive and physical impairments, who required total assistance and a mechanical lift for transfers, was improperly transferred by a CNA using a gait belt as a one-person assist. This action, which was not in accordance with therapy assessments or the care plan, resulted in the resident being found alone with a head injury and hip fracture. The facility did not ensure adequate supervision or implement required safety interventions for this high-risk individual.
The facility failed to provide adequate pharmaceutical services, as LVNs did not ensure correct narcotic counts during shift changes and failed to document narcotic administration accurately for several residents. A resident was administered the wrong medication due to a failure to verify the correct prescription. These issues highlight discrepancies in narcotic counts and documentation, contrary to facility policy.
A resident with multiple medical conditions was unable to access the call light due to it being wrapped around the wall base, contrary to the care plan and facility policy. Staff interviews confirmed the importance of accessible call lights, and the administrator acknowledged the deficiency.
A facility failed to refer a resident with serious mental disorders for a Level II PASARR evaluation after a significant change in status. The resident, with diagnoses including delusional disorder and bipolar disorder, was not evaluated despite a decline in cognition and the presence of mental health issues. The MDS Coordinator did not realize the need for referral until prompted by a state surveyor, contrary to the facility's policy requiring appropriate screening for specialized services.
A resident with Type 2 Diabetes had a blood sugar level of 422, but the LVN failed to notify the NP or administer the ordered insulin. The resident's care plan required monitoring and communication with the NP for abnormal blood sugar levels, but these protocols were not followed, as confirmed by interviews with facility staff.
A facility failed to document a correct diagnosis for a resident prescribed Seroquel, an antipsychotic medication, for dementia, which was inappropriate. Despite recommendations from a consultant pharmacist to change the diagnosis to delusion disorder, the facility did not update the resident's records in a timely manner. This oversight resulted in the resident receiving unnecessary medication, as the facility did not adhere to its policy of monthly medication regimen reviews.
A facility experienced a medication error rate of 11%, involving two residents. One resident did not receive the full dose of Lacosamide until a state surveyor intervened, due to an LVN not wearing glasses. Another resident received Sucralfate late and missed a dose of Lexapro, as the MA's shift timing and medication unavailability contributed to the errors. The facility's policy requires medications to be administered within one hour of their scheduled time.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in their oxygen therapy orders. One resident was observed without oxygen despite having a continuous order, while another was on oxygen without a documented order. The facility's policies on documentation were not followed, resulting in incomplete records and potential risks for the residents.
Failure to Prevent Elopement and Address Accident Hazards
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with severe cognitive impairment, Alzheimer's disease, and a history of exit-seeking behaviors was able to leave the facility without staff knowledge. The resident was last seen in the lobby in the early evening and was later found by a bystander walking unsteadily on a nearby road, having experienced falls and an incontinent episode. The facility was unaware of the resident's whereabouts for several hours until notified by an external party. Prior to the incident, the resident's care plan did not include interventions for elopement risk, despite previous assessments indicating a history of elopement or exit-seeking behaviors. Staff interviews revealed inconsistent awareness of the resident's risk, and the front door was not secured at the time, allowing the resident to exit undetected. Additionally, the facility was found to have an unsecured, empty oxygen tank on the floor in another resident's room, presenting a potential accident hazard. This situation exposed residents to possible harm, injury, or death due to inadequate monitoring and environmental safety measures. The facility's policies required identification and mitigation of hazards, as well as routine checks and documentation, but these were not effectively implemented in these cases. Interviews with staff indicated that while some were aware of general elopement protocols, there was a lack of specific interventions and communication regarding residents at risk for elopement. Documentation and care planning did not reflect the resident's exit-seeking behaviors, and staff did not consistently monitor or report such behaviors. The failure to secure the environment and provide adequate supervision directly contributed to the resident's elopement and the presence of accident hazards in the facility.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to necessary vision and hearing services. The facility failed to ensure that the resident received support to obtain these services, as required. This lack of assistance resulted in the resident not having access to appropriate vision and hearing care.
Failure to Secure, Label, and Date Medications on Medication Cart
Penalty
Summary
Facility staff failed to properly store, label, and secure medications and biologicals on at least one medication cart. During a medication pass, a nurse left a resident's medications unattended on top of an unlocked medication cart while leaving the room to obtain manual blood pressure cuffs. The medication cart remained unlocked and unattended during the process, and the nurse also left the resident's room door open while administering medications, without pulling the privacy curtain. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had multiple complex medical diagnoses, including chronic atrial fibrillation, stroke, and diabetes. Additionally, an inspection of the medication cart revealed several topical medications and creams that were opened but not dated or labeled with a resident's name. Staff interviews confirmed that there was no consistent practice for dating opened medications, and the facility lacked a policy on this matter. The Director of Nursing and Consultant Pharmacist acknowledged that the pharmacist typically placed the opened date on ointments, but this was not consistently done, and staff were unsure of the effectiveness of undated medications.
Failure to Promptly Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes that required notifications were not made promptly when events impacting the resident occurred, as mandated by regulations.
Medication Error Rate Exceeds 5% Due to Incomplete Administration via G-Tube
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with 3 errors out of 37 opportunities, resulting in an 8 percent error rate. During a medication pass, LVN J did not administer the full dose of carvedilol, misoprostol, and famotidine as ordered by the physician to a resident with multiple complex medical conditions, including chronic atrial fibrillation, coronary artery disease, stroke, diabetes, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living and received medications via gastrostomy tube. On the observed medication pass, LVN J prepared the medications by crushing them and placing them in a medication cup, but did not stir or rinse the cup, leaving a significant amount of residue. The nurse was about to discard the cup with the remaining medication when a surveyor intervened and pointed out the residual. LVN J acknowledged the error and subsequently administered the remaining medication after adding water. LVN J stated she had received gastrostomy tube training but was nervous during the process. The facility's policy required medications to be administered safely, timely, and as prescribed.
Failure to Disinfect Glucometer Between Residents
Penalty
Summary
A deficiency occurred when an LVN failed to follow infection prevention and control protocols during blood glucose monitoring for two residents. The LVN used the same accu-check machine to check the blood glucose levels of both residents without wiping or sanitizing the device between uses. After checking the first resident, the LVN placed the machine inside the medication cart, then proceeded to use it on the second resident, and subsequently stored it in his uniform pocket and then in the medication cart, again without cleaning it. The LVN stated that in his previous employment, cleaning the device between residents was only done for those on contact isolation, and he had not received orientation at the current facility. He acknowledged awareness that wiping the device was intended to prevent infection. The two residents involved had significant medical histories, including diabetes, hypertension, chronic kidney disease, dementia, and other conditions that could increase their vulnerability to infection. The facility's infection prevention and control policy required all reusable equipment to be cleaned and disinfected according to established procedures. However, the LVN did not adhere to these protocols, as observed during the medication pass, and this lapse was confirmed through interviews and record review.
Failure to Prevent Neglect and Abuse, Resulting in Wound Deterioration and Resident Distress
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by the lack of implementation of required interventions and inadequate wound care management. One resident, a cognitively intact female with paraplegia and multiple complex medical conditions including stage 3 and 4 pressure ulcers, osteomyelitis, and a suprapubic catheter, did not receive prescribed wound care treatments, turning and repositioning, or assistance with transfers to a chair as ordered. Documentation and interviews revealed that wound dressings were not changed as required, the resident was not turned or repositioned according to care plans, and she was left in soiled conditions for extended periods. The resident and her family repeatedly reported these issues to facility leadership, but corrective actions were not taken, resulting in wound deterioration, severe sepsis, and hospitalization for surgical wound debridement. Staff interviews indicated confusion and lack of accountability regarding wound care responsibilities, with several nurses and CNAs stating that wound care was often missed or improperly delegated, especially when the designated wound care nurse was unavailable. Observations confirmed that wound dressings were not changed daily as ordered, and some residents were found with dressings that had not been replaced for multiple days. The facility's own wound care consultant noted that dressings were frequently saturated and that the resident was not being mobilized as required, further contributing to the risk of infection and poor wound healing. Additionally, the facility failed to protect another resident from alleged verbal and physical abuse by a staff member, allowing the accused staff to continue providing care to the resident after the allegation was made. The resident expressed fear of the staff member, yet no immediate action was taken to prevent further contact. These failures were identified as Immediate Jeopardy situations by surveyors, as they placed residents at risk for physical harm, mental anguish, and neglect. The facility's policies required prompt identification and intervention in cases of abuse and neglect, but these were not followed, resulting in significant deficiencies in resident care.
Failure to Implement Abuse Policy Following Resident Allegation
Penalty
Summary
The facility failed to implement its abuse policy when a resident with Parkinson's disease, who required significant assistance with daily activities and had intact cognition, made allegations of physical and verbal abuse by a licensed vocational nurse (LVN). The resident reported to both the DON and the administrator that the LVN jabbed him with a needle, causing pain, and hit him in the face while administering medication. The resident also expressed fear of retaliation and discomfort with the LVN continuing to provide care. Despite these reports, the facility did not notify the abuse coordinator, did not initiate an investigation, and allowed the alleged abuser continued access to the resident after the allegations were made. Interviews and record reviews revealed that the DON was informed of the resident's complaints, including pain from an injection and fear of the LVN, but did not complete a thorough assessment, notify the abuse coordinator, or report the incident as required by policy. The administrator, who also served as the abuse coordinator, was made aware of the resident's allegations but did not file a report with the state. Both the DON and administrator acknowledged in interviews that proper reporting and investigation procedures were not followed. The resident was subsequently moved to a different hallway, which he perceived as retaliatory, and the LVN continued to have access to him during this period. The facility's failure to follow its abuse, neglect, and exploitation policy resulted in the lack of timely reporting, investigation, and protection for the resident. The events were substantiated by audio recordings, interviews with the resident, staff, and therapy personnel, and review of facility documentation. These failures placed residents at risk for physical harm and mental anguish, as the required protocols to ensure resident safety and address allegations of abuse were not implemented.
Failure to Investigate, Report, and Protect After Abuse Allegation
Penalty
Summary
The facility failed to immediately investigate, report, and protect a resident following allegations of abuse and neglect by a licensed vocational nurse (LVN). The resident, a 51-year-old male with Parkinson's disease and other medical conditions, reported being stabbed in the arm with an insulin needle and scratched on the nose by the LVN. He also described being hit in the face when receiving medication and expressed fear and discomfort regarding the LVN's care. Despite these reports, the facility did not promptly initiate an investigation or remove the LVN from providing care to the resident. Interviews and record reviews revealed that the resident communicated his concerns to both the DON and the administrator, including his fear of retaliation and his desire for the issue to be handled discreetly. The DON acknowledged being informed of the resident's pain and discomfort after an injection but did not conduct a thorough assessment, notify the abuse coordinator, or report the incident as required. The administrator, who also served as the abuse coordinator, was not immediately informed of the allegations and did not file a report with the state upon learning of the situation. The LVN continued to provide care to the resident after the initial report, and the resident was later moved to a different hallway, which he perceived as retaliatory. The facility's own policy required all reports of abuse, neglect, or exploitation to be reported to appropriate agencies and thoroughly investigated, but this was not followed in this case. The failures in immediate investigation, reporting, and protection placed the resident at risk for physical harm and mental anguish. The deficiency was identified as Immediate Jeopardy, and the facility was found out of compliance due to the lack of effective corrective systems at the time of the incident.
Failure to Provide Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents reviewed for wound treatment and services. Specifically, one resident with paraplegia and multiple complex wounds did not receive wound care interventions as ordered, including scheduled bandage changes, regular turning and repositioning, and being placed in a chair twice daily. Documentation and interviews revealed that wound care was not consistently provided, with missed dressing changes and inadequate implementation of physician and wound care specialist orders. As a result, the resident's wounds deteriorated, leading to hospitalization for severe sepsis and surgical wound debridement. Record reviews and staff interviews confirmed that wound care was not provided daily as ordered for two additional residents, with at least one instance where wound dressings were not changed for an entire day. Observations showed soiled and saturated dressings, and staff acknowledged that either the wound care nurse or charge nurses were responsible for providing wound care in the absence of the designated wound care nurse. However, this responsibility was not consistently fulfilled, and dressings were left unchanged, increasing the risk of infection and delayed healing. Interviews with residents, family members, and staff highlighted ongoing concerns about inadequate care, poor communication, and lack of responsiveness to resident needs. One resident and her family reported repeated complaints to facility leadership about missed turning, infrequent dressing changes, and being left in soiled conditions, with little to no resolution. Staff shortages, lack of continuity in wound care nursing, and inconsistent adherence to care plans and physician orders contributed to the deficiencies observed. These failures placed residents at risk of physical harm, including infection and wound deterioration.
Failure to Provide Safe Transfer and Supervision Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents. The resident involved was a bedbound female with severe cognitive impairment, contractures, and multiple comorbidities, including dementia, COPD, and congestive heart failure. She was totally dependent on staff for all activities of daily living and required substantial to total assistance for transfers, with therapy assessments specifying the use of a Hoyer lift for all transfers due to her inability to move or assist herself. Despite these requirements, the resident was transferred by a CNA using a gait belt as a one-person assist, contrary to therapy instructions and the care plan, which specified two-person assistance and the use of a mechanical lift. Following this improper transfer, the resident was found alone in her room with a hematoma on her forehead and a fractured hip. Multiple staff interviews and record reviews confirmed that the resident was unable to move independently and that the transfer method used was not appropriate for her condition. The care plan and therapy notes clearly indicated the need for mechanical lift assistance, and staff were aware of her high risk for falls and injury due to her frailty and cognitive impairment. The incident was not immediately reported, and there was a lack of prompt recognition and response to the resident's injury. Documentation and interviews revealed inconsistencies in staff accounts regarding the events leading up to the injury, and the facility failed to ensure that precautionary interventions and supervision were in place for this known high-risk resident. The failure to follow established care plans and therapy recommendations directly led to the resident sustaining significant injuries while left unsupervised.
Pharmaceutical Service Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by several discrepancies in the administration and documentation of narcotic medications. Licensed Vocational Nurses (LVNs) J and C did not ensure the narcotic count was correct during shift changes for four residents. Additionally, LVN J failed to document the administration of narcotic medications accurately for these residents, which included administering the wrong medication to one resident. Resident #68, a male with moderate cognitive impairment and multiple diagnoses including chronic pain, was prescribed Tramadol 37.5 mg - Acetaminophen 325 mg. However, he was administered Tramadol 50 mg instead, due to a failure to verify the correct medication. This error was compounded by the lack of documentation on the narcotic log, leading to discrepancies in the narcotic count. Similar issues were observed with Resident #18, who did not have the administration of Acetaminophen-Codeine #3 properly documented, and Resident #25, whose administration of Norco was not recorded on the narcotic log. Resident #3, who has moderate cognitive impairment and a history of pain, was also affected by these documentation failures. The facility's policy requires that controlled substances be accurately documented and counted at the end of each shift, but these procedures were not followed. Interviews with the staff revealed a lack of attention to detail and hurried practices during shift changes, contributing to the inaccuracies in narcotic counts and documentation.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #79, had reasonable access to a call light system, which is crucial for requesting staff assistance. During an observation, it was noted that Resident #79's call light cord was wrapped around the call light base on the wall, making it inaccessible to him. This deficiency was identified through interviews, observations, and record reviews. Resident #79, a man with multiple medical conditions including metabolic encephalopathy, pulmonary embolism, type 2 diabetes, chronic kidney disease, dementia, and other disorders, was unable to reach the call light due to its improper placement. His care plan specifically included an intervention to place the call light within his reach, which was not adhered to. Interviews with staff members, including a CNA and an LVN, confirmed that the call light was not within reach of Resident #79, and they acknowledged the importance of having the call light accessible to residents. The facility's administrator also stated that the call lights should be placed where residents can use them and that the current placement did not meet her expectations. The facility's policy on answering call lights emphasized that the call light should be within easy reach of residents, which was not the case for Resident #79.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorders for a Level II PASARR evaluation upon a significant change in status assessment. This deficiency was identified for one of the eighteen residents reviewed for PASARR evaluations. The resident in question, a female with multiple diagnoses including delusional disorder, mood disorder, generalized anxiety disorder, psychosis, and bipolar disorder, was not referred to the appropriate state-designated authority for further evaluation. Upon admission, the resident's MDS assessment indicated moderately impaired cognition, and she was not evaluated by PASARR, with no serious mental illness noted. However, subsequent assessments showed a decline in cognition and the presence of serious mental health diagnoses, including anxiety, depression, and a psychotic disorder. Despite these findings, the resident was not referred for a Level II PASARR evaluation, which could have identified the need for specialized mental health services. The MDS Coordinator admitted to not realizing the need for a PASARR referral until prompted by a state surveyor. The facility's policy requires that all new admissions be appropriately screened to determine the need for specialized services, but this was not adhered to in this case. The oversight in the PASARR process could potentially lead to residents not receiving necessary mental health services, as highlighted by the coordinator's acknowledgment of the risk of residents falling through the cracks.
Failure to Administer Insulin and Notify NP for High Blood Sugar
Penalty
Summary
The facility failed to ensure that Resident #35 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. On 5/13/24, LVN M recorded a blood sugar level of 422 for Resident #35 but did not document notifying NP B or administering the 10 units of insulin that were ordered. This oversight was identified during a review of Resident #35's medical records, which showed no documentation of insulin administration or notification to the nurse practitioner. Resident #35, a male with a history of Type 2 Diabetes, was at risk for hyperglycemia due to his condition. His care plan included monitoring blood sugar levels and notifying the nurse practitioner if levels were outside the specified range. Despite these instructions, there was no record of communication with NP B regarding the elevated blood sugar level on 5/13/24, nor was there any documentation of insulin being administered to address the high blood sugar. Interviews with NP B, RN P, and the ADON confirmed that the facility's protocol required staff to notify the nurse practitioner of any blood sugar readings outside the specified range and to document any subsequent orders and actions taken. However, in this instance, LVN M did not follow these procedures, resulting in a lack of appropriate response to Resident #35's high blood sugar level.
Failure to Document Correct Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a psychotropic drug prescribed to a resident was free from unnecessary use. Specifically, the facility did not document a correct diagnosis, nor did it monitor the effectiveness and side effects of Seroquel, an antipsychotic medication, prescribed to a resident. The resident, a man with dementia, affective disorder, and anxiety disorder, was administered Seroquel for dementia, which was not an appropriate diagnosis for the medication. The resident's care plan included monitoring for adverse medication reactions and signs of depression, but the facility did not update the underlying diagnosis for the Seroquel prescription despite recommendations from the consultant pharmacist. The pharmacist had advised that the medication should be prescribed for an appropriate psychiatric diagnosis, such as delusion disorder, rather than dementia. The facility's Assistant Director of Nursing (ADON) acknowledged that the diagnosis should have been changed in March when the recommendation was made and agreed upon by the physician. The facility's Medication Regimen Reviews policy required the consultant pharmacist to review each resident's medication regimen monthly to identify errors, including documentation errors. However, the facility did not act on the pharmacist's recommendation in a timely manner, resulting in the resident receiving Seroquel under an incorrect diagnosis for several months. This oversight placed the resident at risk of receiving unnecessary medications.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11% due to three errors out of 27 opportunities. This involved two residents, one of whom did not receive the full dose of Lacosamide, a medication for seizure control, until a state surveyor intervened. The Licensed Vocational Nurse (LVN) responsible for administering the medication admitted to not wearing glasses, which led to the oversight of leaving 2.5 to 5 mL of the medication in the cup. The Assistant Director of Nursing (ADON) acknowledged that all medication should be administered as ordered, and the facility conducts competency checks for feeding tube medication administration. Another resident was affected by medication administration errors when a Medication Aide (MA) administered Sucralfate later than scheduled and failed to administer Lexapro as ordered. The MA's shift started at 8:00 a.m., and she was responsible for two halls of residents, which contributed to the delay. The Pyxis machine did not have the Lexapro, and the pharmacy was notified to send it immediately. The ADON noted that medications should be reordered seven days in advance to ensure availability and acknowledged the importance of administering Sucralfate before meals. The facility's policy on administering medications, dated December 2012, states that medications should be administered safely, timely, and as prescribed, within one hour of their scheduled time unless specified otherwise. The Administrator expressed the expectation that medications be administered correctly and according to the physician's order. The report highlights the facility's failure to adhere to these policies, resulting in a medication error rate exceeding the acceptable threshold.
Inaccurate Medical Records and Oxygen Therapy Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to discrepancies in their oxygen therapy orders. Resident #48, a female with multiple diagnoses including COPD and respiratory failure, was observed without oxygen despite having a continuous oxygen order in her records. Interviews revealed that there was a discussion about discontinuing her oxygen, but no order was placed to reflect this change. The nursing staff continued to sign off on the administration of oxygen, indicating a lack of communication and oversight in updating her medical records. Resident #63, a male with conditions such as heart failure and dementia, was observed using oxygen continuously, yet there was no physician order documented for this treatment. Despite being on oxygen, his medical records did not reflect this, and the nursing staff failed to identify the absence of an order. This oversight could lead to the resident receiving unnecessary oxygen, as there was no documented need or physician directive for its use. The facility's policies on charting and documentation, as well as medication and treatment orders, were not adhered to, resulting in incomplete and inaccurate medical records. The Assistant Director of Nursing acknowledged the responsibility for overseeing these errors, highlighting a systemic issue in ensuring that medical records are updated and accurate. The lack of proper documentation and communication among staff members contributed to the deficiencies observed in the care of these residents.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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