Lake Lodge Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Worth, Texas.
- Location
- 3800 Marina Dr, Lake Worth, Texas 76135
- CMS Provider Number
- 455903
- Inspections on file
- 46
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Lake Lodge Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple serious conditions, including acute respiratory failure, CHF, pulmonary edema, diabetes, and obesity, had no order or care plan for weight loss medication or self-administration of medications. An LVN observed the resident self-injecting a syringe provided by a family member, who gave conflicting explanations that it was for anxiety, then just water, while another nurse heard it described as a weight loss medication. A CNA reported that the resident told her his family member was giving him weight loss medication, but she did not report this information to her supervisor. Other licensed staff stated they were unaware of any outside medications and would have reported such information. This failure to report occurred despite facility policy requiring all individuals to recognize and report potential abuse, neglect, or situations that may constitute neglect, resulting in the cited deficiency.
Staff failed to follow infection control procedures when a medical assistant used reusable wrist BP cuffs on multiple residents in succession without disinfecting the cuffs between uses. Over the course of a morning medication pass, the assistant obtained BP readings on eight residents with varying medical conditions, including Parkinson’s disease, CKD, diabetes, and hypertension, and with cognitive status ranging from intact to severely impaired, but only performed hand hygiene and did not clean the cuffs. In interviews, the assistant reported sanitizing cuffs only when residents had COVID, while other nursing staff and the DON stated that cuffs are required to be sanitized between each resident to prevent cross contamination, contrary to what was observed.
A CNA provided a list containing names and medical appointment details of ten residents to a resident, intending for it to be given to the volunteer Ombudsman. The list included sensitive health information such as upcoming or missed appointments with various specialists. The resident who received the list was cognitively intact and later gave it to the DON. The CNA admitted to breaching confidentiality, and facility records confirmed prior training on privacy policies.
Staff failed to use required PPE, including gowns, and did not consistently perform hand hygiene while providing high-contact care to a resident on enhanced barrier precautions for a wound and Foley catheter. Despite clear care plans and facility policies, multiple staff members provided wound care, incontinence care, and assistance with dressing using only gloves, and one LVN did not perform hand hygiene between glove changes. Staff interviews revealed awareness of the requirements but cited forgetfulness and lack of PPE supplies as reasons for non-compliance.
A resident with dementia and physical impairments reported missing money to a housekeeper, who failed to notify the administrator or initiate a timely report of the alleged misappropriation. The incident was not reported to facility leadership or authorities as required by policy, resulting in a delay in investigation and notification.
Three residents experienced deficiencies in their living environment, including a restroom that was not cleaned daily and prolonged lack of hot water in restrooms. One resident's restroom contained standing feces and a strong odor, while multiple residents had to use alternative hygiene methods due to the absence of hot water. Staff interviews and facility logs confirmed that these issues persisted for an extended period and were not consistently reported or addressed according to facility policy.
Residents report that their requests and recommendations during council meetings are not being addressed, with the administration unresponsive and the grievance process ineffective. Complaints include long wait times for care, staff using personal phones during care, and selective snack distribution. Night shift staff are described as loud and unprofessional, with cultural differences cited as a factor. An incident involved an aide entering a shower room during a resident's shower, leaving the door open. Food menu variety is also a concern.
The facility failed to assess and obtain informed consent for bed rail use for two residents with dementia and fall risks. Both residents were observed using bed rails without documented assessments or consent forms. Interviews with staff and visitors revealed a lack of adherence to the facility's policy, which requires assessment, consent, and care planning before installing bed rails.
A resident with severe cognitive impairment received expired insulin due to improper labeling and storage practices at the facility. The LVN administered insulin pens that were not dated upon opening, and the pens were stored with office supplies, leading to confusion about their usability. The facility's policy required insulin to be dated and stored separately, but these procedures were not followed, resulting in the administration of potentially ineffective medication.
A facility experienced a 7% medication error rate due to two incidents: a CMA administered Methocarbamol to the wrong resident, and an LVN gave expired Lantus insulin to a resident. The errors were identified during medication pass observations, revealing non-compliance with facility policies on medication labeling and dating.
A facility failed to properly store and label insulin, leading to the administration of expired insulin to a resident with diabetes. Insulin pens were found undated and stored with office supplies, contrary to policy. The LVN was unaware of the opening dates, and the ADON and DON acknowledged the lapse in medication management practices.
A resident with Alzheimer's Disease experienced a delay in receiving medical treatment due to the facility's failure to promptly follow up on x-ray results. The resident complained of knee pain, and an x-ray revealed a fracture, but the results were not communicated in a timely manner, leading to an 8-hour delay in sending the resident to the hospital. Staff interviews highlighted a lack of a written policy and inconsistent follow-up on x-ray orders.
A resident with significant medical needs, including a tracheostomy and anoxic brain damage, was found without access to a call button, which was placed on a dresser instead of within reach. Staff interviews confirmed the oversight, acknowledging the responsibility to ensure call lights are accessible to all residents, as per facility policy on resident rights.
A resident with a history of brain injury and a previous order for a fall mat experienced a fall resulting in a skin tear due to the facility's failure to provide the necessary care devices. Multiple staff members were aware of the missing fall mat but did not ensure it was in place, leading to the resident's injury.
A resident with a history of traumatic subdural hemorrhage and brain injury fell and sustained a skin tear due to the facility's failure to ensure a fall mat was in place as ordered. The CNA was aware of the missing fall mat but did not take action, leading to the resident's injury. Interviews with staff revealed a lack of adherence to the resident's care plan and MD orders.
A resident with severe cognitive impairment and a history of falls sustained injuries after falling out of bed due to the facility's failure to implement fall precautions and report the incident promptly. The fall mat was not in place, and staff did not follow the care plan and MD orders, leading to neglect.
A resident with severe cognitive impairment and multiple medical conditions fell out of bed and sustained injuries. The facility failed to report the incident to the state in a timely manner and did not document an investigation as required by their policy.
Failure to Report Resident Disclosure of Outside Weight Loss Medication
Penalty
Summary
The deficiency involves staff failing to report a resident’s disclosure that he was receiving a weight loss medication from his family that was not provided or ordered by the facility. The resident was an older adult male with acute respiratory failure as his primary diagnosis and additional conditions including anxiety disorder, acute on chronic systolic congestive heart failure, acute pulmonary edema, type 2 diabetes mellitus, and obesity. His medical record showed no physician order for a weight loss medication and no care plan addressing weight loss medication or self-administration of medications; his care plan specified that medications were to be given as ordered by the physician. On one occasion, a nurse (LVN A) documented entering the resident’s room and witnessing a family member handing the resident a syringe, then observing the resident self-inject into his lower abdomen. The family member stated at that time that the injection was for anxiety and claimed that everyone in the facility knew about it. LVN A requested to see the syringe, but the family member refused and later stated it was just water used as a placebo. The nurse documented the event and notified the DON and physician. Another nurse (LVN D) reported that the same family member told staff at the nurse’s station that the medication was for weight loss, and LVN D stated she did not hear the family member say it was for anxiety. A CNA (CNA B) later reported that the resident had told her his family member was giving him medication for weight loss. CNA B stated she never actually saw the family member give the medication and had not heard from other staff that the resident was taking weight loss medication, and she did not report the resident’s statement to her supervisor because she did not think it needed to be reported at the time. Other licensed nursing staff (RN C and LVN D) stated they had not been told by the resident that he was taking medications not provided by the facility and indicated they would have reported such information to the DON, ADM, and physician if they had known. The facility’s abuse/neglect policy states that each individual is responsible for recognizing and reporting situations that may constitute abuse or neglect, and that any person with reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state, and/or adult protective services. Despite this policy and the expectation from the DON and ADM that staff report knowledge of residents receiving outside medications, CNA B did not report the resident’s disclosure about weight loss medication, leading to the cited deficiency.
Failure to Disinfect Reusable BP Wrist Cuffs Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an infection prevention and control program by not sanitizing reusable blood pressure (BP) wrist cuffs between residents. On the identified date, a medical assistant (MA) used two wrist blood pressure monitors (BPM #1 and BPM #2) to obtain BP readings for eight residents without disinfecting the wrist cuffs between uses. The facility’s own infection control plan required that reusable equipment be appropriately cleaned, disinfected, or reprocessed, and staff interviews confirmed that BP cuffs were expected to be sanitized between residents to prevent cross contamination. Surveyors observed the MA attempting to obtain a BP reading on one male resident using BPM #1, then immediately using the same device on another resident’s wrist without sanitizing the cuff. The MA then proceeded through a series of residents, using BPM #1 and BPM #2 on their wrists and repeatedly failing to sanitize the cuffs after each BP measurement. After each encounter, the MA washed and dried her hands before exiting the room, but no cleaning of the wrist cuffs was performed between residents. The residents involved had multiple medical diagnoses, including Parkinson’s disease, tremors, traumatic brain injury history, type 2 diabetes mellitus, chronic kidney disease stage 4, and essential (primary) hypertension. Their cognitive status ranged from no cognitive impairment (BIMS scores 14–15), to moderate impairment (BIMS 9), to severe impairment (BIMS 1), and some were unable to complete interviews. During an interview, the MA stated that the cuffs were sanitized between each resident only when residents had COVID, and showed the surveyor the wipes used for cleaning equipment. Other nursing staff, including LVNs and the DON, stated that BP cuffs must be sanitized between each resident to avoid cross contamination, underscoring that the observed practice did not follow facility policy or expected infection control procedures. This failure could place residents at risk of infection.
Unauthorized Disclosure of Resident Medical Information
Penalty
Summary
A certified nursing assistant (CNA) assigned as the facility's transport person provided a list containing the names and medical appointment details of ten residents to another resident. The list included specific information about each resident's upcoming or missed medical appointments, such as MRI, orthopedic, podiatry, pain management, pulmonary, urology, nephrology, and dermatology visits. The CNA gave this list to a resident with the intention that it be delivered to the volunteer Ombudsman. The resident who received the list was cognitively intact, as indicated by a BIMS score of 15, and later presented the list to the Director of Nursing (DON), expressing frustration over the CNA's suspension. The CNA admitted to providing the list and acknowledged that this action breached residents' confidentiality. The volunteer Ombudsman confirmed that he did not receive the list. Facility records showed that the CNA had previously completed training on confidentiality and had signed a privacy and non-disclosure agreement. The facility's policy states that residents have the right to personal privacy and confidentiality of their personal and medical records. The incident was identified through interviews and record reviews, and it involved the unauthorized disclosure of protected health information to an unauthorized individual.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident on enhanced barrier precautions due to a wound and an indwelling Foley catheter. On the observed date, multiple staff members, including a CNA and two LVNs, did not use the required personal protective equipment (PPE) such as gowns while providing high-contact care activities like wound care, dressing, and incontinence care. Specifically, staff entered the resident's room, which was marked for enhanced barrier precautions, and performed care activities wearing only gloves but no gowns, despite facility policy and physician orders requiring both gloves and gowns for such interactions. During wound care and incontinence care, one LVN failed to perform hand hygiene between glove changes when moving from dirty to clean tasks. The staff involved acknowledged during interviews that they were aware of the requirements for PPE and hand hygiene but cited reasons such as forgetting or lack of PPE supplies immediately available outside the resident's room. The absence of a PPE cart outside the room was noted as a contributing factor for non-compliance by one CNA. The resident involved was a female with a history of hypertension, end stage renal disease, and cerebral vascular accident, and was assessed as moderately cognitively impaired. Her care plan and physician orders specifically required enhanced barrier precautions, including the use of gloves and gowns for high-contact activities. Facility policy also emphasized the importance of hand hygiene and proper PPE use to prevent the transmission of infection.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged violation involving misappropriation of a resident's property within the required 24-hour timeframe to the administrator and appropriate authorities. A female resident with vascular dementia, hemiplegia, and other significant medical conditions reported that $90 was stolen from her bedside table over the course of several days. The resident, who was her own responsible party and had a BIMS score indicating intact cognition, did not initially report the missing money to facility leadership but mentioned it to a housekeeper. The housekeeper, upon being informed by the resident about the missing money, did not report the incident to the administrator, believing the resident had already done so. The housekeeper assisted the resident in securing some remaining money by placing it in an envelope and hiding it in a book in the resident's drawer, but did not consider offering a lock box or formally reporting the theft. Interviews with other staff, including CNAs and the business office, revealed that they were unaware of the missing money and had not received any reports regarding theft or misappropriation. The business office confirmed the resident had made several cash withdrawals but had not been informed of any missing funds. Both the administrator and DON stated they were not aware of the incident until the day of the survey and emphasized that all staff are expected to report such incidents immediately, as per facility policy and recent in-service training. Facility policy requires all allegations of abuse, neglect, exploitation, or misappropriation of resident property to be reported to the administrator, who must then notify the appropriate authorities within specified timeframes. The failure of the housekeeper to report the resident's allegation of missing money resulted in a delay in investigation and notification, contrary to facility policy and regulatory requirements. This lapse was identified during the survey through interviews and record reviews, which confirmed that the incident was not reported until the surveyor's inquiry.
Failure to Maintain Clean Restrooms and Hot Water Access for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents by not ensuring daily cleaning of a resident's restroom and by not providing hot water in the restrooms for multiple residents. One resident's restroom was observed to have standing feces in the toilet and a strong foul odor that extended into the resident's room, with the restroom door closed. The resident reported that housekeeping cleaned her room but not the restroom, and staff interviews confirmed that the restroom was not cleaned because it was believed the resident did not use it. The toilet was also found to be clogged, and this issue was not reported in the maintenance log as required by facility policy. Multiple residents, including those with chronic conditions such as COPD and those requiring assistance with activities of daily living, did not have access to hot water in their restrooms for an extended period. Staff and residents reported that the lack of hot water had persisted for more than a week, and water temperature logs confirmed repeated and prolonged outages of hot water on several halls. Residents had to use alternative means for personal hygiene, such as antibacterial wipes or being taken to other halls for showers, and expressed dissatisfaction and discomfort with these arrangements. Facility records showed inconsistent documentation of water temperature checks, with significant gaps in the log and repeated notations of no hot water available. Maintenance staff attributed the hot water outages to recurring slab leaks and aging infrastructure, and invoices confirmed ongoing plumbing repairs. Despite these issues, the facility's own policies required daily checks and prompt repair of hot water systems, as well as regular cleaning and maintenance of resident restrooms, which were not consistently followed.
Resident Council Concerns and Staff Inaction
Penalty
Summary
Residents have reported that their requests and recommendations made during resident council meetings are not being addressed by the facility staff. The administration has been unresponsive, with residents being told that their issues have been overlooked and need to be restarted from the beginning. The grievance process, which should be initiated with the social worker, is reportedly not being followed, with the administrator acting as the grievance representative but failing to respond to residents' concerns. Additionally, there are complaints about long wait times for care, staff engaging in personal conversations and using personal cell phones during care provision, and selective distribution of snacks, particularly during the 6 PM to 6 AM shift. Residents feel that their rights are being dismissed, and there is a lack of respect for their choices and rights, especially during the night shift. There are also issues with the night shift staff being loud and unprofessional, with cultural differences being cited as a contributing factor. The social worker has been inconsistent in following through with grievances, with some cases remaining unresolved for months. Residents have expressed concerns about potential retaliation from management for filing grievances. An incident was reported where an aide entered a shower room to converse with another aide while a resident was undressed, leaving the door open. Additionally, there are complaints about the lack of variety in the food menu, with residents feeling that the state should have more control over kitchen operations. The facility's grievance process appears to be ineffective, with ongoing issues not being resolved in a timely manner.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of bed rails and enabler bars for two residents, identified as Residents #3 and #63. Both residents were observed using bed rails without documented assessments or consent forms in their medical records. Resident #3, who has a history of dementia, muscle weakness, and falls, was found asleep in bed with raised half bedrails on multiple occasions. Despite the resident's cognitive impairments and reliance on a wheelchair for mobility, there was no documentation of an assessment for the safe use of bed rails or a signed consent form in the resident's care plan. Similarly, Resident #63, who also suffers from severe dementia and repeated falls, was observed with a raised half bed rail. The resident's care plan did not include the use of bed rails as an intervention, and there was no evidence of an assessment or consent form in the medical records. Interviews with the resident's visitor and facility staff revealed that the resident felt more secure with the bed rails, but neither the resident nor the visitor recalled any assessment or consent process being completed. Interviews with facility staff, including the Maintenance Manager, CNA, ADON, DON, and ADM, highlighted a lack of adherence to the facility's policy on bed rail use. The policy requires an assessment for risk of entrapment, informed consent, and proper care planning before installing bed rails. Despite these requirements, the facility did not provide adequate documentation or follow the necessary procedures for Residents #3 and #63, leading to the deficiency identified in the report.
Expired Insulin Administered Due to Improper Labeling and Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, specifically in the administration of insulin. A Licensed Vocational Nurse (LVN) administered expired insulin to a resident with type 2 diabetes mellitus and high blood pressure. The insulin pens used were not labeled with the date they were opened, which is a requirement to ensure the medication's potency and effectiveness. The LVN was unaware of when the insulin pens were opened and assumed they were still effective because the resident was newly admitted. The resident in question was a female with severe cognitive impairment, as indicated by her BIMS score, and had long-term and short-term memory problems. During a medication pass observation, it was noted that the insulin pens were stored improperly with office supplies, and two of the pens lacked opening dates. The LVN believed the insulin was still within the usable time frame, but this assumption was incorrect due to the lack of proper labeling and storage. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that the facility's policy required insulin to be dated upon opening and stored separately from non-medical items. The ADON and DON were responsible for conducting medication cart audits, but the oversight in labeling and storage was missed. The facility's policy also specified the expiration time frames for different types of insulin, which were not adhered to in this case.
Medication Administration Errors Lead to 7% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a 7 percent error rate. This was due to two specific incidents involving medication administration errors. In the first incident, a Certified Medication Aide (CMA) administered Methocarbamol 500 MG intended for one resident to another resident. The CMA admitted to being nervous and mistakenly took the medication belonging to the roommate of the intended recipient. In the second incident, a Licensed Vocational Nurse (LVN) administered expired Lantus insulin to a resident. The LVN was unaware of the expiration date and believed the insulin was still effective because the resident had been recently admitted. The errors were identified during observations of medication passes and interviews with the involved staff. The facility's policies required medications to be dated when opened, and the manufacturer's guidelines for insulin indicated it should be used within 28 days of opening. However, the LVN did not adhere to these guidelines, leading to the administration of expired insulin. Interviews with the Director of Nursing (DON) and the administrator revealed expectations for staff to follow the seven rights of medication administration and ensure medications were properly labeled and dated. Despite these policies, the errors occurred, contributing to the facility's medication error rate exceeding the acceptable threshold.
Improper Storage and Labeling of Insulin in Medication Cart
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, specifically insulin, in accordance with professional principles. During an observation, it was found that expired insulin was not removed from the nurse medication cart in the secure unit. Additionally, insulin pens were stored alongside office stationery items such as pens, markers, paper clips, and rubber bands, which is against the facility's policy for medication storage. A resident with type 2 diabetes mellitus and severe cognitive impairment was involved in this incident. The resident had active orders for both long-acting and short-acting insulin. During a medication pass, it was observed that the insulin pens were undated, and one of the pens was expired. The LVN administering the medication was unaware of when the insulin pens were opened and proceeded to administer insulin from an expired pen to the resident. Interviews with the LVN, ADON, and DON revealed a lack of adherence to medication storage policies. The LVN admitted to not knowing who placed the stationery items with the insulin and was unaware of the opening dates of the insulin pens. The ADON and DON acknowledged that insulins should be dated and stored separately from other items to prevent contamination. Despite regular audits, the issue was not identified until the survey, indicating a lapse in the facility's medication management practices.
Delayed X-ray Results Lead to Hospitalization
Penalty
Summary
The facility failed to provide timely radiology services for a resident, leading to a delay in diagnosis and treatment. The resident, who had Alzheimer's Disease and severe cognitive impairment, complained of right knee pain, which was assessed as swollen and tender. An x-ray was ordered, but the results indicating a fracture were not promptly communicated to the facility, resulting in a delay in sending the resident to the hospital for further evaluation and treatment. The deficiency was identified when the Director of Nursing (DON) reviewed the nursing documentation and discovered the delay in receiving and acting upon the x-ray results. The x-ray company did not follow their protocol of faxing or calling the facility with critical results, and the facility staff did not access the results through the available portal. This communication breakdown led to an 8-hour delay in addressing the resident's fracture. Interviews with facility staff revealed a lack of a written policy on x-ray services and inconsistent follow-up on ordered x-rays. Staff were in-serviced on the importance of timely follow-up on stat x-rays and the need to notify the physician if results were delayed. The facility's failure to ensure timely communication and follow-up on diagnostic services resulted in delayed medical treatment and hospitalization for the resident.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility did not place the call button within reach of a resident who was dependent on staff for assistance. The resident, a male with anoxic brain damage, tracheostomy, and other medical conditions, was observed in bed with the call button placed on a dresser, making it inaccessible. This oversight was noted during an observation and attempted interview, where the resident was unable to respond to questions about the call button. Interviews with staff, including an LVN, the DON, the Administrator, a CNA, and the Corporate Compliance Nurse, revealed that it was the responsibility of all staff to ensure call lights were within reach of residents. Despite the resident's inability to use the call button frequently, it was acknowledged that it should be accessible to him. The CNA admitted to placing the call pad on the dresser and forgetting to return it to the bed, where the resident could access it. The facility's policy on resident rights emphasized the importance of providing reasonable accommodation for resident needs and preferences, which was not adhered to in this instance.
Failure to Prevent Resident Fall Due to Missing Fall Mat
Penalty
Summary
The facility failed to ensure that Resident #1 was free from neglect when they did not provide the necessary care devices to prevent injury from a fall. Resident #1, who had a history of traumatic subdural hemorrhage with brain injury and a previous order for a fall mat, experienced a fall resulting in a skin tear. The CNA was aware that the fall mat was missing but did not notify the head nurse, leading to the resident's fall and subsequent injury. The deficiency was further highlighted by the fact that multiple staff members, including the DON, LVN, and RN, were aware of the missing fall mat but failed to ensure it was in place. The DON admitted that the fall mat should have been in place and that the staff did not review MD orders, care plans, and assessments to ensure the resident's safety. The incident occurred over several shifts, indicating a systemic failure to follow through on care protocols. Interviews with various staff members revealed a lack of familiarity with Resident #1's care requirements and a failure to review and implement MD orders. The facility's policy on abuse and neglect was not followed, as the staff did not provide the necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. This neglect led to Resident #1's fall and injury, demonstrating a significant lapse in the facility's duty of care.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide the necessary care devices to prevent injury from a fall for a resident with a history of traumatic subdural hemorrhage and brain injury. The resident had a previous order for a fall mat, which was not in place at the time of the incident. As a result, the resident experienced convulsions/seizures, fell, and sustained a skin tear on the forehead. The resident's medical history included a traumatic subdural hemorrhage with loss of consciousness, conversion disorder with seizures, and chronic respiratory failure. The resident was nonverbal and had severely impaired cognition, as indicated by a BIMS score of 0. Despite these conditions, the facility staff failed to ensure that the fall mat was in place, which was a critical intervention to prevent falls and related injuries. The CNA on duty was aware that the fall mat was missing but did not take action to rectify the situation, leading to the resident's fall and subsequent injury. Interviews with facility staff, including the CNA, DON, and other nursing staff, revealed that there was a lack of adherence to the resident's care plan and MD orders. The DON acknowledged that the fall prevention precautions were not followed, and the CNA admitted that the fall mat was not applied next to the resident's bed. This failure to implement and monitor fall prevention devices as ordered contributed directly to the resident's fall and injury. The facility's policy on fall prevention strategies was not effectively executed, resulting in the identified deficiency.
Failure to Implement Fall Precautions and Report Neglect
Penalty
Summary
The facility failed to implement their written policies and procedures regarding allegations of neglect for a resident who fell out of bed and sustained injuries to his forehead. The resident, who had a history of traumatic subdural hemorrhage, neuromuscular dysfunction, and chronic respiratory failure, was found to have severely impaired cognition and was nonverbal. Despite having a care plan that included fall precautions such as a floor mat next to the bed, these measures were not followed, leading to the resident's fall and subsequent injuries. On the day of the incident, the resident's fall mat was not in place, and the nursing staff did not ensure its presence during their shifts. The resident fell out of bed, resulting in skin tears on his forehead. The incident was not reported immediately, and the fall mat was not placed back after the fall. Interviews with the staff revealed that they were aware of the missing fall mat but failed to take corrective action. The Director of Nursing (DON) confirmed that the fall mat was not in place and acknowledged that the staff did not follow the care plan and MD orders. The facility's policy on abuse and neglect requires immediate evaluation and reporting of such incidents, but this protocol was not followed. The staff's failure to implement the fall precautions and report the incident promptly led to the resident's injuries. The DON and other staff members admitted that neglect occurred due to the failure to provide the necessary care as outlined in the resident's care plan and MD orders.
Failure to Report and Investigate Resident Fall
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not follow its policy on reporting neglect when a resident fell out of bed and sustained injuries to his forehead. The incident was not reported to the state in a timely manner, and there was no documentation of an investigation into the fall and injuries as required by the facility's policy. The resident involved was a male with a history of traumatic subdural hemorrhage, conversion disorder with seizures, chronic respiratory failure with hypoxia, and dysphagia. He was severely cognitively impaired and nonverbal, with a feeding tube and a stage 4 wound. The resident fell out of bed and sustained two injuries to his forehead. Despite the fall and injuries being reported to the Director of Nursing (DON) and the Administrator, the incident was not immediately reported to the state, and no investigation was documented. Interviews with staff revealed that the fall was reported to the charge nurse and the DON, and the resident was assessed and treated for his injuries. However, the Administrator did not initially report the incident to the state, as he did not consider the injuries life-threatening. The facility's policy required immediate reporting and documentation of the investigation, which was not followed in this case.
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.
