Lake Village Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewisville, Texas.
- Location
- 169 Lake Park Rd, Lewisville, Texas 75057
- CMS Provider Number
- 675560
- Inspections on file
- 34
- Latest survey
- November 28, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Lake Village Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities was left in bed wearing only a shirt and brief after an LVN provided incontinence care and removed the bed linens, leaving the room door open and failing to ensure visual privacy. Video showed the resident remained without sheets or a blanket and with the door open for several hours until a CNA, who had been instructed earlier but became busy and forgot, eventually entered the room and applied a fitted sheet, top sheet, and blanket. Staff interviews and written statements corroborated that the resident was visible from the hallway during this period, in violation of resident dignity and privacy expectations.
A resident with severe cognitive impairment, pancreatic cancer, and significant pain had a written order from hospice to change scheduled Hydromorphone 4 mg/mL from every 6 hours to every 4 hours, with an additional PRN order. Due to miscommunication between the DON, an LVN, and hospice staff, the new every-4-hour order was not entered into the system on the day it was received, and the MAR was not updated. The resident continued to receive Hydromorphone under a standing PRN order rather than according to the revised scheduled dosing, resulting in a failure to administer medications in accordance with the physician’s order during the cited period.
A resident with intellectual and developmental disabilities did not receive a recommended repositioning wedge as outlined in the PASRR evaluation, due to the facility's failure to update the care plan and submit a timely request for specialized services. Staff, including the MDS Coordinator, DON, and Administrator, were unaware of the recommendation, and the intervention was not reflected in the care plan or physician orders.
A nurse failed to perform required hand hygiene before and after glove use and between handling medications and resident care items while administering medications to a resident with cellulitis and impaired cognition. This occurred despite facility policy and staff expectations for hand hygiene to prevent infection transmission.
The facility failed to maintain effective infection control practices, as CNAs did not change gloves or sanitize hands during incontinent care, and an LVN did not sanitize medical equipment between residents. These actions risked cross-contamination and infection spread.
A CNA in a facility failed to maintain a resident's dignity by standing behind her while assisting with eating, rather than sitting beside her as required. The resident, who needed moderate assistance due to lack of coordination and muscle weakness, was not properly observed for swallowing difficulties. Facility staff confirmed that sitting beside residents during meals is essential for dignity and safety.
A resident's personal and medical information was exposed when a nurse left a laptop open and unattended in a hallway, displaying sensitive data. Staff interviews confirmed the expectation to secure such information, aligning with the facility's confidentiality policy.
A facility failed to include CPAP usage in a resident's care plan, despite the resident's diagnosis of obstructive sleep apnea and regular use of the device. The care plan lacked goals and interventions for the CPAP, which was confirmed through staff interviews and record reviews. This oversight could lead to confusion among staff regarding the necessary care for the resident.
A resident with obstructive sleep apnea was using a CPAP machine without a physician order, as required by facility policy. Despite the resident's regular use of the CPAP, the comprehensive care plan did not include it, and staff confirmed the absence of a necessary physician order. This oversight was acknowledged by the facility's LVN, ADON, Administrator, and DON, who all recognized the importance of having a physician order for the CPAP to ensure proper treatment and monitoring.
A facility failed to properly dispose of a controlled medication, Tramadol, for a resident. An LVN discarded the medication in a trash can instead of using the designated solution, despite the facility's policy and available resources for proper disposal. Interviews with staff confirmed the expectation for narcotics to be disposed of correctly to prevent unauthorized access.
A nurse's cart was left unlocked in a hallway, containing various medications, posing a risk of unauthorized access and potential harm. The LVN was unaware of the oversight, and the facility's policy requires carts to be locked when unattended.
The facility did not ensure a clean and homelike environment, as resident rooms and hallway handrails were found unclean. Observations showed dirt on handrails and a white substance in rooms. A resident reported infrequent cleaning, and the Housekeeping Supervisor cited staffing issues. The Administrator acknowledged the cleanliness as a dignity and infection control concern.
The facility failed to maintain food service safety standards, as observed with an ice scoop stored in a wet plastic bag and a stained ice machine. The Dietary Supervisor and Administrator acknowledged the risk of infection due to inadequate cleaning, contrary to the facility's policy and FDA guidelines.
The facility failed to maintain effective infection control during a flu outbreak, leading to the spread of the virus among residents. Observations revealed inconsistent use of PPE, lack of appropriate signage, and poor communication with families. Staff interviews highlighted confusion about infection control protocols, contributing to the rapid spread of the flu.
The facility failed to maintain the required RN coverage of at least 8 consecutive hours a day, 7 days a week, for 14 days between August and September 2023. This lapse was due to scheduling issues and the resignation of the ADON responsible for scheduling. The deficiency was identified through a review of time sheets and acknowledged by the DON and Administrator.
The facility failed to ensure that the call light system was accessible to three residents, preventing them from obtaining assistance when needed. Observations revealed that call lights were placed out of reach, causing frustration and potential safety risks for the residents.
The facility failed to maintain a clean and homelike environment for six residents, with observations revealing various cleanliness issues such as stains on bedside tables, bathroom floors, and sinks. Interviews with staff indicated that the leadership was aware of the issues but had not effectively addressed them due to vacant leadership positions, leading to potential infection risks.
A resident with severe cognitive impairment did not receive showers consistently as scheduled, and there was a lack of documentation and attempts to persuade the resident to take showers. Staff interviews confirmed the issue, and the DON acknowledged the challenge in maintaining resident care due to the absence of an ADON.
The facility failed to ensure proper food storage, labeling, and kitchen sanitation. Observations revealed unlabeled and undated food items, exposed food in the freezer, dirty ice machines and ice chests, and uncovered tea dispensers and trash cans. The Dietary Manager was also observed preparing food without a head covering.
A resident with acute kidney failure and neuromuscular dysfunction of the bladder was observed with an exposed catheter bag on multiple occasions, violating the facility's policy on dignity and respect. Interviews with staff confirmed the oversight and the importance of maintaining resident dignity by using privacy bags for catheter bags.
A resident with a history of falls and severe cognitive impairment was found using a scoop mattress without a physician's order or care plan. Interviews with facility staff revealed that the mattress was used at the family's request to prevent falls, but no assessment or documentation supported its use, violating the facility's policy on restraints.
The facility failed to develop comprehensive care plans for two residents, one requiring catheter care and another at high risk for falls. Despite physician orders and assessments indicating the need for specific interventions, these were not included in the residents' care plans, as confirmed by staff interviews and observations.
The facility failed to ensure that a fall mat was placed alongside the bed of an 82-year-old female resident with severe cognitive impairment and a history of repeated falls. The resident was found lying in bed with the fall mat leaning against a chest of drawers instead of being placed next to the bed. The LVN and DON confirmed that staff should ensure the resident's environment is free of hazards, including placing the fall mat correctly.
The facility failed to ensure that two residents who needed respiratory care were provided such care consistent with professional standards. The nasal cannulas were not properly stored when not in use, and the humidifier bottles did not have water in them, increasing the risk of respiratory infections and irritation.
A resident with a history of falls experienced a fall and hit her head, but the facility inaccurately documented that the family was notified immediately. Interviews revealed the family was contacted two hours later, and the nurse admitted to being unable to reach them initially and getting distracted by other incidents.
Resident Left Without Linens and Visual Privacy After Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure full visual privacy and dignity for a male resident with severe cognitive impairment. The resident, an older adult male with dementia, pancreatic cancer, anxiety, hypertension, hypothyroidism, depression, frequent falls, and pain, had a BIMS score of 3, indicating severe cognitive impairment. His care plan was in place, and he was admitted with multiple chronic conditions. On the night in question, video evidence showed that at 2:19 AM an LVN entered the resident’s room, which had an open door, to provide incontinence care. During this care, the LVN removed the resident’s sheet and blanket and left him in bed wearing only a shirt and brief, with no linens covering him, and did not close the door or draw curtains. The video further showed that from 2:19 AM until 4:43 AM, the resident remained in this state, with the door open and without bed linens, curtains, or a closed door to provide visual privacy. At 4:43 AM, the LVN returned to the room, with the door still open, and then left again after speaking with a CNA in the hallway. Audio from the video captured the LVN telling the CNA that she had previously instructed the CNA to take care of the resident, and the CNA responding that she had forgotten because she had gotten busy. The CNA then entered the room and provided appropriate clothing and linens, including a fitted sheet, blanket, and top sheet, to cover the resident and restore his privacy and dignity. Staff interviews and written statements confirmed the sequence of events. The LVN’s written statement indicated she found the resident wet, with his penis outside the brief, removed the wet linens and brief, provided perineal care, and expected the CNA to complete the linen replacement. The CNA’s statement confirmed that she was asked to assist but delayed going to the room because she was busy, and when she eventually entered around 4:00 AM, the resident was lying in bed with only underwear, socks, and a shirt, with no linens and the door open so he was visible from the hallway. The administrator, DON, and other staff acknowledged awareness of the incident and that the resident had been left in bed with only a brief and shirt and without linens for an extended period, during which he was visible from the hallway, contrary to the facility’s resident rights policy and posted resident rights materials regarding dignity and respect.
Failure to Timely Enter and Implement New Hydromorphone Order
Penalty
Summary
The deficiency involves the facility’s failure to timely enter and implement a new physician order for scheduled pain medication for Resident #1. The resident was an elderly male with diagnoses including dementia, pancreatic cancer, anxiety, hypertension, hypothyroidism, depression, frequent falls, and pain, and had a BIMS score of 3 indicating severe cognitive impairment. On 11/04/2025, a written order was issued to change his Hydromorphone 4 mg/mL from every 6 hours to every 4 hours, with an additional PRN Hydromorphone order. The facility did not input this new every-4-hour order into the system on the day it was received, so the MAR did not reflect the updated dosing schedule. According to progress notes and interviews, Hospice Nurse D delivered the written order on 11/04/2025 and documented that the existing every-6-hour Hydromorphone order was discontinued and replaced with an every-4-hour schedule plus a PRN order. Hospice Nurse D reported that the facility had been administering the PRN Hydromorphone routinely and that the change to every 4 hours was intended to keep the resident more comfortable. She stated that the facility should have implemented the order the same day to avoid any risk of the resident missing the newly scheduled regimen. Review of the MAR showed that the new every-4-hour order was not entered, and the resident continued under the previous standing PRN order, with pain medication still being administered. Interviews with facility staff revealed miscommunication and assumptions regarding responsibility for entering the order. The DON stated that Hospice Nurse D arrived near the end of her shift, attempted to give her the written order, and was directed to speak with LVN A. The DON reported that Hospice Nurse D placed the orders in a box and informed LVN A that the DON was aware of them. LVN A stated that it was her first day working with the resident, that she initially declined to take the order by phone and requested a written order, and that when Hospice Nurse D later attempted to speak with her in person, she directed her to the DON because she was on the phone. LVN A observed the DON and Hospice Nurse D discussing the orders and assumed the DON would handle them. As a result, the new Hydromorphone every-4-hour order was not entered into the system on 11/04/2025, constituting a failure to administer medications according to the physician’s orders during the identified period of non-compliance.
Failure to Implement PASRR Recommendations for Specialized Services
Penalty
Summary
The facility failed to incorporate recommendations from the Pre-Admission Screening and Resident Review (PASRR) evaluation into the assessment, care planning, and transitions of care for a resident with intellectual and developmental disabilities. Specifically, the facility did not submit a complete and accurate request for specialized services in the required online portal within 20 business days after the annual interdisciplinary team meeting. The PASRR Comprehensive Service Plan recommended a repositioning wedge for the resident, but this intervention was not included in the resident's care plan or physician orders. The resident in question was an adult male with a history of frontal lobe executive function deficit following a cerebral infarction, bipolar disorder, schizophrenia, and other speech disorders. He was PASRR positive for intellectual and developmental disabilities and had functional quadriplegia, morbid obesity, and activity limitations. Despite these complex needs and the explicit recommendation for a repositioning wedge to address his tendency to lean to one side, the care plan and order summary did not reflect this intervention, and staff were unaware of the recommendation. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed a lack of awareness and follow-through regarding the PASRR recommendation. The MDS Coordinator was not informed of the need for a repositioning wedge, and the DON and Administrator were also unaware of the recommendation until it was brought to their attention during the survey. The facility's policy required proper screening and implementation of specialized services as determined by the interdisciplinary team, but this was not followed in this instance.
Failure to Follow Hand Hygiene Protocol During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the actions of an LVN during medication administration to a resident with a history of hypertension and cellulitis. The LVN was observed not performing hand hygiene before donning gloves, after removing gloves, or between handling medications and resident care items. Specifically, the LVN prepared and administered oral medications, including antibiotics and pain medication, without using hand sanitizer or washing hands at critical points, such as before entering the resident's room, after glove removal, and after exiting the room. The LVN also handled medication cups, pudding containers, and the resident's bed controls without appropriate hand hygiene. The resident involved had moderately impaired cognition and was being treated for cellulitis of the lower right leg, requiring antibiotics and pain management. The facility's own hand hygiene policy, which requires hand washing or use of alcohol-based hand rub before and after direct resident contact, before preparing or handling medications, after contact with objects in the resident's vicinity, and after glove removal, was not followed. Interviews with the LVN, DON, and Administrator confirmed the expectation for proper hand hygiene practices, which were not met during the observed medication administration.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs and an LVN during resident care. Specifically, two CNAs did not adhere to proper hand hygiene protocols while providing incontinent care to a resident. They failed to change gloves and sanitize their hands after handling soiled materials and before touching clean items, which is a critical step in preventing cross-contamination and infection. Additionally, an LVN did not sanitize medical equipment, such as a blood pressure cuff and pulse oximeter, between uses on different residents. This oversight occurred while the LVN was administering medications and checking vital signs for multiple residents. The lack of sanitization of these devices between residents poses a risk of transferring infections from one resident to another. The facility's policies on hand hygiene and infection control were not followed, as staff did not perform hand hygiene before and after resident care or after removing gloves. The facility's infection control plan emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections, yet these protocols were not adhered to during the observed incidents.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident during mealtime. A CNA was observed assisting a resident with eating while standing behind her, rather than sitting beside her, which is the expected practice to ensure dignity and proper observation of the resident's needs. The resident, an elderly female with a diagnosis of lack of coordination and muscle weakness, required moderate assistance with eating. The CNA acknowledged that standing behind the resident was inappropriate and attributed it to a lack of space at the table, although she admitted she should have moved the resident to a more suitable location. Interviews with facility staff, including the ADON, Administrator, and DON, confirmed that the standard practice is for staff to sit beside residents during mealtime to promote dignity, respect, and safety. The staff recognized that standing behind a resident could convey a sense of haste and disrespect, potentially compromising the resident's dignity and ability to communicate any distress. The facility's policy on dignity and respect emphasizes treating residents with kindness and respect, which was not adhered to in this instance.
Breach of Resident Confidentiality Due to Unsecured Laptop
Penalty
Summary
The facility failed to secure confidential and personal medical records for a resident, leading to a breach of privacy and confidentiality. During an observation, a nurse's cart was found unattended in the hallway with a laptop displaying the resident's personal and medical information, including their name, status, location, gender, date of birth, age, physician's name, latest vital signs, allergies, code status, emergency instructions, and physician orders. This information was visible to anyone passing by, as the laptop screen was facing the hallway. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), confirmed that the laptop should have been closed, locked, or minimized to protect the resident's information. The staff acknowledged the importance of maintaining confidentiality and recognized that the failure to do so could lead to unauthorized exposure of sensitive information. The facility's policy on confidentiality emphasizes the responsibility of all individuals handling resident information to protect its confidentiality.
Failure to Include CPAP in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with obstructive sleep apnea, who required the use of a CPAP machine. The resident's care plan, dated February 23, 2025, did not include any mention of CPAP usage, despite the resident's condition and the necessity of the device for her care. This oversight was identified during a review of the resident's records, which showed no physician order for the CPAP, and was confirmed through interviews with the resident and staff. The resident, who was unable to complete an interview for the BIMS score, was observed using the CPAP machine regularly, both at night and during naps. However, the care plan lacked any goals or interventions related to the CPAP, which was acknowledged by the LVN and the MDS Nurse. The MDS Nurse admitted that the absence of a care plan for the CPAP was due to the lack of a physician order, despite documentation indicating the resident's use of the device. This gap in the care plan could lead to confusion among staff regarding the necessary care and interventions for the resident. Interviews with facility staff, including the ADON, Administrator, and DON, highlighted the importance of having a comprehensive care plan to ensure consistent and appropriate care for residents. The facility's policy mandates that the interdisciplinary team develop a care plan within seven days of completing the Resident MDS, which should include all identified needs. The failure to include the CPAP in the care plan represents a significant deficiency in meeting the resident's medical needs as identified in the comprehensive assessment.
Lack of Physician Order for CPAP in Resident with Sleep Apnea
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident diagnosed with obstructive sleep apnea, as there was no physician order for the resident's CPAP machine. The resident, who was unable to complete an interview for the BIMS score, had been using the CPAP every night and during naps for months. However, the comprehensive care plan did not include CPAP usage, and there was no physician order documented for the CPAP in the resident's records. This oversight was confirmed by both the LVN and the ADON, who acknowledged the necessity of a physician order for the CPAP to ensure proper treatment and monitoring. Interviews with facility staff, including the Administrator and the DON, revealed a consensus that a physician order was essential for the CPAP, as it is a medical device requiring supervision to ensure safe and effective treatment. The absence of a physician order meant that staff might not be aware of the resident's use of the CPAP, potentially impacting the assessment of its effectiveness. The facility's policy on physician orders and oxygen delivery emphasized the need for orders to guide the administration of treatments, highlighting the deficiency in the resident's care plan and physician orders.
Improper Disposal of Controlled Medication
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident, specifically in the disposal of a controlled medication, Tramadol. During an observation, an LVN was seen preparing the resident's pain medication when the tablet fell onto the nurse's cart. The LVN decided to waste the medication due to contamination, placing it in a pill crusher pouch and crushing it. However, instead of using the designated solution for disposing of narcotics, the LVN discarded the pouch with residual medication into a trash can, citing a lack of access to the solution. Interviews with staff, including a medication aide, the DON, ADON, and the Administrator, revealed that the facility had a solution available for the proper disposal of narcotics, which was not utilized in this instance. The DON and ADON confirmed that narcotics should not be disposed of in the trash, as this could lead to unauthorized access by residents, staff, or visitors. The facility's policy on controlled medications emphasized safeguarding access and proper disposal, which was not adhered to in this case.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with one of the seven nurse's carts. During a medication pass on hall 300, a nurse's cart was left unlocked, containing various medications such as blister packs, eyedrops, insulin, and insulin paraphernalia. This oversight was noted by several staff members who passed by without noticing the unlocked cart. The Assistant Director of Nursing (ADON) later observed the unlocked cart and acknowledged the risk of residents accessing the medications, which could lead to accidental ingestion or allergic reactions. Interviews with the involved Licensed Vocational Nurse (LVN), the Administrator, and the Director of Nursing (DON) confirmed the expectation that medication carts should always be locked when unattended. The LVN admitted to being unaware that the cart was left unlocked and recognized the potential dangers. The Administrator and DON reiterated the importance of securing medication carts to prevent unauthorized access by residents, staff, or visitors, which could result in accidental ingestion or overdose. The facility's policy on medication storage emphasizes the need for medications to be stored in locked compartments, aligning with the professional principles that were not adhered to in this instance.
Facility Fails to Maintain Cleanliness in Resident Rooms and Hallways
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations and interviews. Specifically, the facility did not ensure that resident rooms 303b and 307b were thoroughly cleaned and sanitized. Observations revealed a large circular white patch of powdery substance on the top of a 5-drawer chest in one of the rooms, and a white substance circling the floor around the toilet. A resident in one of the rooms reported that her room was only cleaned once a week, contrary to the facility's policy of daily cleaning, and noted that her trash can was not emptied and the floors were not cleaned. Additionally, the facility failed to clean the hallway handrails, which were observed to have dark and light dirt along the brown wooden rails. The Housekeeping Supervisor acknowledged the oversight, attributing it to having only one housekeeper responsible for cleaning two halls. The Administrator recognized the cleanliness issues as a dignity and infection control concern, indicating a lapse in maintaining the facility's policy of providing a safe and clean environment.
Deficiency in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation in the facility's dining area, it was noted that the ice scoop was placed in a clear plastic bag with water at the bottom, and the ice scoop itself had black marks on it. Additionally, the ice machine had light brownish stains on its inside front opening. These conditions were not in compliance with the facility's policy on dietary services and infection control, which mandates that all work surfaces, utensils, and equipment should be cleaned and sanitized after each use. Interviews with the Dietary Supervisor and the Administrator revealed that the ice machine was cleaned at least three times a month, and the ice scoop and holder were run through the washing machine daily. However, the presence of water in the plastic bag and the stains on the equipment indicated a lapse in maintaining sanitary conditions. The Administrator acknowledged the risk of not addressing these concerns, which could result in residents becoming ill. The facility's policy and the FDA Food Code emphasize the importance of preventing contamination to avoid foodborne illnesses.
Inadequate Infection Control Measures During Flu Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to the spread of the flu among residents. Observations revealed that residents with the flu did not have appropriate signage on their doors, and personal protective equipment (PPE) was not consistently available or used by staff. For instance, a CNA entered a flu-positive resident's room wearing only a mask, and another resident's room lacked the necessary PPE and signage, despite the resident being in isolation for the flu. Additionally, flu-negative roommates were not cohorted separately from flu-positive residents, and families of flu-negative roommates were not notified about the risk of infection or offered prophylactic treatment for the flu. Interviews with staff and family members further highlighted the deficiencies. A family member of a flu-negative resident was unaware that their relative was sharing a room with a flu-positive resident and had not been informed about the option for prophylactic treatment. Staff interviews revealed a lack of clarity and consistency in following infection control protocols, such as wearing appropriate PPE and ensuring proper isolation measures. The Director of Nursing (DON) admitted to seeing staff not wearing PPE correctly and acknowledged that some residents were not tested for the flu unless they showed symptoms. The facility's failure to adhere to CDC guidelines and its own infection control policies contributed to the rapid spread of the flu. The DON noted that the outbreak began when residents first showed symptoms, but there was a delay in receiving lab results, which delayed the implementation of isolation measures. Additionally, some staff mistakenly believed that isolation ended after five days, leading to premature removal of PPE bins. The facility's inadequate response to the flu outbreak, including poor communication with families and inconsistent use of PPE, placed residents at risk of cross-contamination and further illness.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 14 days between August and September 2023. This deficiency was identified through a review of the facility's time sheets, which showed that on specific dates, the facility only had RN coverage for 4 hours each day. The dates with insufficient RN coverage included multiple weekends in August and September 2023. This lapse in coverage was not initially recognized by the Director of Nursing (DON) until the report was run for the survey. The DON attributed the issue to difficulties in maintaining a scheduler and the resignation of the Assistant Director of Nursing (ADON) who was responsible for scheduling RN coverage during that period. In interviews, the DON and the Administrator acknowledged the lapse in RN coverage and the associated risks. The DON mentioned that the ADON had failed to complete her responsibilities, leading to her resignation after disciplinary discussions. The Administrator confirmed that he was aware of the weekend RN staffing concerns and stated that they had since hired an RN dedicated to weekends. The facility's policy on RN coverage, which requires an RN to provide services for at least 8 consecutive hours a day, 7 days a week, was not adhered to during the specified period, placing residents at risk of not receiving necessary care that only an RN could provide.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system in the rooms of three residents was accessible, which could prevent them from obtaining assistance when needed. Resident #228, a male with a fractured right arm and moderate cognitive impairment, was observed with his call light placed on a drawer out of his reach. He expressed that while he did not need assistance at the moment, it would be beneficial to have the call light within reach for future needs. His care plan specifically indicated that the call light should be within reach due to his fall risk and weakness, but this was not adhered to during the observation. Resident #7, a female with a high risk for falls and cognitive intactness, was found with her call light on the floor near her feet while she was seated in a recliner. She expressed frustration as she had difficulty bending over to retrieve the call light due to back pain. Her care plan also required the call light to be within reach, but this was not followed, leading to her struggle to access it. The resident's frustration and difficulty in accessing the call light were evident during the observation. Resident #39, a female with coordination issues and extensive assistance needs, was observed in her wheelchair with the call light placed on a drawer behind her. She was unaware of the call light's location. Both the LVN and ADON confirmed the importance of call lights being within reach for resident safety and communication. The facility's policies also mandated that call lights be accessible to residents, but these were not followed, as evidenced by the observations and interviews conducted with the staff and residents.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six residents. Observations revealed various cleanliness issues in the residents' rooms, including white fluid stains on bedside tables, brownish stains on bathroom floors, black dirt stains along the walls, and light brown stains around bathroom sinks and faucets. These deficiencies were noted in the rooms of six residents, indicating a lack of proper sanitation and maintenance, which could lead to infection risks and decreased quality of life for the residents. Interviews with the Housekeeping Manager, DON, and Administrator revealed that the facility's leadership was aware of the cleanliness issues but had not effectively addressed them due to vacant leadership positions. The Housekeeping Manager admitted that her staff should have cleaned the areas in question and acknowledged the risk of infection due to inadequate cleaning. The DON and Administrator also recognized the infection control concerns and attributed the inconsistency in cleanliness checks to the vacant leadership roles, which hindered the effectiveness of their Angel rounds designed to ensure room cleanliness.
Failure to Ensure Consistent Showering for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, Resident #51, a male with severe cognitive impairment and a history of falls, did not receive showers consistently as scheduled. The resident was supposed to receive showers on Tuesdays, Thursdays, and Saturdays, but records showed only four instances where showers were documented, all of which indicated the resident refused. There was no documentation in the facility's system regarding attempts to persuade the resident to take a shower or notifications to family members or the resident's physician about the refusals. Interviews with staff revealed that CNAs were aware of the requirement to document whether a resident received or refused a shower, but this was not consistently done. The CNA and LVN/Charge nurse both acknowledged the lack of documentation and attempts to persuade the resident. The Director of Nursing (DON) confirmed the issue and noted that the absence of an Assistant Director of Nursing (ADON) made it challenging to stay on top of all resident care. The facility's policy on baths and showers emphasized the importance of promoting cleanliness and documenting all appropriate information, which was not adhered to in this case.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed multiple deficiencies in the facility's only kitchen, including unlabeled and undated food items in the refrigerator and freezer, such as a large bag of bread sticks, a package of pie crust, a gallon container of Dill Pickle Relish, and a gallon container of Italian dressing. Additionally, a large bag of French toast sticks in the walk-in freezer was not sealed and exposed to air-borne contaminants. The ice machine had dark reddish stains on the inside door hinges, and the ice chest in the dining area was dirty. The tea dispenser and trash can in the kitchen were uncovered, exposing them to air-borne contaminants. The Dietary Manager was observed preparing food without a head covering, which she acknowledged could result in hair contaminating the food. Interviews with the Dietary Manager and the Administrator confirmed awareness of these issues. The Dietary Manager admitted to forgetting to wear a hair net and acknowledged the risks associated with the observed deficiencies. She also stated that she had trained staff to date items correctly but needed to remind them to include the month, date, and year. The Administrator expected the Dietary Manager to ensure compliance with all guidelines, including wearing a hair net. The facility's policy on food storage and supplies emphasized maintaining storage areas in an orderly manner to prevent foodborne illnesses, which was not adhered to in this instance.
Failure to Provide Privacy Bag for Catheter
Penalty
Summary
The facility failed to treat Resident #228 with dignity and promote enhancement of his quality of life by not providing a privacy bag for his catheter bag. Resident #228, a [AGE] year-old male with acute kidney failure and neuromuscular dysfunction of the bladder, was observed on multiple occasions with his catheter bag exposed. On 01/24/2024, the catheter bag was visible hanging on the side frame of the bed, and on 01/25/2024, it was observed hanging below the wheelchair seat without a privacy bag. The resident confirmed that he had never seen his catheter bag with a privacy bag since having the catheter for six days. The facility's policy and physician orders required the use of a privacy bag for catheter bags to maintain resident dignity, which was not followed in this case. Interviews with the ADON, CNA, DON, and Administrator revealed a consensus that the catheter bag should have been covered to avoid embarrassment and maintain the resident's dignity. The ADON acknowledged the oversight and provided an improvised cover for the catheter bag during the observation. The CNA admitted responsibility for not ensuring the privacy bag was in place, and the DON emphasized the importance of catheter care and dignity for residents. The Administrator reiterated that all staff were responsible for ensuring residents' dignified existence and committed to monitoring the situation. The facility's policy on dignity and respect, revised in 2007, mandates that all residents be treated with kindness, dignity, and respect, which was not upheld in this instance.
Failure to Ensure Resident was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that Resident #13 was free from physical restraints not required to treat medical symptoms. Resident #13, a [AGE] year-old female with a history of right hip fracture and multiple falls, was observed using a scoop mattress without a physician's order or a comprehensive care plan. The resident's cognitive status was severely impaired, and the scoop mattress was used to limit her ability to get out of bed due to her history of falls. However, there was no documented assessment, order, or care plan for the use of the scoop mattress, which is considered a form of restraint. Interviews with the ADON and DON revealed that the scoop mattress was implemented at the family's request to prevent falls, but neither staff member confirmed the existence of a physician's order or assessment for its use. The DON acknowledged that the resident should have had an assessment, order, and care plan for the scoop mattress but noted that the resident could still get off the mattress. The facility's policy on Freedom From Abuse, Neglect, Exploitation, revised in October 2022, mandates that residents be free from physical restraints not required to treat medical symptoms, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, Resident #288 and Resident #7, as required by regulations. Resident #288, a male with acute kidney failure and neuromuscular dysfunction of the bladder, had an indwelling catheter but did not have a care plan addressing catheter care. Despite physician orders specifying catheter care every shift and monitoring for signs of complications, the care plan lacked any mention of these necessary interventions. This oversight was confirmed through observation and interviews with the RN and MDS Nurse, who acknowledged the absence of a care plan for catheter care for Resident #288. Similarly, Resident #7, a female with a high risk for falls due to muscle wasting and abnormalities of gait, did not have any interventions for fall prevention in her care plan. Despite being assessed as high risk for falls and requiring supervision for various activities, her care plan did not include any specific measures to mitigate this risk. This deficiency was also confirmed through interviews with the RN and MDS Nurse, who recognized the importance of having a fall prevention plan for high-risk residents. Interviews with the Director of Nursing (DON) and the Administrator further highlighted the importance of comprehensive care plans in addressing the specific needs of residents. Both acknowledged that without a care plan, residents' health issues would not be adequately managed. The DON stated that care plans are a team approach and should be updated upon admission, quarterly, and when there is a change in the resident's condition. The facility's policy on comprehensive person-centered care planning was reviewed, which mandates the development of a care plan for each resident, but this was not adhered to in the cases of Resident #288 and Resident #7.
Failure to Place Fall Mat for Resident with Repeated Falls
Penalty
Summary
The facility failed to ensure that a fall mat was placed alongside the bed of an 82-year-old female resident with severe cognitive impairment and a history of repeated falls. During an observation, the resident was found lying in bed with the bed in a low position, but the fall mat was leaning against a chest of drawers instead of being placed next to the bed. This oversight was confirmed by an LVN, who acknowledged that the absence of the fall mat could result in the resident falling and injuring herself. The LVN also stated that staff are expected to check the resident's environment every two hours to ensure it is free of hazards. The Director of Nursing (DON) was informed of the incident and confirmed that staff should ensure the resident's bed is in the lowest position, the call light is within reach, and the fall mat is placed alongside the bed. The DON mentioned that staff might have forgotten to place the fall mat back after the resident had eaten lunch. The facility's policy on Fall Management, dated June 2018, states that the environment should be as free of accident hazards as possible and that appropriate assessments and interventions should be provided to prevent falls and minimize complications if falls occur.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that two residents who needed respiratory care were provided such care consistent with professional standards of practice. Resident #58 and Resident #10's nasal cannulas were not properly stored when not in use, and their humidifier bottles did not have water in them. These deficiencies were observed during a survey, where it was noted that the nasal cannulas were either loosely coiled on the oxygen tank or wrapped around the backrest of a wheelchair, and the humidifier bottles were empty. Both residents had relevant diagnoses that required continuous oxygen therapy, and the lack of proper humidification and storage of nasal cannulas could lead to respiratory infections and irritation of the nasal and throat passages. Resident #58, a [AGE] year-old male with diagnoses including respiratory failure with hypoxia and pneumonia, was observed resting in bed with an oxygen supplement via nasal cannula connected to an empty humidifier bottle. The resident was unaware of the lack of water in the humidifier. Similarly, Resident #10, a [AGE] year-old male with respiratory failure and interstitial lung disease, was also observed with an oxygen supplement via nasal cannula connected to an empty humidifier bottle. Both residents' nasal cannulas were not stored in a sanitary manner when not in use, increasing the risk of respiratory infections. Interviews with the facility's staff, including an LVN, RN, ADON, DON, and the Administrator, confirmed that the humidifiers should always have water to prevent nasal and throat irritation and that nasal cannulas should be bagged when not in use to maintain cleanliness. The staff acknowledged the deficiencies and the potential health risks posed by these lapses in care. The facility's policy on oxygen delivery and maintenance was reviewed, which indicated that delivery device components should be placed in a bag when not in use, highlighting the failure to adhere to established protocols.
Inaccurate Documentation of Family Notification After Resident Fall
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident who experienced a fall. Specifically, the facility inaccurately documented that the family of the resident was notified immediately following the fall. The resident, a [AGE] year-old female with a history of repeated falls and muscle wasting, fell out of her wheelchair and hit her head, resulting in a hematoma. The nurse on duty documented that the family was notified immediately, but interviews revealed that the family was not contacted until at least two hours after the incident. The nurse admitted to making several attempts to contact the family but was unable to reach them due to a busy tone and subsequently got distracted by other falls occurring in the facility. The Director of Nursing confirmed that the documentation was incorrect and should have reflected the attempts made rather than stating the family was notified. This discrepancy in documentation could lead to inaccurate medical records and delayed family notification in critical situations.
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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