Lakeside Health And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Kemp, Texas.
- Location
- 110 N State Hwy 274, Kemp, Texas 75143
- CMS Provider Number
- 676497
- Inspections on file
- 27
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Lakeside Health And Wellness during CMS and state inspections, most recent first.
A CNA was observed speaking loudly and in a demeaning manner to a male resident with severe cognitive impairment, prompting intervention by other staff who removed the resident and reported the incident. The resident's care plan documented significant communication and cognitive deficits, and staff statements confirmed the inappropriate interaction, which violated the facility's abuse prevention policy.
A CNA used a resident's debit card without permission to purchase personal items during a store outing, resulting in unauthorized charges of over $230. The resident, who had intact cognition and multiple medical conditions, identified the unauthorized purchases and reported the incident to the Activity Director, leading to an internal investigation.
A resident with severe cognitive and physical impairments was receiving a pureed diet per physician order, but the care plan was not updated to reflect this change. The MDS nurse was responsible for updating care plans but had not revised the document to match the current dietary order, despite facility policy requiring timely updates based on new interventions.
A resident with multiple chronic conditions did not have staples removed from the back of the head as ordered by a physician due to a failure to properly enter the order into the EMR system. The treatment nurse was unaware of the removal order, and the oversight was discovered during a survey, resulting in a delay in care.
A resident with COPD and other comorbidities was found using oxygen therapy without a current physician's order, and the oxygen tubing and water were not changed or dated as required. Staff interviews confirmed that the lack of an active order and failure to follow respiratory care protocols led to improper care and risk of infection.
A resident with an indwelling urinary catheter suffered a 3.5 cm penile tear due to improper catheter care at an LTC facility. Despite a care plan requiring monitoring for catheter issues, the facility failed to secure the catheter properly, leading to friction and pulling. The injury was discovered by the resident's family, who reported inadequate care. The DON acknowledged the catheter was not given enough slack, contributing to the injury. The facility's policy on catheter care was not provided during the survey.
The facility failed to document the administration of controlled drugs for three residents, leading to discrepancies in medication records. A medication aide and an LVN did not record the administration of morphine, pregabalin, and Norco, respectively, during medication passes. This lack of documentation was acknowledged by the staff involved and highlighted by the DON and Administrator as a risk for medication errors and discrepancies.
A long-term care facility was found to have a medication error rate of 18.75%, involving two residents. One resident did not receive medications as prescribed due to improper administration by an LVN, who failed to follow physician orders for enteral medication administration. Another resident received incorrect medications and had a medication administered outside the prescribed time frame by an MA. The facility lacked competency checks for the staff involved, contributing to these errors.
The facility failed to provide palatable food at an appetizing temperature for three residents, who reported the food was often cold, bland, and overcooked. Observations confirmed these issues, and the Dietary Manager acknowledged receiving complaints. The Administrator noted that test trays were bland, highlighting a deficiency in meeting the facility's policy on food quality.
The facility's kitchen operations were found deficient in food safety standards. Dietary staff failed to wear hair restraints properly, and the dishwasher did not reach the required temperature for effective sanitation. Additionally, the correct chlorine test strips were not used, potentially risking foodborne illnesses. Interviews confirmed the importance of these measures, aligning with the facility's policy on utensil sanitation.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by staff not wearing PPE during care of a resident on isolation, improper glove changes and hand hygiene during incontinent care, and improper handling of linens. These actions posed risks of cross-contamination and infection spread among residents.
The facility failed to properly document advance directives for two residents. One resident's OOH-DNR form was incomplete due to a misunderstanding by the Social Worker, while another resident's preferred code status was not entered into the electronic medical record due to an oversight by nursing staff. These deficiencies could lead to confusion in emergencies.
A resident's medical records were left visible on an unattended medication cart, breaching confidentiality. The resident, with moderate cognitive impairment and multiple diagnoses, had her EMR left open by a medical assistant who entered a supply room. The DON and Administrator confirmed this was a HIPAA violation, stressing the importance of maintaining confidentiality.
A facility failed to include a resident's preferred code status in the baseline care plan, despite the resident having complex medical conditions. The social worker completed a code status assessment, but the information was not entered into the care plan. The MDS Coordinator acknowledged the omission, which was not corrected despite verbal discussions. The administration recognized the importance of including this information to respect the resident's wishes.
A resident with severe cognitive impairment was not assisted with facial hair removal, despite expressing embarrassment and the facility's policies emphasizing the importance of grooming and personal hygiene. The resident, receiving hospice care, required partial assistance, but staff did not address this need during care routines. Interviews revealed that staff were not specifically trained to look for facial hair, impacting the resident's dignity.
A facility failed to ensure proper administration of medications through a gastrostomy tube for a resident with multiple health conditions. The LVN did not confirm tube placement as ordered and improperly prepared medications by crushing them together. Interviews revealed a lack of competency checks for the LVN, and the facility's policy was not followed, posing a potential risk to the resident's health.
The facility failed to provide proper respiratory care for two residents. One resident's oxygen concentrator was not set according to the physician's order, while another resident's concentrator was found dirty. Staff interviews revealed confusion over responsibilities for equipment cleaning and monitoring, contributing to these deficiencies.
A resident in an LTC facility experienced significant medication errors when an LVN prepared to administer metoprolol despite low blood pressure and failed to administer Eliquis, mistaking it for a blood pressure medication. The resident, with a history of cerebral infarction and other conditions, was dependent on staff for care and received medications via a gastrostomy tube. The LVN crushed multiple medications together, contrary to the care plan, and did not confirm tube placement as ordered. The DON and Administrator acknowledged the errors and the potential for harm.
The facility failed to secure medication carts, leaving them unlocked and unattended. An RN, MDS Coordinator, and MA each left their respective carts unsecured, acknowledging the risk of unauthorized access to medications. The DON and Administrator emphasized the importance of locking carts for resident safety.
A facility failed to coordinate hospice care and maintain updated documentation for a resident with parkinsonism receiving hospice services. The hospice binder lacked updated information, including the certification of terminal illness and the plan of care. Interviews revealed unclear responsibilities and no policy to ensure current documentation, leading to inadequate care coordination.
The facility failed to ensure that RN N, an agency staff member, received necessary training on abuse, neglect, and exploitation. Despite claims of frequent in-services, there was no evidence that RN N completed the required training, either through the agency or the facility. Interviews revealed a lack of structured processes for training agency staff, contrary to the facility's policy requiring all staff to be trained before resident contact.
A resident with moderately impaired cognition was verbally abused by an agency nurse, who used derogatory language when the resident requested assistance. The incident was not promptly reported or addressed by the facility staff, leading to a deficiency in protecting the resident from abuse.
A resident with moderate cognitive impairment experienced verbal abuse from an RN employed through a staffing agency. The incident was not immediately reported by a witnessing CNA, leading to a delay in addressing the abuse. The facility failed to ensure the RN had completed necessary abuse training, contributing to the incident and putting residents at risk.
A resident with moderate cognitive impairment experienced verbal abuse from a nurse, which was not reported immediately as required. Despite multiple staff witnessing the incident, it was not communicated to the abuse coordinator or administrator. The facility's policy mandates prompt reporting of abuse, which was not followed in this case.
A resident with chronic health issues suffered physical abuse during a shower when a CNA used excessive force, resulting in injuries. Despite the resident's protests, the CNA continued the aggressive behavior, and the facility failed to immediately remove the CNA from resident care duties, placing the resident at further risk. Interviews revealed inconsistencies in the handling of the situation, and the facility's policy on abuse and neglect was not followed.
A resident with mild cognitive deficit and physical limitations was physically abused by a CNA during a shower, resulting in injuries. The facility failed to follow its abuse prevention policy by allowing the CNA to continue providing care after the incident. Staff interviews confirmed the failure to remove the alleged perpetrator from resident care duties, placing the resident at risk for further harm.
A LTC facility failed to provide proper pharmaceutical services, resulting in medication errors for three residents. One resident did not receive her prescribed Nifedipine despite its availability in the emergency kit. Another resident was mistakenly given Ativan and Trazodone due to a medication aide's error. A third resident did not receive her prescribed Amlodipine during a medication pass. The facility's policies on medication administration were not followed, leading to these deficiencies.
The facility failed to maintain effective infection control practices during resident care. A CNA used a soiled wipe on a resident's vaginal area, and another CNA did not perform hand hygiene between glove changes or when exiting and re-entering the room. Both CNAs left a trash bag with soiled gloves in the resident's room. The DON and Administrator confirmed these actions did not meet the facility's infection control expectations.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was observed standing over a male resident with severe cognitive impairment, loudly talking and telling the resident, "you tripping," in response to the resident's statements. The resident, who had a history of cerebral infarction, ataxia, osteoporosis, hypertension, and radiculopathy, was wheelchair-bound and required varying levels of assistance with activities of daily living. The resident's care plan noted communication deficits, impaired cognitive function, and short-term memory loss, with interventions including task segmentation, cueing, reorientation, and supervision. Multiple staff members witnessed or were aware of the incident. One CNA overheard the loud and demeaning manner in which the CNA spoke to the resident, removed the resident from the situation, and informed the nurse. A licensed vocational nurse (LVN) also overheard the CNA speaking condescendingly and intervened by asking the CNA to clock out and leave, then notified the Abuse Coordinator. Written statements from these staff members corroborated the observations of patronizing and demeaning language directed at the resident. Interviews with the resident and his family revealed that neither recalled the incident or reported feeling unsafe, and the family had not observed any changes in the resident's mood or behavior. However, the facility's policy requires that residents be free from abuse, mistreatment, and neglect, and the actions of the CNA were inconsistent with this policy. The deficiency was identified based on staff observations and statements, as well as a review of the resident's records and care plan.
Misappropriation of Resident Funds by CNA During Outing
Penalty
Summary
A certified nursing assistant (CNA) used a resident's debit card to purchase personal items totaling $230.83 during an outing to a local store, without the resident's permission. The resident, a male with diagnoses including spinal stenosis, spondylosis, dementia, hypertension, Parkinsonism, and dysphagia, was assessed as having intact cognition and was able to identify which items were his and which were not. The resident reported the unauthorized purchases to the Activity Director after the outing, specifying that the CNA had bought items for herself using his funds. The Activity Director confirmed the resident's report and notified facility leadership, prompting an investigation. The CNA claimed the cashier was at fault for scanning her items with the resident's, but did not return to the facility after being suspended pending investigation. Facility records and interviews confirmed that the CNA's actions constituted misappropriation of the resident's property, as defined by facility policy, which prohibits the use of a resident's belongings or money without consent.
Failure to Update Care Plan Following Change in Diet Order
Penalty
Summary
The facility failed to review and revise the care plan for a resident after a change in dietary orders, as required. Record review showed that the resident, who had multiple diagnoses including dementia, dysphagia, COPD, peripheral vascular disease, obstructive uropathy, osteoarthritis, and depression, was admitted and readmitted with significant cognitive and physical impairments. The comprehensive MDS assessments indicated the resident required a mechanically altered diet, and physician orders dated 10/01/2025 specified a regular diet with pureed texture. However, the resident's care plan, last revised on 08/04/2025, continued to list a regular mechanical soft diet with thin liquids and was not updated to reflect the new pureed diet order. Observation confirmed that the resident was receiving a pureed diet, and the resident reported having received 'baby food' for some time. Interviews with the MDS nurse and DON revealed that care plan updates were the responsibility of the MDS nurse, who acknowledged ongoing updates to individual care plans. The DON and Administrator both stated that care plans should be updated as orders are received and reviewed quarterly, and that discrepancies between care plans and physician orders could result in harm. Facility policy requires care plans to be revised based on changing needs and current interventions, but this was not followed in this instance.
Failure to Follow Physician Orders for Staple Removal
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with physician orders and professional standards of practice. Specifically, a male resident with multiple diagnoses, including congestive heart failure, hypertension, diabetes type II, chronic kidney disease stage 3, and peripheral vascular disease, returned from the emergency room with two staples in the back of his head following a fall. Physician orders directed that the staples be removed five days after insertion. However, the order to remove the staples was not properly entered into the electronic medical record (EMR) system, resulting in the treatment not being scheduled or completed as ordered. Observations and interviews revealed that the treatment nurse was monitoring the staples but was unaware of the removal order due to the order not appearing on the Treatment Administration Record (TAR). The MDS nurse was aware of the presence of staples and the scheduled removal but did not know if the removal had occurred. The DON confirmed that the order was inaccurately coded in the EMR, preventing the treatment nurse from being prompted to remove the staples. The resident was observed with staples still in place beyond the ordered removal date, and the issue was only identified during the survey process.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Specifically, the resident did not have a current physician's order for oxygen use, and there were no orders in place for changing the oxygen tubing and water or for cleaning the filter. Observations revealed that the resident was using oxygen via nasal cannula at 2.5 L/min with undated tubing and an empty water bottle that had not been changed since a previous date. Interviews with nursing staff and the DON confirmed that the tubing and water were not changed or dated as required, and that the lack of an active order for oxygen contributed to the oversight. The facility's policy required verification of a physician's order and periodic checking of the water level but did not specify the frequency for changing tubing. The resident involved had a history of chronic obstructive pulmonary disease, emphysema, a pulmonary nodule, dementia, and high blood pressure. The care plan indicated a need for oxygen therapy per medical orders, but the most recent order had been discontinued months prior. Staff interviews acknowledged that the failure to maintain proper respiratory care practices, including changing and dating the tubing and water, and the absence of a current order, placed the resident at risk for infection and improper oxygen administration. The deficiency was identified through observation, record review, and staff interviews.
Inadequate Catheter Care Leads to Resident Injury
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, resulting in a significant injury. The resident, a male with a history of chronic obstructive pulmonary disease, dementia, benign prostatic hyperplasia, and urinary retention, was admitted to the facility with an intact cognition and required assistance with daily activities. Despite having a care plan that included monitoring for catheter-related issues, the facility did not properly secure the resident's Foley catheter, leading to a 3.5 cm tear in his penis and necessitating an emergency room visit. The deficiency was identified when the resident's family member noticed a malodor and blood in the resident's groin area, prompting an assessment that revealed the penile tear. The family member reported that the facility had not been providing the necessary catheter care, which was corroborated by the Director of Nursing (DON), who acknowledged that the catheter was not given enough slack, causing friction and pulling. The DON admitted that the staff failed to ensure the catheter was properly secured, which contributed to the injury. Interviews with the staff and the resident's family confirmed that the penile erosion was not present upon the resident's admission to the facility. The facility's failure to secure the catheter properly and provide adequate care was further highlighted by the absence of documentation regarding the injury in the resident's medical records. The facility's policy on Foley catheter care was requested but not provided during the survey, indicating a lack of adherence to established protocols for catheter maintenance.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to establish a system for the accurate reconciliation and documentation of controlled drugs, which affected three residents. The deficiency was identified through observations, interviews, and record reviews. For Resident #8, the facility did not ensure that the medication aide (MA V) accurately documented the administration of morphine, a controlled medication, on the narcotic record. This oversight occurred during a medication pass when MA V administered the morphine tablet but failed to record it, potentially leading to discrepancies in medication records. Similarly, for Resident #22, MA V did not document the administration of pregabalin, another controlled medication, on the narcotic record. This failure was observed during a medication pass, where MA V removed the pregabalin tablet from the narcotic box and administered it without recording the action. MA V acknowledged the oversight, noting that it could result in medication errors or discrepancies since the administration was not documented at the time. For Resident #15, a licensed vocational nurse (LVN W) failed to document the administration of Norco, a controlled medication, on the narcotic record. During a random controlled drug count, a discrepancy was found between the expected and actual count of Norco tablets. LVN W admitted to administering the medication but not recording it due to being busy with other residents. The Director of Nursing (DON) and the Administrator both emphasized the importance of immediate documentation to prevent errors and ensure medication accountability.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 18.75% due to 12 errors out of 64 opportunities. This involved two residents, one of whom did not receive their scheduled morning medications as prescribed. The errors were identified during a survey, which included observations, interviews, and record reviews. Resident #57, a male with multiple diagnoses including cerebral infarction and congestive heart failure, was affected by improper medication administration. The resident's care plan required medications to be given as ordered, without cocktailing, and with specific procedures for enteral administration. However, LVN W crushed and mixed all medications together, contrary to the physician's orders, and failed to administer certain medications due to a misunderstanding of their purpose. Additionally, the nurse did not verify the placement of the gastrostomy tube as required, which could have led to further complications. Resident #18, a female with dementia and other gastrointestinal issues, also experienced medication administration errors. MA X administered a multivitamin instead of the prescribed multivitamin with minerals and failed to give Reglan within the specified time frame before meals. This deviation from the physician's orders was acknowledged by MA X, who admitted to not having the correct medication on the cart and administering Reglan outside the prescribed time window. The facility's Director of Nursing confirmed the lack of competency checks for the staff involved, which contributed to these errors.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for three residents. Residents reported that the food was often cold, bland, and overcooked. During interviews, Resident #14 mentioned that the food was usually too cold, Resident #6 stated that the food lacked taste and was overcooked, and Resident #39 described the food as bland. Observations by surveyors confirmed these complaints, noting that the food was bland and not served at the appropriate temperature. The Dietary Manager acknowledged receiving complaints about the food and agreed that the food sampled was bland. The Administrator also noted that test trays he sampled were bland and expressed expectations for the dietary staff to ensure food was served at appropriate temperatures and was appetizing. The facility's policy on test trays emphasized the importance of providing food that is appealing, palatable, and served at the correct temperature, but this was not consistently achieved, leading to the deficiency.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Dietary staff did not wear hair restraints properly, with hair visibly protruding from hairnets, which could lead to contamination of food. This was observed with two dietary staff members during meal preparation. Additionally, the dishwasher was not operating at the required temperature of 120°F during the wash cycle, registering only 115°F, which is insufficient for proper sanitation. Furthermore, the dietary aide was unable to locate the correct chlorine test strips necessary for verifying the dishwasher's sanitation effectiveness. Interviews with the dietary aide, maintenance employee, and dietary manager confirmed the importance of maintaining proper hair coverage and dishwasher temperature to prevent foodborne illnesses. The dietary aide acknowledged the oversight in hair coverage and the significance of maintaining the correct dishwasher temperature for sanitization. The maintenance employee reiterated the need for the dishwasher to reach 120°F to kill bacteria effectively. The dietary manager emphasized the expectation for staff to use hairnets correctly and to utilize test strips for ensuring dish sanitation. The facility's policy on mechanical cleaning and sanitation of utensils mandates a wash water temperature of at least 120°F and the use of test kits to measure the concentration of sanitizing solutions.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. One significant issue involved the MDS Coordinator not applying personal protective equipment (PPE) before flushing a resident's PICC line, despite the resident being on contact isolation precautions due to an active infection. This oversight was acknowledged by the MDS Coordinator, who admitted that not wearing PPE posed a risk of infection transmission. The Director of Nursing (DON) and the Administrator both confirmed that staff were expected to wear PPE when providing care to residents on isolation to prevent the spread of infection. Another deficiency was observed during the provision of incontinent care to a resident by a CNA. The CNA failed to change gloves and perform hand hygiene after removing a dirty brief and before applying a clean one. Additionally, the CNA touched various surfaces in the resident's room with dirty gloves, including the wipes container, which was then returned to the linen cart, posing a risk of cross-contamination. The CNA admitted to being in a hurry and not following proper procedures, which could lead to urinary tract infections in residents. The DON emphasized the importance of proper glove changes and hand hygiene during incontinent care to prevent infections. Further issues were noted with the handling of linens. A hospice aide was seen carrying unbagged dirty linens down the hall, and a CNA left a bag with trash and an unbagged bed pad on the floor in a resident's room. Additionally, clean linen carts on two halls were found with their covers open, which could lead to contamination of the linens. Staff interviews confirmed that these practices were against the facility's infection control policies, and the DON and Administrator both stated that proper procedures should be followed to prevent cross-contamination and ensure resident safety.
Deficiencies in Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the proper completion of an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form for a resident. The resident, an elderly female with multiple diagnoses including dementia, had a DNR code status indicated on her face sheet and care plan. However, the OOH-DNR form was not completed accurately as the witnesses only signed in the section for two witnesses and did not sign at the bottom of the form as required. The Social Worker, responsible for ensuring the DNRs were completed, misunderstood the signing requirements, and the Director of Nursing (DON) was unsure of the correct procedure. This oversight could lead to confusion in a life-or-death situation. Another resident, a female with a history of epilepsy, schizoaffective disorder, and heart failure, did not have her preferred code status documented in the physician orders or on the face sheet. Although a code status assessment was completed indicating her preference for full code status, the necessary physician order was not placed in the electronic medical record. The nursing staff, responsible for entering this information, missed the order because it was not part of the standard admission batch orders. The Assistant Director of Nursing (ADON) acknowledged the importance of having the code status readily available but had not audited the resident's chart. The facility's policy on Do Not Resuscitate Orders requires that a DNR form be completed and signed by the attending physician and resident, and placed prominently in the medical record. The Corporate Regional Nurse provided this policy during the investigation. The Administrator and DON both recognized the importance of having the code status included in admission orders and on the face sheet to ensure staff can quickly identify a resident's wishes in an emergency. However, these procedures were not followed, leading to the deficiencies noted in the report.
Breach of Resident Confidentiality Due to Unattended EMR
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical records, specifically for a resident with a history of diabetes mellitus, bipolar disorder, and anxiety. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, had her electronic medical record (EMR) left open and visible on an unattended medication cart. This occurred when a medical assistant (MA) left the cart to enter a supply room without closing the EMR screen. During interviews, the MA acknowledged the oversight and recognized the importance of closing the EMR screen to protect the resident's personal information. The Director of Nursing (DON) and the Administrator both confirmed that the expectation was for the EMR screen to be locked when not in use to maintain confidentiality. The Administrator identified the incident as a HIPAA violation and a breach of resident information, emphasizing that all staff are responsible for ensuring the confidentiality of resident information.
Failure to Include Code Status in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included the necessary healthcare information for a resident, specifically omitting the resident's preferred code status. This deficiency was identified for a resident who was admitted with multiple complex diagnoses, including epilepsy, schizoaffective disorder, traumatic brain injury, and heart failure. The baseline care plan did not address the resident's preferred code status or advanced directive, which is a critical component of person-centered care. Interviews revealed that the social worker completed a code status assessment indicating the resident's preference for a full code status, but this information was not entered into the baseline care plan. The MDS Coordinator, responsible for ensuring the completion of the baseline care plan, acknowledged that the code status section did not auto-populate due to the timing of the assessment. Despite verbal discussions about the resident's code status, the omission was not corrected in the written care plan. The facility's administration recognized the importance of including the code status in the baseline care plan to respect the resident's wishes, but the error was not caught during the review process.
Failure to Assist Resident with Facial Hair Removal
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal hygiene for a resident, specifically in assisting with facial hair removal. The resident, a female with severe cognitive impairment due to dementia, was observed with approximately 1-inch black and gray facial hairs on the sides of her mouth. Despite being able to communicate and understand others, the resident was not offered assistance with facial hair removal, which she expressed embarrassment about when asked by the surveyor. The resident was receiving hospice services and required partial to moderate assistance with personal hygiene. The comprehensive care plan indicated that the resident needed one staff member to assist with personal hygiene and oral care, and adjustments were to be made to compensate for her changing abilities. However, the hospice CNA, who provided care three times a week, did not notice or offer assistance with facial hair removal, and the facility staff did not address this need during their care routines. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that facial hair removal was typically performed during bathing, but staff had not asked the resident if she needed assistance. The DON and Administrator acknowledged the importance of offering facial hair removal to maintain the resident's dignity, but staff were not specifically trained to look for facial hair during daily rounds. The facility's policies on ADLs and CNA standards of clinical practice emphasized the importance of assisting residents with grooming and personal hygiene, yet this was not adequately implemented for the resident in question.
Failure to Ensure Proper Administration of Enteral Medications
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received appropriate treatment and services to prevent complications. Specifically, the facility did not confirm the placement of the gastrostomy tube as ordered by the physician. The resident, a male with a history of cerebral infarction, essential hypertension, congestive heart failure, gastrostomy status, and dysphagia, was dependent on staff for feeding and other personal care needs. The care plan required checking the tube placement and gastric contents per facility protocol, but this was not consistently done. During an observation, LVN W was seen preparing the resident's medications by crushing them together, contrary to the physician's orders which specified that medications should not be cocktailed. LVN W did not confirm the gastrostomy tube placement via auscultation as required before administering medications. The surveyor intervened before the medications were administered. LVN W admitted to not following the correct procedure and acknowledged the risk of adverse reactions and tube displacement due to her actions. Interviews with the Director of Nursing (DON) and the Administrator revealed that there was no competency skills check-off for LVN W regarding medication administration via the gastrostomy tube. Both the DON and the Administrator confirmed that medications should be administered separately and that tube placement should be verified as per the physician's orders. The facility's policy also outlined these procedures, but they were not followed, leading to a potential risk for the resident's health.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For Resident #56, the oxygen concentrator was not set according to the physician's order. The resident, who has chronic obstructive pulmonary disease, was observed with her oxygen set between 3-4 liters per minute, despite the physician's order specifying 2 liters per minute. LVN A confirmed the discrepancy and acknowledged the importance of adhering to the physician's order to prevent potential harm from incorrect oxygen levels. For Resident #43, the facility did not ensure the cleanliness of the oxygen concentrator. The resident, who has chronic respiratory failure, was observed with a concentrator covered in dust and debris. RN D, who provided care to the resident, admitted to not noticing the dirt and believed the Staffing Coordinator was responsible for cleaning. However, the Staffing Coordinator stated that housekeeping, CNAs, or nurses should handle the cleaning. The DON emphasized the importance of maintaining clean equipment to prevent infections. Interviews with the DON and the Administrator highlighted the need for regular checks on oxygen settings and cleanliness. The facility's policy on oxygen administration did not address the cleaning of oxygen concentrators, contributing to the oversight. The lack of clarity on responsibilities for cleaning and monitoring oxygen settings led to these deficiencies, potentially compromising resident safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of metoprolol and Eliquis. On the date in question, LVN W prepared to administer metoprolol to the resident despite the resident's low blood pressure, which was contrary to the physician's orders. Additionally, LVN W did not prepare to administer Eliquis, an anticoagulant, mistakenly believing it was a blood pressure medication. This oversight could have placed the resident at risk of medical complications due to not receiving the therapeutic effects of their medications. The resident involved was a male with a history of cerebral infarction, essential hypertension, congestive heart failure, gastrostomy status, and dysphagia. The resident was dependent on staff for various activities of daily living and received medications through a gastrostomy tube. The resident's care plan included specific instructions for medication administration, such as not cocktailing medications and ensuring blood pressure was checked before administering certain medications. During the medication administration process, LVN W crushed multiple medications together, which was against the facility's policy and the resident's care plan. The LVN also failed to confirm the placement of the gastrostomy tube via auscultation as ordered by the physician. The Director of Nursing and the Administrator both acknowledged that the medications should have been administered as per the physician's orders, and the failure to do so could have resulted in harm or a change in the resident's condition.
Medication Carts Left Unlocked in Facility
Penalty
Summary
The facility failed to ensure that all drugs were stored in locked compartments, accessible only by authorized personnel, for three of six medication carts reviewed. Specifically, the 100-200 nurses' cart was left unlocked and unattended at the nurses' station by an RN, who admitted to forgetting to lock it. The RN acknowledged the importance of keeping medication carts locked to prevent drug diversion or adverse effects from incorrect medication use. Additionally, the MDS Coordinator left the treatment cart unlocked while attending to a resident's PICC line, and the medication cart for hall 300-400 was left unsecured by an MA. Both staff members recognized their responsibility to lock the carts and the potential risk of residents accessing medications not intended for them. The DON and Administrator both stated their expectations for staff to lock medication carts before leaving them unattended, emphasizing the importance of this practice for the safety of residents and visitors.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, which compromised the quality of care. Specifically, the facility did not ensure that the hospice records for a resident were included in their records at the facility. This lack of documentation and coordination could potentially place residents at risk of receiving inadequate end-of-life care. The resident in question was an elderly female with a diagnosis of parkinsonism, who had been receiving hospice services at the facility. Despite having a terminal prognosis and being on hospice care, the facility's records were not updated with the necessary hospice documentation, including the certification of terminal illness and the updated plan of care and medication since August. Interviews with facility staff and hospice representatives revealed a lack of clarity and responsibility regarding the maintenance of hospice documentation. The hospice nurse was responsible for updating the hospice binder with the necessary paperwork, but during a period when the regular hospice nurse was on vacation, the substitute nurse found that the binder lacked updated information. Facility staff, including an LVN and the Corporate Regional Nurse, indicated that there was no policy in place to ensure the hospice binder was checked for current documentation. The Director of Nursing (DON) and the Administrator were uncertain about who was responsible for ensuring the facility had the most updated hospice information, suggesting that Admissions or Medical Records might typically handle it. This lack of clear responsibility and procedure contributed to the deficiency in hospice care coordination.
Inadequate Abuse Training for Agency Staff
Penalty
Summary
The facility failed to provide adequate training to their staff, specifically to RN N, on recognizing and reporting abuse, neglect, exploitation, and misappropriation of resident property. Despite the Director of Nursing (DON) and the Administrator stating that frequent in-services on abuse were conducted, it was unclear if RN N, who was employed through an agency, had received any such training. The facility relied on the staffing agency to provide abuse training to their staff, but there was no confirmation that RN N had completed this training either through the agency or the facility. Interviews with the Administrator, Regional Compliance Nurse, Human Resources, and the Staffing Coordinator revealed a lack of a structured process for ensuring agency staff received necessary abuse and neglect training. The facility's policy required all staff to attend training sessions on resident rights and abuse prevention before having any resident contact, but this was not consistently applied to agency staff. The absence of documented training for RN N highlighted a gap in the facility's compliance with their own policies, potentially placing residents at risk.
Failure to Protect Resident from Verbal Abuse by Agency Nurse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a nurse employed through a staffing agency. The incident involved a resident who reported that a nurse called her derogatory names when she requested assistance with adjusting the air conditioning. The resident, who had a moderately impaired cognition, expressed feeling scared and awful due to the nurse's attitude and language. The incident was reported to the facility's administration, but the nurse involved was not immediately contacted for a statement. Interviews with various staff members revealed inconsistencies in the reporting and handling of the incident. A CNA witnessed the verbal abuse but did not report it, assuming that the RN supervisor would handle the situation. The RN supervisor, however, was not informed of the specific details of the verbal abuse. The Director of Nursing (DON) and the Administrator were aware of the incident but did not take immediate steps to obtain a statement from the agency nurse or ensure she was removed from the facility to protect the residents. The facility's policy on abuse and neglect clearly states that verbal abuse is not tolerated, yet the response to the incident was inadequate. The facility relied on the staffing agency to provide abuse training to agency staff, and there was uncertainty about whether the nurse involved had received any training from the facility. The lack of immediate action and communication among staff members contributed to the deficiency in protecting the resident from verbal abuse.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of a resident who experienced verbal abuse from a registered nurse (RN) employed through a staffing agency. The incident involved the RN making a derogatory comment to the resident, which was not immediately reported by a certified nursing assistant (CNA) who witnessed it. The CNA assumed that another staff member would handle the situation, leading to a delay in reporting the abuse to the appropriate authorities within the facility. The resident involved was a female with a moderately impaired cognitive status, as indicated by her BIMS score of 12. She required assistance with various activities of daily living and was on anti-anxiety medication. The verbal abuse incident made her feel awful and scared, as she was uncertain about the RN's future actions. Despite the resident's distress, the facility's Director of Nursing (DON) and Administrator were not informed of the incident until much later, highlighting a breakdown in communication and reporting procedures. Additionally, the facility did not ensure that the RN had completed the necessary abuse training, as required by their policies. The DON and Administrator were unaware if the RN had received any abuse training, either from the staffing agency or the facility itself. This lack of training and oversight contributed to the failure to prevent and address the abuse incident promptly, putting residents at risk of unreported abuse and neglect.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by regulations. This deficiency was identified in the case of a resident who was subjected to verbal abuse by a nurse. The incident occurred when a resident requested to be taken outside to smoke, and the nurse responded with a derogatory comment. Despite multiple staff members being present, the incident was not reported to the abuse coordinator or the administrator as required. The resident involved was a female with a moderately impaired cognition, as indicated by her BIMS score. She was admitted to the facility with a diagnosis of a displaced spiral fracture of the right tibia and required assistance with various activities of daily living. The resident reported feeling awful and scared following the verbal abuse incident, which was not immediately addressed by the facility staff. Interviews with staff revealed a lack of communication and reporting of the incident. A CNA who witnessed the event did not report it, assuming another staff member would handle it. The RN supervisor on duty was unaware of the incident, and the DON and Administrator were not informed until later. The facility's policy on abuse and neglect mandates prompt reporting of such incidents, which was not adhered to in this case.
Failure to Protect Resident from Abuse During Shower
Penalty
Summary
The facility failed to protect a resident from physical abuse by a CNA during a shower. The incident occurred when the CNA used excessive force while rubbing the resident's chest, resulting in a 5 cm superficial laceration, surrounding bruising, and closed fractures of the 2nd and 3rd ribs. The resident, who had a history of chronic respiratory failure, muscle contractures, and rheumatoid arthritis, required maximum assistance for activities of daily living and was dependent on a wheelchair. Despite the resident's protests and requests to stop, the CNA continued the aggressive behavior, causing physical harm. Following the incident, the resident was not immediately protected from further contact with the CNA. The CNA continued to provide care to the resident after the shower incident, which was against the facility's policy to protect residents from harm during investigations of abuse allegations. The resident expressed fear and anxiety about being in the shower room with new staff and was visibly upset and scared during the transfer back to bed. The facility's failure to immediately remove the CNA from resident care duties placed the resident at risk of further harm. Interviews with staff and the resident's family member revealed inconsistencies in the handling of the situation. The resident's family member provided evidence that contradicted the facility's initial assessment of the incident. The facility's administrator and staff failed to adequately separate the alleged perpetrator from the resident, and there was a lack of immediate action to ensure the resident's safety. The facility's policy on abuse and neglect was not followed, leading to a situation of immediate jeopardy for the resident.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and mistreatment of residents, as evidenced by an incident involving a resident who was physically abused by a CNA in the shower room. The resident, who had a history of chronic respiratory failure, muscle weakness, and mild cognitive deficit, required maximum assistance for activities of daily living. During a shower, the CNA reportedly used excessively hot water and scrubbed the resident's chest aggressively, resulting in a skin tear and rib fractures. Despite the resident's protests, the CNA continued the aggressive behavior, and another CNA who entered the room did not intervene appropriately. The incident was further compounded by the failure of the charge nurse, LVN D, to immediately remove the alleged perpetrator, CNA A, from resident care duties. Instead, CNA A was allowed to continue providing care to the resident after the incident, which is a direct violation of the facility's abuse prevention policy. The policy clearly states that employees accused of abuse should be reassigned to non-resident care duties or suspended without pay pending investigation. This failure to follow protocol placed the resident at risk for further harm and demonstrated a lack of adherence to established procedures for handling abuse allegations. Interviews with staff and the resident revealed that the incident was not handled according to the facility's policies. The resident expressed fear and anxiety about being in the shower room with new staff, and staff members acknowledged that the alleged perpetrator should have been immediately removed from resident care. The facility's failure to protect the resident during the investigation of the abuse allegation highlights a significant lapse in ensuring resident safety and compliance with abuse prevention policies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to medication errors and omissions. Resident #2 did not receive her prescribed Nifedipine for hypertension on a specific date, despite the medication being available in the facility's emergency kit. The Medication Aide (MA) responsible did not recall the incident, and it was noted that only a nurse could access the emergency kit. The Director of Nursing (DON) confirmed that the emergency kit should be used when medications are not delivered on time. Resident #3 was mistakenly administered Ativan and Trazodone, medications not prescribed to her, due to an error by MA D. The MA had pre-prepared another resident's medication and inadvertently gave it to Resident #3 after being distracted by a phone call. The error was immediately recognized and reported, and the resident was assessed and found stable. The MA acknowledged the mistake and received education on proper medication administration procedures. Resident #4 did not receive her prescribed Amlodipine during a medication pass observed by a surveyor. MA C, who administered the medications, initially claimed to have given the Amlodipine but later could not produce the medication card as evidence. The DON and Administrator emphasized the importance of following physician orders and not pre-preparing medications. The facility's policy on medication administration was reviewed, highlighting the need for accuracy and adherence to prescribed orders.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the care of a resident. CNA A was observed using a disposable wipe visibly soiled with feces to clean a resident's vaginal area, instead of disposing of it and using a clean wipe. This action was acknowledged by CNA A, who admitted the importance of using a clean wipe to prevent infections. CNA B was observed failing to perform hand hygiene between glove changes, before exiting the resident's room, and prior to re-entering the room. CNA B acknowledged the oversight and recognized the importance of hand hygiene in preventing the spread of bacteria and infections. Additionally, both CNAs failed to remove a trash bag containing dirty gloves visibly soiled with feces from the resident's room after providing care. Interviews with the DON and the Administrator confirmed that the facility's expectations for infection control were not met. Both emphasized the importance of disposing of soiled wipes, performing hand hygiene, and removing contaminated items from resident rooms to prevent cross-contamination and infections. The facility's policies on hand hygiene and care for residents with urinary incontinence were not adhered to during the observed incident.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
