Lakeside Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lubbock, Texas.
- Location
- 4306 24th St, Lubbock, Texas 79410
- CMS Provider Number
- 675093
- Inspections on file
- 44
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Lakeside Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with CHF, acute respiratory failure, acute kidney failure, and GAD had a new PRN Lorazepam oral concentrate order, with pharmacy records confirming delivery of a 30 mL bottle. The EMAR showed no administrations, and during a narcotic audit the prescription box was found in the narcotic refrigerator without the medication bottle. Interviews with the ADM, DON, LVNs, and a CMA revealed that narcotic counting practices were inconsistent, particularly for medications stored in the narcotic refrigerator, and required narcotic count sheets were missing for several days. Facility policy and verification forms required end-of-shift reconciliation of all controlled substances, but the lack of documented counts and failure to consistently include the refrigerator narcotics resulted in an unreconciled, missing controlled medication for this resident.
A resident with dementia, Parkinson’s disease, muscle weakness, and a high fall risk was found in bed without a call light within reach, despite being cognitively intact and care-planned to have the call light accessible and to receive prompt assistance. The call light cord was discovered wrapped and stored behind a roommate’s nightstand, and the resident reported not knowing it was there, while the roommate stated they would press their own call light when the resident needed staff. Multiple LVNs, the DOR, DON, and ADM confirmed the resident could use a call light, that all staff were responsible for ensuring call lights were within reach during rounds and room entries, and that facility policy required each resident to have a means to call staff from the bed and other areas, but this was not followed for this resident.
A resident with diabetes, osteoporosis, and a lumbar compression fracture experienced a significant unplanned weight loss of over 10% body weight within about one month after admission. The care plan called for maintaining weight within 3% of a target, monitoring intake each meal, and RD evaluation PRN, but the facility did not obtain weekly admission weights or a readmission weight as required by policy, and a large early weight drop was overlooked. The RD noted weight loss but made no recommendations and did not document a visit, and was not formally consulted despite policy requiring notification for significant changes. The resident reported losing more than sixteen pounds, limiting food choices due to blood sugar concerns, disliking some menu items, bringing her own protein shakes, and not being offered liquid supplements, while intake records showed multiple days with 50% or less meal consumption. Staff interviews confirmed inconsistent understanding and implementation of weight-monitoring procedures, leading to a failure to implement timely nutritional interventions for the resident’s significant weight loss.
A resident with spastic quadriplegic cerebral palsy was observed using a chest harness in a wheelchair without a physician order, consent, or documented evaluation, despite being unable to remove the device independently. Staff considered the harness a positioning device, but facility policy defined it as a restraint due to the resident's inability to remove it, and required a physician order and consent, which were not present.
A deficiency was cited for not ensuring a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or actions that led to this failure.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a fractured patella and other conditions was prescribed Oxycodone/Acetaminophen for pain, but nursing staff failed to consistently document administration on both the MAR and narcotic count sheet. Additionally, two nurses did not properly report or witness the wastage of missing pills as required by policy, leading to discrepancies in medication records and unreported medication loss.
A resident with severe cognitive impairment and multiple medical and behavioral diagnoses did not have a comprehensive care plan addressing all identified needs, including cognitive loss, communication, urinary incontinence, behavioral symptoms, pressure ulcers, and the use of a wander guard. The care plan was incomplete despite facility policy and staff interviews confirming these areas should have been included.
Nine residents reported not having access to grievance forms, not knowing they could file grievances anonymously, and not being informed about the grievance procedure, with no postings or forms available in prominent locations. The ADM confirmed that forms were only available through staff and there was no process for anonymous submission, contrary to facility policy.
Two residents did not have their care plans updated or individualized to address vision, activities, and pressure ulcer risks, despite assessments indicating these needs. Staff interviews confirmed that care plans should be comprehensive and reflect all identified needs, but the required interventions and goals were missing or incomplete.
Multiple residents had triggered MDS items that were not included in their care plans, and care plans were not developed, reviewed, or revised by an interdisciplinary team within the required timeframe.
During a lunch meal, staff failed to follow proper hand hygiene and food handling procedures, including inadequate handwashing, handling food with bare hands, and serving food at unsafe temperatures. Several food items were served below the required holding temperature, and burnt food was provided to residents. Observations showed that much of the food was left uneaten, and staff interviews confirmed lapses in following established food safety and hygiene policies.
Staff failed to sanitize a blood pressure cuff between multiple residents and did not consistently perform hand hygiene or change gloves appropriately during incontinence care, despite having received training and facility policies requiring these infection control measures. Residents involved had complex medical histories, and these lapses were directly observed and confirmed in staff interviews.
A resident dependent on a mechanical lift for transfers was left in a wheelchair overnight due to a malfunctioning lift. Despite staff attempts to use the lift, it did not function, and the resident refused manual transfer, fearing for staff safety and his own. The resident's care plan required a mechanical lift, but there was no physician order for alternative methods. Staff interviews revealed a lack of training on alternative transfers and lift operation, highlighting communication and training issues.
A resident with a history of stroke, diabetes, and hypertension was found with an indwelling catheter but without physician orders for its use and care. The resident was unsure of the catheter's purpose, and staff interviews revealed a lack of clarity regarding its necessity and care instructions. The DON and Interim Administrator acknowledged the absence of orders and the potential risks, such as infection, due to this oversight.
A resident with a complex medical history, including dysphagia, was given medication by a CNA who was not certified to administer medications. The ADON, during a busy medication pass, prepared a Tylenol tablet and asked the CNA to administer it, citing the CNA's familiarity with residents. This action violated the facility's policy, which mandates that only licensed personnel administer medications.
A long-term care facility failed to maintain accurate drug records and reconcile controlled medications for a resident with dementia and Alzheimer's. Discrepancies in morphine administration were found, with staff not counting liquid morphine during shift changes, leading to an 8 ML discrepancy. The facility's policies did not explicitly require counting all medications, contributing to the oversight.
A long-term care facility failed to maintain an effective infection control program, as staff members did not adhere to enhanced barrier precautions during resident care. An LVN did not change gloves or wash hands during wound care and transfers, while CNAs failed to wash hands or wear gowns as required. Despite training, staff did not consistently follow infection control protocols, risking the spread of infections.
A resident with a surgical hip replacement did not receive wound care as per physician's orders, leading to a deficiency in care. The facility failed to perform daily dressing changes, resulting in blood-soaked dressings and sheets. Staff interviews revealed lapses in following procedures and documentation, contributing to the deficiency.
A facility failed to provide and document necessary wound care for a resident with a pressure ulcer, as per physician's orders. The resident, with multiple health conditions, required daily wound care, but there was no documentation of care on a specific date. Interviews revealed confusion among nursing staff about wound care responsibilities, and the DON confirmed that the absence of documentation indicated the care was not performed, placing the resident at risk for infection and worsening of the ulcer.
A resident with multiple medical conditions was not provided full privacy during peri and wound care by a CNA and ADON, leading to exposure. Despite training and facility policies, privacy curtains were not fully closed, and no sheet was used to cover the resident, resulting in a breach of privacy.
The facility failed to maintain an effective infection control program as CNAs did not adhere to hand hygiene protocols during incontinent care for residents. Despite training, CNAs neglected to wash hands before, during, and after care, increasing infection risk. Interviews confirmed staff awareness of protocols, yet routine habits led to non-compliance.
A resident with multiple health issues developed pressure ulcers that were not adequately treated according to physician orders. The facility failed to implement a comprehensive care plan, resulting in uncovered and untreated wounds. Staff interviews revealed a lack of awareness and inconsistent adherence to wound care schedules, despite training. The absence of a care plan policy further contributed to the deficiency.
A resident with multiple pressure ulcers was found with uncovered and improperly dressed wounds, despite physician orders for regular care. Staff interviews revealed a lack of awareness and adherence to the care plan, with some staff unaware of the resident's condition. The resident, who was in pain due to the open ulcers, denied removing the dressings. The facility's failure to follow physician orders placed the resident at risk of complications.
Failure to Reconcile and Account for Controlled Medication in Narcotic Refrigerator
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective system for acquiring, receiving, dispensing, administering, and reconciling controlled medications, specifically Lorazepam Oral Concentrate 2 mg/mL prescribed for one resident. The resident was an adult male admitted with diagnoses including unspecified diastolic congestive heart failure, acute respiratory failure, acute kidney failure, and generalized anxiety disorder. An order dated 03/18/2026 directed that 0.25 mL of Lorazepam oral concentrate be given by mouth every four hours as needed for anxiety, and the pharmacy shipment summary showed that a 30 mL bottle of this medication was delivered to the facility on that date. The Medication Administration Record from 03/18/2026 through 03/31/2026 showed no administrations of this PRN medication during that period. The Administrator reported that on 03/24/2026, following an audit of narcotic medications conducted by the DON and nursing staff, the prescription box for the resident’s Lorazepam was found in the narcotics refrigerator, but the bottle of medication was missing. Interviews with multiple LVNs revealed inconsistent practices regarding narcotic counts, particularly for medications stored in the narcotic refrigerator. Some LVNs stated they counted only the PRN narcotics on the medication carts and did not count the narcotics in the refrigerator, while others stated they believed they were counting all narcotics, including those in the refrigerator. One LVN, who assisted with the narcotic audit, stated that when she removed all items from the narcotic refrigerator, she discovered an empty box labeled for the resident’s Lorazepam without the corresponding bottle inside, and a subsequent search did not locate the medication. Further record review and interviews showed that the facility lacked completed narcotic count sheets for the period from 03/18/2026 to 03/24/2026, despite a policy requiring controlled substances to be reconciled upon receipt, administration, disposition, and at the end of each shift. The DON acknowledged that the narcotic refrigerator was not being consistently counted and that there was no specific system in place to ensure it was included in shift-to-shift reconciliations. The facility’s written policy and the Narcotic Book/EMAR Verification Sheet required that at each shift change both nurses verify all scheduled and PRN narcotics, document the actual number of cards, bottles, and patches, and turn in the form and any empty cards or bottles to the DON every shift without exception. The absence of narcotic count documentation for the relevant dates, combined with staff reports that the refrigerator narcotics were not always included in counts, led to the discovery that the resident’s newly received Lorazepam bottle was missing and could not be reconciled.
Failure to Keep Resident Call Light Within Reach at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system was available and within reach at a resident’s bedside as required by facility policy and the resident’s care plan. Record review showed the resident was an older male with unspecified dementia and Parkinson’s disease with dyskinesia, who was cognitively intact per a BIMS score of 14. His care plan identified an ADL self-care performance deficit due to muscle weakness related to Parkinson’s disease, a need for assistance by one to two staff for transfers, and a high risk for falls related to gait/balance problems and psychoactive drug use. The care plan specifically directed that his call light be kept within reach and that he receive a prompt response to all requests for assistance. During an observation and interview, the resident was found lying in bed without a call light within reach. He stated he had never had a call light in his room. The surveyor observed that the call light cord was wrapped and placed behind his roommate’s nightstand, approximately three feet from his bed, and the resident reported he did not know it was there. The roommate confirmed that the resident did not have a call light and that the roommate would press his own call light when the resident needed staff. When the roommate pressed his call light, an LVN entered the room in response, located the resident’s call light behind the nightstand, unwrapped it, and placed it within the resident’s reach, confirming it was functional and acknowledging it should have been within reach while the resident was in bed. Multiple staff interviews, including with the DOR, several LVNs, the DON, and the ADM, confirmed that the resident was capable of using his call light, even though he did not use it frequently and often sought staff by going out of his room. They each stated that the call light should always be within the resident’s reach while in his room for safety and that all staff were responsible for ensuring call lights were within reach during nursing rounds, every time staff entered a room, and as they walked down hallways. Review of the facility’s “Call System, Residents” policy stated that each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor, and that the resident call system is to be routinely maintained and tested by maintenance. Despite these expectations and policies, the resident’s call light had been wrapped and stored behind the roommate’s nightstand, leaving him without an accessible means to call for assistance while in bed until it was discovered during the survey.
Failure to Monitor and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident who experienced a significant, unplanned weight loss of 16.8 pounds, representing a 10% loss of body weight between early December and mid-January. The resident was an older adult female with diagnoses including a lumbar compression fracture, Type 2 diabetes mellitus, osteoporosis, and a cognitive communication deficit, but with intact cognition per an admission BIMS score of 15. Her admission MDS documented an admission weight of 158 pounds, no poor appetite, independent eating with setup assistance, and an LCS regular diet with thin liquids. The comprehensive care plan, initiated shortly after admission and later revised, identified a nutritional problem related to diabetes and set a goal for the resident to maintain weight within 3% of 145.8 pounds, with interventions to provide the ordered diet, monitor and record intake each meal, and have the RD evaluate and recommend diet changes as needed. Weight records showed the resident’s weight decreased from 158 pounds on admission to 145.8 pounds by early January and then to 141.2 pounds by mid-January, meeting the facility policy’s threshold for significant weight loss. The facility’s policy required residents to be weighed on admission, the next day, and weekly for two weeks, then monthly if no concerns, and to recheck any 5% or greater weight change the next day, with immediate written notification to the dietitian if confirmed. The DON later stated that newly admitted residents were usually weighed upon admission, weekly for four weeks, then monthly, and that residents should also be weighed upon readmission from the hospital. However, the resident was not weighed weekly upon admission, was not weighed upon readmission from a hospital stay in December, and the DON acknowledged being unsure why these weights were missed. The DON also stated he was not aware of the extent of the resident’s weight change and that the significant change noted on the early January weight was overlooked. The dietitian’s documentation and statements further showed that required nutritional follow-up was not completed or recorded in response to the resident’s weight changes. The dietitian reported seeing the resident shortly after admission and again in early January, noting some weight loss but believing the admission weight might be inaccurate based on the resident’s reported usual weight of 145–150 pounds. No recommendations were made at that time, and the dietitian did not enter a note in the electronic health record for the early January visit. The resident reported losing over sixteen pounds since admission, attributed her weight loss to limiting foods that might raise her blood sugar, described herself as a picky eater who did not care for some facility foods, and stated she brought her own protein shakes and was not offered liquid supplements by the facility. She also reported being weighed only once or twice a month and not recalling a dietitian visit since admission. Meal intake records showed variable intake, with multiple days where she consumed 50% or less of meals, despite the care plan goal of consuming at least 75% of three meals daily. These actions and inactions in monitoring weights, confirming significant changes, notifying the dietitian, and implementing timely nutritional interventions led to the resident’s significant weight loss. Staff interviews corroborated that the facility’s processes for weight monitoring and nutritional follow-up were not consistently implemented for this resident. The CNA responsible for passing lunch trays stated the resident usually consumed 75–100% of meals and was receiving sandwiches as snacks, and that she would notify the kitchen and offer alternatives if residents complained about food. The LVN stated that CNAs on day shift were responsible for obtaining monthly weights and that she believed new residents were weighed on admission and monthly, with the DON responsible for notifying the physician of changes. The DON stated that a transportation aide obtained weights and turned them in for entry into the electronic record, and he was unsure why the resident was not weighed weekly or upon readmission. The administrator stated he was not aware of the resident’s significant weight loss until a care plan meeting and that he and the DON were ultimately responsible for ensuring weights were monitored and significant changes were addressed. The facility’s written policy on weight assessment and intervention, including thresholds and required actions for significant weight loss, contrasted with the actual practice documented for this resident, resulting in a failure to implement appropriate monitoring and interventions to prevent or address her significant weight loss.
Failure to Obtain Physician Order and Consent for Use of Chest Restraint
Penalty
Summary
A deficiency was identified when a resident with spastic quadriplegic cerebral palsy and a history of falls was observed using a chest harness in his wheelchair. The resident required substantial to maximal assistance with positioning, mobility, and transfers, and was cognitively moderately impaired. Despite the use of the chest harness, there was no physician order, consent, or documented evaluation of need for the device in the resident's medical record. The quarterly MDS assessment did not indicate the use of a trunk restraint, and the comprehensive care plan lacked any mention of a restraint or the chest harness. Staff interviews revealed that the chest harness was used daily to prevent the resident from falling, and the resident was unable to remove the harness independently. Both the LVN and the DON acknowledged that the resident could not unbuckle the harness himself. The DON and ADM stated that the harness was considered a positioning device rather than a restraint, and therefore did not require the same documentation or physician oversight. However, the facility's own policy defined a restraint as any device that the resident could not remove easily and that restricted freedom of movement, which applied to the chest harness in this case. Further review of facility documentation showed that the use of the chest harness was noted as a stability device to prevent the resident from slipping out of his chair. Despite this, there was no evidence of a risk assessment, consent, or physician order for its use, as required by facility policy. The policy also specified that restraints should only be used upon written physician order, with documented consent and ongoing evaluation, none of which were present for this resident.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Accurately Document and Report Administration and Wastage of Controlled Substances
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident who was prescribed Oxycodone/Acetaminophen 10/325MG, resulting in multiple documentation and reporting errors by nursing staff. Specifically, one nurse did not document the administration of the medication on the Medication Administration Record (MAR) after giving it to the resident. Additionally, two other nurses failed to record the administration of the same medication on the Narcotic Record Count Sheet after giving it to the resident. These lapses led to inconsistencies between the MAR and the narcotic count sheet, making it unclear how many doses were actually administered and how many pills should have remained in inventory. Further compounding the issue, one nurse failed to notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) about a discrepancy involving two missing pills, as required by facility policy. Instead, the nurse documented the pills as wasted on the narcotic count sheet and had another nurse sign as a witness, even though the witnessing nurse did not actually observe the medication being wasted. This was contrary to facility policy, which requires two nurses to witness and sign off on the destruction of controlled substances. Interviews with staff revealed confusion and lack of adherence to proper procedures for documenting, counting, and reporting discrepancies with controlled medications. The resident involved was an older female admitted with a fractured patella, muscle weakness, and lack of coordination, and had an order for Oxycodone/Acetaminophen as needed for pain. Documentation reviews and staff interviews confirmed that the required records for administration and wastage of the medication were incomplete or inaccurate, and that staff did not consistently follow the facility’s policies for handling controlled substances. The discrepancies in documentation and failure to report missing medication were directly observed and verified by facility administration during the investigation.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical and psychosocial needs. The resident, an elderly female with diagnoses including benign intracranial hypertension, mixed hyperlipidemia, Type 2 diabetes with hyperosmolar hyperglycemic coma, intermittent explosive disorder, cognitive communication deficit, and unspecified dementia, was admitted with significant cognitive impairment as evidenced by a BIMS score of 00. The comprehensive assessment identified several care areas requiring attention, such as cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, falls, nutritional status, pressure ulcers, and psychotropic drug use. Despite these identified needs, the resident's care plan did not address several critical areas, including cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, and pressure ulcers. Additionally, the care plan failed to include the physician's order for a wander guard or the rationale for its use, and did not address the resident's behaviors related to her diagnoses. Observations confirmed the presence of a wander guard and ongoing behavioral symptoms, such as repeated tapping, yet these were not reflected in the care plan. Interviews with staff revealed a lack of awareness regarding the incomplete care plan and uncertainty about whether all required care areas were included. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for each resident. However, the care plan for this resident was incomplete and did not reflect all areas identified in the comprehensive assessment. Staff interviews indicated that care plans were supposed to be updated upon admission, quarterly, and as changes occurred, but the process was not fully implemented, resulting in the omission of essential care planning for the resident.
Failure to Provide Grievance Information and Access to Residents
Penalty
Summary
The facility failed to provide information to residents and their representatives regarding their rights to file grievances or concerns. During a Resident Council meeting, nine residents who had been in the facility for over six months reported that they did not have access to grievance forms, were unaware they could file grievances anonymously, and had never had the grievance procedure discussed during council meetings. These residents also stated they had not seen postings of the grievance procedure in prominent locations and did not know where to acquire a grievance form, who to submit it to, or what the process entailed after filing. Observations confirmed that the facility did not have instructions regarding the grievance procedure posted in prominent locations, and grievance forms were not readily available nor was there a method to submit grievances anonymously. The Administrator, who served as the Grievance Officer, stated that grievance forms were kept in staff offices and residents could not obtain them without asking staff. Staff typically completed the forms for residents, and there was no established procedure for anonymous submissions. The grievance policy, last updated in 2017, required that information on filing grievances be made available to residents, but this was not being implemented as described.
Failure to Develop and Update Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, specifically neglecting to address their vision, activities, and pressure ulcer risks. For one resident, the care plan was not revised or updated to include interventions and goals related to vision, despite documentation indicating vision impairment and risk for pressure ulcers. The Minimum Data Set (MDS) and Care Area Assessment (CAA) summaries identified these issues, but the care plan did not reflect them. For the second resident, the care plan lacked documentation and interventions for visual function, activities, and pressure ulcers, even though the resident's assessments indicated impaired vision, use of corrective lenses, and risk for pressure ulcers. The relevant sections of the MDS were either incomplete or not addressed in the care plan, and the CAA summaries triggered concerns that were not care planned. Interviews with facility staff, including the Administrator, DON, and MDS Coordinator, confirmed that care plans are intended to be individualized and updated based on assessments and resident needs. However, the care plans for these residents were not updated or individualized as required, and the facility's policy mandates that care plans include measurable objectives, timeframes, and interventions for all identified needs.
Failure to Develop and Update Care Plans for Triggered MDS Items
Penalty
Summary
Several residents were found to have discrepancies in their care plans, specifically with care plan items not being developed as required. Record review revealed that for at least three residents, there were multiple triggered Minimum Data Set (MDS) items that were not addressed in their care plans. The care plans were not completed within the required timeframe following the comprehensive assessment, nor were they prepared, reviewed, and revised by a team of health professionals as mandated.
Failure to Provide Palatable, Safe, and Properly Handled Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature during a lunch meal observation. Kitchen staff member A was observed not following proper handwashing procedures, often rinsing hands with water only and not washing for the required 15 seconds with soap. The staff member also handled food with bare hands, picked up food items directly, and then donned gloves without proper hand hygiene. Additionally, the staff member used gloved hands to pick up brisket from the serving bar and returned it to the steam table, served burnt rolls, and handled rolls and potatoes with bare hands while serving residents. Hot dog buns were left open in their package for an extended period. Temperature checks of the food revealed that several items were not maintained at appropriate temperatures. For example, the roast on a regular plate was measured at 120°F, potatoes at 101.8°F, and carrots at 122.9°F, all of which are within the temperature danger zone for food safety. Pureed and mechanical diet items also showed inconsistent temperatures, with some items above and others below the required holding temperature of 135°F. Observations further indicated that ten plates of food were left uneaten on the table, suggesting issues with food palatability and temperature. Interviews with staff confirmed a lack of adherence to food safety and hand hygiene policies. Kitchen staff member A acknowledged being trained years ago and recognized that not following policy could negatively impact residents' health and nutrition. The administrator and kitchen supervisor both stated expectations for compliance with food safety and hand hygiene protocols, referencing facility policies that require proper handwashing, glove use, and maintenance of safe food temperatures. Record reviews of facility policies supported these requirements, emphasizing the importance of hygiene and temperature control in food preparation and service.
Failure to Follow Infection Control Protocols for Equipment and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not following established protocols for cleaning and hand hygiene. During medication administration, a medication aide (MA) used a blood pressure cuff on several residents consecutively without sanitizing the equipment between uses, despite having been trained to do so. The aide acknowledged awareness of the protocol but stated she forgot to disinfect the cuff, which was confirmed by direct observation and staff interviews. Additionally, certified nursing assistants (CNAs) did not adhere to proper hand hygiene practices during incontinence care. One CNA changed gloves without performing hand hygiene between glove changes, while another failed to change gloves and perform hand hygiene before placing a clean brief on a resident. Both CNAs had received training on infection control and recognized the importance of these practices but admitted to forgetting the required steps during care. The residents involved had significant medical histories, including conditions such as cerebral infarction, type two diabetes, urinary tract infection, major depressive disorder, and cerebrovascular disease. Facility policy required cleaning and disinfection of non-critical resident care items, such as blood pressure cuffs, and mandated hand hygiene before moving from contaminated to clean body sites and after glove removal. Despite these policies and recent staff training, the observed lapses in infection control protocols led to the identified deficiencies.
Resident Left in Wheelchair Overnight Due to Inoperable Mechanical Lift
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was dependent on a mechanical lift for transfers due to muscle weakness, neuropathy, and other conditions, was left in his wheelchair overnight because the mechanical lift was reportedly inoperable. Despite multiple attempts by staff to use the lift, it did not function properly, and the resident refused manual transfer due to concerns about staff safety and his own fear of being dropped. The resident's care plan indicated that he required a mechanical lift with two staff assistance for transfers, but there was no physician order for the use of a mechanical lift or alternative transfer methods. On the night in question, the staff did not report the malfunctioning lift to the appropriate personnel, and the resident remained in his wheelchair until the following morning. The resident expressed discomfort but did not experience pain or require immediate medical attention during the night. Interviews with staff revealed a lack of training on alternative transfer methods and mechanical lift operation. The facility had only one mechanical lift, and there was confusion among staff about the appropriate number of personnel required for a manual transfer if the lift was not operational. The incident highlighted a breakdown in communication and training, as well as a failure to adhere to the resident's care plan and ensure his comfort and safety.
Lack of Physician Orders for Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter had the necessary physician orders for its use and care. The resident, a female with a history of cerebral infarction, type 2 diabetes, essential hypertension, and a urinary tract infection, was observed with an indwelling catheter but without corresponding physician orders. The resident, who had an intact cognitive status, was unsure of the reason for the catheter's placement, and staff interviews revealed a lack of clarity regarding the catheter's necessity and care instructions. The Director of Nursing (DON) and Interim Administrator acknowledged the absence of physician orders and the potential risks associated with this oversight, such as infection or inadequate catheter care. The DON, new to the facility, was uncertain about the catheter's origin, suspecting hospice involvement, but could not confirm the diagnosis necessitating the catheter. The facility's policy required documentation of clinical indications for catheter use, which was not adhered to in this case, leading to a deficiency in providing appropriate catheter care and increasing the risk of urinary tract infections for the resident.
Improper Medication Administration by Uncertified Staff
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate dispensing and administration of drugs, as evidenced by an incident involving the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA). On a hectic day, the ADON prepared a Tylenol Extra Strength tablet for a resident and handed it to the CNA, who was not certified to administer medications, to give to the resident. This action was prompted by the ADON's need for assistance during a busy medication pass, and the CNA's familiarity with the residents was cited as a reason for this decision. The resident involved had a complex medical history, including acute respiratory failure, epilepsy, insomnia, anxiety, depression, dysphagia, cerebral palsy, and congenital hypertonia. The resident required substantial assistance with eating and was on a mechanically altered diet with thickened liquids due to swallowing difficulties. Despite these needs, the medication administration record showed no documentation of the Tylenol being given on the day in question, raising concerns about the accuracy and safety of medication administration. Interviews with staff and observations confirmed the incident, with multiple staff members expressing concern about the risks associated with an uncertified person administering medications. The ADON acknowledged the mistake and stated it was a spur-of-the-moment decision. The CNA, who administered the medication, also recognized the error and stated it would not happen again. The facility's policy clearly states that only licensed or state-permitted personnel may prepare and administer medications, highlighting the deviation from standard procedures in this case.
Medication Reconciliation Failure in LTC Facility
Penalty
Summary
The facility failed to ensure that the drug records for a resident were in order and that an account of all controlled drugs was maintained and periodically reconciled. This deficiency was identified during a review of the medication administration records for a resident diagnosed with dementia, Alzheimer's disease, and altered mental status. The resident was prescribed morphine sulfate for pain management, but discrepancies were found in the medication administration records and the actual amount of morphine present in the facility. The investigation revealed that the facility did not monitor, review, or reconcile the resident's medication administration record from April to October 2024. The medication administration logs showed inconsistencies in the documentation of morphine administration, with missing doses and discrepancies between the recorded and actual amounts of morphine. Interviews with staff, including the DON, ADON, and various LVNs, indicated that the liquid morphine was not being counted during shift changes, and the staff had become relaxed in the process, relying on verbal confirmations rather than physical counts. The facility's policies on medication administration and documentation did not explicitly require the counting of all medications, including liquids, during shift changes. The lack of adherence to proper medication reconciliation procedures led to an 8 ML discrepancy in the morphine count, which was discovered by a new nurse. The failure to maintain accurate medication records and perform regular counts placed residents at risk of not receiving prescribed medications and potential drug diversion.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions and inactions of staff members during the care of two residents. Specifically, LVN D did not adhere to enhanced barrier precautions, failed to change gloves, and neglected to wash her hands or use alcohol-based hand rub (ABHR) during wound care for two residents and during the transfer of one resident to bed. Additionally, LVN D did not wear the appropriate personal protective equipment (PPE) during these procedures, which is a requirement under the facility's infection control policy. CNA G and CNA H also failed to follow enhanced barrier precautions. Both CNAs did not wash their hands or use ABHR before entering and after exiting a resident's room. Furthermore, CNA H did not wear a gown while transferring a resident to bed, despite the facility's policy requiring gloves and gowns for high-contact resident care activities. These lapses in protocol were observed despite the presence of signage indicating the need for enhanced barrier precautions. Interviews with the staff, including LVN D, CNA G, CNA H, the Director of Nursing (DON), and the Administrator, revealed a lack of adherence to the facility's infection control policies. Although the staff had been trained on enhanced barrier precautions, they did not consistently apply this training in practice. The DON and Administrator acknowledged the deficiencies and recognized the potential for the spread of infections due to these lapses in infection control practices.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident received wound care in accordance with physician's orders and professional standards of practice. The resident, a female with a history of surgical hip replacement, epilepsy, end-stage renal disease, and major depressive disorder, was admitted to the facility with specific orders for daily dry dressing changes to her left hip incision. However, the facility did not adhere to these orders, as evidenced by the lack of documentation for a dressing change on one of the specified dates. On a particular day, a CNA discovered the resident with blood-soaked dressings and sheets, indicating that the wound care had not been performed as required. The charge nurse confirmed that the dressing had not been changed for two days, despite the presence of old and new blood and a foul odor emanating from the dressing. The nurse acknowledged that the dressing should have been changed daily, as per the physician's orders, and reported the issue to the on-call ADON. Interviews with facility staff, including the DON and the administrator, revealed that the failure to perform and document the dressing changes was due to a lapse in following the established procedures. The DON admitted that if there was no documentation, the care was likely not provided, and emphasized the importance of adhering to physician's orders to prevent potential negative outcomes such as infection or wound deterioration. The facility's policy on wound care documentation was not followed, contributing to the deficiency.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, as per the physician's orders. The resident, a cognitively intact female with multiple health conditions including multiple sclerosis and schizoaffective disorder, had a documented pressure ulcer on the coccyx. The physician's orders required daily wound care, which included cleansing, drying, applying triad, and covering with a dressing. However, there was no documentation of the wound care being performed on a specific date, indicating a lapse in following the prescribed treatment plan. Interviews with the nursing staff revealed a lack of clarity and communication regarding wound care responsibilities. The charge nurse and medication nurse both stated they did not perform the wound care for the resident on the specified date. The Director of Nursing (DON) acknowledged that due to low census, the medication nurse was responsible for wound care between medication passes, and all staff had been notified of this change. However, the absence of documentation suggested that the wound care was not completed, which the DON confirmed should have been documented with date, time, and initials. This failure to follow physician's orders and document care placed the resident at risk for infection and worsening of the pressure ulcer.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to respect a resident's right to personal privacy during care procedures. Specifically, a CNA did not provide full privacy for a resident during peri care by not completely closing the privacy curtains or using a towel or sheet to cover the resident. This resulted in the resident's body being exposed during the procedure. Additionally, the ADON also failed to ensure privacy during wound care by not fully drawing the privacy curtain and not providing a sheet to cover the resident, leading to exposure while care was being administered. The resident involved was a female with multiple medical conditions, including metabolic encephalopathy, urinary tract infection, hyperlipidemia, depression, high blood pressure, anemia, type 2 diabetes, fibromyalgia, Sjogren syndrome, and acid reflux disease. The resident had a BIMS score indicating moderate cognitive impairment. During the care procedures, a camera was present in the room, allowing the family to view the resident, and a CNA entered the room while the resident was exposed. Interviews with the ADON, DON, and CNA confirmed that privacy protocols were not followed, despite training and facility policies emphasizing the importance of maintaining resident privacy.
Inadequate Hand Hygiene Practices in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNAs who did not adhere to hand hygiene protocols during the provision of incontinent care to residents. Specifically, CNA A did not wash her hands before or during the care of Resident #2, who had multiple pressure ulcers and was incontinent. Despite being trained in infection control practices, CNA A only washed her hands for 10 seconds after completing the care, contrary to the facility's policy of washing hands for at least 15 seconds. Similarly, CNA A did not wash her hands before, during, or after providing incontinent care to Resident #3, who had a history of sepsis and other serious health conditions. The CNA assisted the resident with toileting and cleaning without performing hand hygiene, increasing the risk of cross-contamination. This lack of adherence to hand hygiene protocols was also observed in the care of Resident #4, where both CNA A and CNA B failed to wash their hands before, during, and after providing care, despite the resident's cognitive intactness and need for extensive assistance due to incontinence. Interviews with the CNAs, ADON, DON, and the Administrator revealed that the staff had been trained in infection control practices, including handwashing, through regular in-services and competency checks. However, the CNAs admitted to not following the protocols due to routine habits and nervousness. The facility's policies clearly outlined the importance of hand hygiene in preventing the spread of infections, yet the staff did not consistently apply these practices, leading to the identified deficiencies.
Failure to Implement Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple pressure ulcers, which were not adequately treated according to physician orders. The resident, a male with a history of lung cancer, anemia, and other health issues, was admitted without pressure ulcers but was at risk of developing them. Despite verbal orders for wound care to the coccyx, left hip, and left thigh, the care plan did not address the resident's tendency to remove his own dressings, leading to uncovered and untreated wounds. Observations revealed that the resident's pressure ulcers were not properly covered, with one dressing hanging off and another wound completely uncovered. Interviews with staff, including CNAs and the ADON, indicated a lack of awareness and inconsistent adherence to the wound care schedule. The ADON and DON acknowledged the orders for wound care but could not explain why the dressings were not applied as required. The resident expressed pain due to the open wounds and stated that he had not removed any bandages himself. The facility's failure to follow physician orders and ensure proper wound care was compounded by the absence of a care plan policy, as confirmed by the DON. Despite training provided by the DON, the staff did not consistently report or address uncovered pressure ulcers, potentially leading to infection and worsening of the resident's condition. The administrator and DON both emphasized the importance of following physician orders, yet the deficiency persisted, highlighting a gap in the facility's care planning and implementation processes.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to uncovered and improperly dressed pressure ulcers. Observations revealed that the resident's pressure ulcer on the left thigh was uncovered, and the dressing on the coccyx was hanging off, exposing the ulcer. The dressing was soaked with drainage, and there was blood on the resident's gown and bedding. These observations were made despite physician orders for the ulcers to be cleaned and covered every night shift. Interviews with staff indicated a lack of awareness and adherence to the care plan. A CNA stated she was unaware of the uncovered ulcers and had seen them uncovered before. The ADON acknowledged the orders for cleaning and covering the ulcers but was unsure why they were not followed. The LVN, who was working PRN, was unaware of the resident's wounds and planned to address them after completing medication pass. The DON and Administrator both expected staff to follow physician orders and cover the ulcers promptly. The resident, who was moderately cognitively impaired and incontinent, reported being in pain due to the open ulcers. The resident denied removing the dressings himself. The facility's failure to ensure the resident's pressure ulcers were properly dressed and covered as per physician orders placed the resident at risk of complications, including infection and worsening of the ulcers.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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