Landmark Of Plano Rehabilitation And Nursing Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Plano, Texas.
- Location
- 1621 Coit Rd, Plano, Texas 75075
- CMS Provider Number
- 455861
- Inspections on file
- 48
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Landmark Of Plano Rehabilitation And Nursing Cente during CMS and state inspections, most recent first.
A resident with intact cognition, multiple chronic conditions (CHF, Type II DM, hyperlipidemia, MDD, HTN), bowel incontinence, and dependence on staff for toileting and incontinent care reported that staff did not change his brief for five hours and called law enforcement, who responded for an elder abuse complaint. The resident stated he was changed before breakfast, later used his call light for help, and that staff brought his meal without changing him. The DON acknowledged speaking with the responding officer and informing the administrator, identified as the abuse coordinator responsible for reporting to HHSC, but the allegation was not reported to the State Agency as required by facility policy and state reporting timeframes. Other staff (a CNA and an LVN) described the resident’s care needs and routine changing practices and denied that he waited five hours, but their interviews confirmed the facility was aware of the allegation and still failed to submit the required report.
A resident with multiple chronic conditions and self-care deficits was evaluated and recommended for Occupational Therapy (OT), but did not receive any OT services as outlined in her treatment plan. The OT discharge summary was initiated but not completed, and the facility lacked documentation and a policy related to rehabilitation services.
Two residents who were dependent on staff for ADLs did not consistently receive scheduled showers or bed baths, as confirmed by missing documentation, resident interviews, and staff admissions. Despite care plans requiring regular hygiene assistance, staff failed to provide or document these services, and supervisory staff were unaware of the lapses.
The facility did not ensure that OOH-DNR forms for three residents were completed correctly, with missing required signatures from residents, representatives, witnesses, and/or the attending physician, resulting in invalid advance directives. Staff interviews revealed a lack of awareness about these documentation errors, and one resident was not listed on the code status list despite having a DNR order.
A resident with severe cognitive impairment and multiple behavioral health diagnoses was denied access to her private bathroom, which was kept locked by staff due to concerns about her flushing inappropriate items. Instead, staff escorted her to a locked community restroom, limiting her independence and access to a homelike environment as required by facility policy.
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.
Three residents with pressure ulcers did not receive necessary care, including the use of properly set or functioning low air loss mattresses and timely wound dressing changes. One resident's mattress was set for the wrong weight, while two others lacked required pressure-relieving mattresses despite having wounds. Staff interviews revealed confusion about responsibilities for mattress settings and ordering, and care plans did not consistently document required interventions.
Two residents did not have their blood pressure documented prior to receiving prescribed antihypertensive medications, as required by physician orders. Staff interviews confirmed the expectation to check and record blood pressure before administration, but medication administration records and care plans lacked this documentation. Facility policy required such monitoring, but it was not consistently followed.
The facility did not maintain complete and accurate documentation of wound care for three residents with complex medical needs, resulting in multiple missed entries in treatment records and nursing notes. Despite physician orders and care plans requiring regular wound care, the electronic charting system showed unresolved entries, and staff interviews confirmed that treatments may have been performed but not properly documented.
Three residents with significant medical needs did not consistently receive scheduled showers or bed baths due to a persistent shortage of towels, despite staff and management being aware of the issue. Staff interviews confirmed that the lack of towels prevented the provision of necessary ADL care, and residents reported missed showers without explanation. Grievances were filed regarding the lack of bathing services.
A resident with multiple chronic conditions reported symptoms of a UTI, but staff failed to assess, document, or follow up on her complaint in a timely manner. Communication breakdowns among nursing staff and lack of documentation resulted in no urine specimen being collected or physician orders being implemented, delaying appropriate care.
A resident with severe cognitive impairment lost nearly all personal clothing during her stay, despite her family providing labeled items at admission and after additional purchases. Staff interviews revealed inconsistent inventory practices, lack of documentation, and no missing items policy, resulting in the resident being left with only minimal clothing at the time of her death.
A CNA at a facility took an unauthorized photo of a resident's private area during incontinence care, causing distress to the resident. The resident, who was cognitively intact, reported the incident to a family member, leading to police involvement. The CNA admitted to taking and deleting the photo. Staff and residents were aware of the policy against taking photos of residents.
The facility failed to maintain an effective infection control program during incontinence care for two residents. A resident with bowel and bladder incontinence did not receive proper care as CNA B failed to change gloves and perform hand hygiene after cleaning the resident. Another resident, severely cognitively impaired, was also at risk as CNA C did not perform hand hygiene after changing gloves. The DON confirmed the expectation for staff to change gloves and perform hand hygiene during care, as per the facility's handwashing policy.
The facility failed to provide adequate ADL care to residents due to staffing shortages. A resident reported delays in incontinent care, while two others did not receive scheduled showers. Staff confirmed the lack of sufficient personnel, impacting care and documentation. Management acknowledged the issue but had not addressed it effectively.
The facility failed to provide sufficient nursing staff, affecting the care of three residents. A resident reported long waits for incontinent care, while two others missed scheduled showers due to staffing shortages. Staff interviews confirmed that tasks were often incomplete, impacting residents' self-esteem and potentially leading to health issues. Management was aware of the problem, but no sufficient nursing staff policy was provided.
A resident's call light was found on the floor and out of reach, preventing them from requesting assistance. The resident, who was cognitively intact and at risk for falls, expressed difficulty in calling for help. The DON acknowledged that staff should have ensured call lights were within reach during rounds, and maintenance checks were conducted monthly. The call light policy was not provided before the surveyor's exit.
A resident's personal health information was exposed when an LVN left a laptop unlocked on a medication cart during a medication pass. The laptop, displaying the resident's medications, was unattended for 1-2 minutes, visible to staff and residents in the hallway. The resident had a history of heart failure, diabetes, and high blood pressure. The DON confirmed that the facility's policy requires screens to be locked or minimized when not in sight.
A CNA improperly handled a resident's leaking gastrostomy tube without notifying a nurse, risking complications. The CNA did not follow proper hygiene practices and acted outside her scope of practice. The resident had a history of heart failure, diabetes, and catheter-related infection. The facility's policies did not address the required competency for G tube care.
A facility failed to maintain accurate clinical records when a physician's visit notes for one resident were mistakenly documented in another resident's file. This error was not initially recognized by the staff, including the DON and Corporate Nurse. The Administrator noted the physician was new to the system and the nursing staff did not verify the accuracy of physician notes. The facility's documentation policy stresses accuracy and completeness, yet this incident shows a lapse in adherence to these standards.
A CNA in a long-term care facility failed to follow proper infection control procedures while managing a resident's leaking G-tube. The CNA did not wash hands or wear gloves, contrary to the facility's infection control policy. The DON, new to the facility, confirmed the lapse and the importance of hand hygiene to prevent infection spread.
A resident's call light was found non-functional, posing a risk of not receiving timely assistance. The resident, who was cognitively intact and at risk for falls, attempted to use the call light for help but it did not work. The DON confirmed the issue, and the Maintenance Director noted that call lights were checked monthly, but the malfunction was not detected. A call light policy was requested but not provided.
A resident's walker was damaged during transport, and despite notifying the social worker and therapy department, it was not repaired or replaced, leading the resident to attempt a temporary fix with zip ties. The walker remained unsafe, posing a risk of falls. Facility staff were either unaware or did not perceive the issue as a risk, and there was no policy for repairing assistive devices.
A resident with a gastrostomy tube did not receive the correct water flushes before and after medication administration, as required by physician orders. The LVN administering the medications failed to flush the tube between each medication, contrary to the specified orders. The DON confirmed the expectation to follow these orders to prevent medication interactions. The facility lacked a specific policy for medication administration via feeding tubes, contributing to the deficiency.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect and abuse to the State Agency within the required timeframe. On 11/28/2025, law enforcement responded to the facility at 8:55 AM for a complaint of elder abuse after a resident reported that staff had not changed his brief in over five hours. The facility’s own abuse policy required that any person with reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state, and/or adult protective services, and that the administrator or designee must report qualifying incidents to HHSC within specified timeframes. Despite this, the allegation made on 11/28/2025 that the resident’s brief had not been changed in five hours was not reported to the State Agency. The resident involved was an adult male with a BIMS score of 15, indicating intact cognition, and diagnoses including congestive heart failure, Type II diabetes, hyperlipidemia, major depressive disorder, and hypertension. He used a manual wheelchair and required one-person assistance for transfers, turning, positioning, dressing, and toileting, and had frequent bowel incontinence requiring staff assistance with incontinent care. During an observation and interview on 1/20/2026, the resident stated he had called the police because it took five hours before someone came to change his brief. He reported that he was changed before breakfast, later used his call light for help changing his brief, and that although someone entered his room to bring his meal, they did not change him at that time. Interviews with staff confirmed that the allegation was known to facility leadership but not reported as required. The DON stated he was present when law enforcement responded, spoke directly with the officer about the abuse allegation, and then informed the administrator, whom he identified as the abuse coordinator responsible for reporting allegations to HHSC. The DON denied that the resident went five hours without care and stated the resident was changed before and after breakfast. CNA A, who worked both shifts that day, reported that the resident required assistance for bowel movements and could not clean himself, and stated that neither he nor other residents had to wait five hours to be changed. LVN B reported the resident was changed before breakfast around 8:00 AM and that residents are checked before each meal, denying the resident was left unattended for five hours. The current administrator, who assumed the role after the incident, stated that the event would have been a reportable allegation and acknowledged that such allegations must be reported to HHSC.
Failure to Provide Occupational Therapy Services as Ordered
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically Occupational Therapy (OT), to a resident as outlined in her plan of treatment. The resident, an older female with diagnoses including hypertensive heart disease with heart failure, polyneuropathy, and chronic pain syndrome, was admitted with significant self-care deficits and required a wheelchair for mobility. Her care plan identified the need to maintain or improve her current level of function, but did not specify interventions related to rehabilitation services. An OT evaluation and plan of treatment were completed, recommending OT three times per week for 60 days. However, the resident did not receive any OT services as recommended. The Occupational Therapy Discharge Summary was initiated but not completed or submitted on the same day as the evaluation. The Director of Therapy, who was not involved in the resident's care at the time, confirmed that the resident did not receive OT and was unable to determine why the services were not provided. Additionally, a Provider Notice of Adverse Benefit Determination indicated that the request for OT services was denied due to insufficient documentation of medical necessity. The facility was unable to provide a policy related to rehabilitation services when requested by the surveyor.
Failure to Provide Scheduled Showers and Bed Baths for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents who were dependent on staff for activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Both residents required maximal or total assistance with showering or bathing, as documented in their care plans and MDS assessments. Despite this, the residents reported not being offered showers or bed baths consistently according to their scheduled days, with one resident stating he had not received a shower in over a week and another indicating inconsistent provision of bed baths, despite his preference and need due to right side weakness. Record reviews revealed missing shower sheets for both residents for the month in question, indicating a lack of documentation and follow-through on scheduled hygiene care. Interviews with staff, including CNAs and an LVN, confirmed that showers and bed baths were not consistently provided. The LVN responsible for ensuring showers were completed admitted to not following up on missing shower records, and the DON was unaware that the residents had not been receiving their scheduled hygiene care. Staff also indicated that there was a reliance on evening shower staff, and if showers were not provided, this was not always communicated or documented appropriately. Facility policy required that residents receive assistance with bathing according to their individualized care plans to promote comfort, cleanliness, and skin integrity. However, the lack of consistent provision and documentation of showers and bed baths for these dependent residents constituted a failure to meet these standards, as evidenced by resident and staff interviews, missing records, and direct observations.
Failure to Ensure Valid Completion of Advance Directives
Penalty
Summary
The facility failed to ensure that residents' rights to formulate and have valid advance directives were upheld for three of eight residents reviewed. Specifically, the Out of Hospital-Do Not Resuscitate (OOH-DNR) forms for these residents were not completed correctly, lacking required signatures from the resident or their representative, witnesses, and/or the attending physician, which rendered the documents invalid. For example, one resident's DNR form was missing a second required signature, another's form lacked both the second signature and the physician's signature, and a third resident's form was missing a witness signature and was signed by a Family Nurse Practitioner instead of the attending physician as required by the form instructions. Record reviews showed that these residents had significant medical histories, including conditions such as hemiplegia following stroke, dementia, atrial fibrillation, Alzheimer's disease, diabetes, and hypertension. Their care plans indicated DNR orders, and their electronic records reflected DNR code status. However, the deficiencies in the completion of the OOH-DNR forms meant that their wishes regarding resuscitation were not properly documented or legally valid. Additionally, one resident was not listed on the facility's code status list, despite having a DNR order in the chart. Interviews with facility staff, including an LVN, the ADON, and the DON, revealed a lack of awareness regarding the incomplete DNR documentation. The ADON stated that the social worker typically reviewed DNRs, but in their absence, she had taken on the responsibility and was unaware of the errors. The DON also indicated that he and the ADON checked the documents for accuracy but did not know why the deficiencies occurred. The facility's policy and the state OOH-DNR form instructions were reviewed, confirming the requirements for valid completion that were not met in these cases.
Resident Denied Access to Bathroom Due to Locked Door
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident with multiple cognitive and behavioral diagnoses, including Frontotemporal Neurocognitive Disorder, dementia, muscle weakness, bipolar disorder, depression, manic disorder, impulse disorder, and cognitive communication deficit. The resident was assessed as severely cognitively impaired. During observation and interviews, it was found that the resident's private bathroom was locked by facility staff. The Maintenance Director and DON stated this was done because the resident had a history of flushing inappropriate items, such as clothes and briefs, which had previously caused plumbing issues and backups in the memory care unit. Instead of access to her own bathroom, the resident was escorted by staff to a community restroom in the memory care unit, which was also kept locked and only accessible by staff. The facility's policy on resident rights requires that residents be treated with respect and dignity in an environment that promotes quality of life and allows for safe and independent access to personal spaces. The locked bathroom restricted the resident's access to her own bathroom, contrary to these requirements.
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 Provide Appropriate Pressure Ulcer Care and Pressure-Relieving Devices
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevent new ulcers from developing for three residents reviewed for treatment and services related to pressure ulcers. For one resident with a stage 4 coccyx pressure ulcer, the low air loss mattress was set incorrectly at a weight of 280 pounds, despite the resident weighing approximately 160-180 pounds. The resident reported discomfort with the mattress, and staff interviews revealed uncertainty about who was responsible for setting and monitoring the mattress settings. Documentation showed that the mattress was supposed to be checked every shift, but the incorrect setting persisted. Two other residents with sacral or buttock wounds did not have functioning low air loss mattresses available to promote healing. Observations confirmed that these residents were in bed without the required pressure-relieving mattresses, despite having wounds that required such interventions. Staff interviews indicated a lack of clarity regarding the process for ordering and setting up low air loss mattresses, and the care plans did not consistently reflect the need for these devices as interventions for wound care. Additionally, one resident's wound dressing was not changed daily as ordered, and care plans lacked specific details about the type of pressure ulcer or treatment orders. Staff interviews revealed inconsistent knowledge about the purpose and management of low air loss mattresses, including who was responsible for ensuring correct settings and timely provision. The facility's policy required high-risk individuals to be placed on pressure-reducing devices, but this was not consistently implemented, resulting in residents being at risk for developing new or worsening pressure ulcers.
Failure to Document Blood Pressure Prior to Administration of Antihypertensive Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of blood pressure medications for two residents. For one resident with multiple diagnoses including hypertensive heart disease and atrial fibrillation, Carvedilol was prescribed with specific parameters to hold the medication if blood pressure was below 110/60 or pulse below 60. However, on nine occasions, there was no documentation that blood pressure was obtained prior to administering the medication, as required by the physician's order. Review of the resident's care plan also revealed no discussion of his blood pressure medication or related health condition. For another resident with diagnoses including Parkinson's disease and low blood pressure, Midodrine was prescribed with instructions to hold the medication if systolic blood pressure was greater than 120. On four occasions, there was no documentation of blood pressure readings prior to administration, and the care plan did not address the blood pressure medication or related condition. In both cases, review of the medication administration records and nursing progress notes did not show evidence that the required blood pressure checks were performed or documented before medication was given. Interviews with facility staff confirmed that it was standard practice to document blood pressure prior to administering such medications and to hold the medication if parameters were not met. Staff also indicated that the electronic charting system should prompt for blood pressure entry, but errors in order entry could bypass this requirement. Facility policy required monitoring and documentation of specific items such as blood pressure when ordered, but this was not consistently followed for the residents in question.
Failure to Document Wound Care Administration in Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents who required wound care, as evidenced by missing documentation of wound care administration on multiple occasions. For one resident with a history of dementia, gangrene, chronic foot ulcers, diabetes, malnutrition, and rheumatoid arthritis, there was no documentation of wound care provided on four specific dates in June, despite physician orders and a care plan indicating the need for daily wound management. The resident's treatment administration record (TAR/WAR) and nursing progress notes did not reflect any reason for the missed documentation or whether the care was provided. Another resident, with diagnoses including diabetes, aphasia, stroke, anoxic brain damage, and dysphagia, also had missing documentation for wound care on three dates in June. This resident required substantial assistance with activities of daily living and had a physician order for sacral wound care. The TAR/WAR did not show that wound care was signed off on the specified dates, and there was no additional documentation in the nursing notes to explain the omissions. Observation confirmed the presence of a wound dressing, but the required documentation was incomplete. A third resident, with a history of cellulitis, chronic leg ulcers, gout, and lymphedema, had no documentation of wound care on four dates in May, despite multiple physician orders for wound management of several leg and toe ulcers. The care plan did not address all of the resident's wounds, and the TAR/WAR and nursing progress notes lacked entries for the missed dates. Interviews with nursing staff revealed that wound care documentation was expected to be completed in the electronic charting system, and missing entries would remain flagged until resolved. However, the system showed unresolved entries, and staff acknowledged that treatments may have been performed but not documented.
Failure to Provide Scheduled Showers Due to Towel Shortage
Penalty
Summary
The facility failed to ensure that three residents who were unable to perform activities of daily living (ADLs) independently received necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Record reviews and interviews revealed that these residents did not consistently receive scheduled showers or bed baths during the month of May 2025, despite care plans indicating the need for substantial or maximal staff assistance. Documentation showed missed or inconsistent bathing dates, and residents reported not being offered showers as scheduled, with no explanations provided for the missed care. Interviews with staff, including a CNA and an RN, confirmed that showers were not always provided due to a lack of available towels, an issue that had been ongoing and reported to management. The CNA stated that on certain days, such as 5/27/25, no scheduled showers were offered because towels were not available until late in the shift. The RN corroborated that aides had reported the towel shortage and that management, including the ADON, was aware of the problem. The ADON acknowledged the lack of towels and stated that she had reported it to the Administrator, but no action had been taken to resolve the issue. Residents involved had significant medical histories, including conditions such as hypertension, diabetes, stroke, hemiplegia, Parkinson's disease, and cognitive impairment, necessitating assistance with ADLs. Despite being well-groomed at the time of observation, residents expressed dissatisfaction with the inconsistency of their bathing schedules and the lack of communication regarding missed showers. Grievance records for April and May also reflected complaints about not being provided with showers.
Failure to Provide Timely UTI Assessment and Care
Penalty
Summary
A deficiency occurred when a resident who reported symptoms of a urinary tract infection (UTI) did not receive timely assessment, treatment, or care in accordance with professional standards, the care plan, and her expressed preferences. The resident, who had a history of hypertension, type 2 diabetes, stroke, amputation, and progressive neurological conditions, reported to staff that she was experiencing frequent urination and burning sensations. Despite informing a nurse of these symptoms, there was no documentation in the resident's progress notes, 24-hour report, or physician orders regarding her complaint or any follow-up actions. Multiple staff interviews revealed a breakdown in communication and documentation. The charge nurse for the 2-10 shift stated she was not informed of the resident's symptoms or any change in condition, and the LVN who was told of the symptoms did not document the complaint, notify the charge nurse, or follow through with obtaining a urine specimen as ordered by the primary care provider. The Assistant Director of Nursing (ADON) was also unaware of the resident's change in condition and only became aware when laboratory personnel requested a urine specimen that had not been collected. The facility's policy required immediate physician notification and documentation for significant changes in status, which was not followed in this case. The lack of timely assessment, documentation, and follow-up resulted in the resident not receiving appropriate care for her reported UTI symptoms. The failure to act according to physician orders, facility policy, and professional standards of practice led to a delay in diagnosis and treatment for the resident.
Failure to Safeguard Resident's Personal Clothing
Penalty
Summary
The facility failed to ensure a resident's right to retain and use personal clothing, resulting in the loss of nearly all of the resident's clothing during her stay. Upon admission, the resident, who had severe cognitive impairment due to dementia and an anxiety disorder, was provided with three weeks' worth of labeled clothing by her family. By January, all of these clothes had disappeared, and the resident was found dressed in a hospital gown. The family had to purchase additional clothing for the resident, which also went missing, leaving her with only one or two pairs of pajamas at the time of her passing. There was no record of grievances filed by the family regarding the missing clothing. Interviews with staff revealed inconsistent and inadequate processes for inventorying and labeling residents' clothing. While some staff believed inventories were completed and uploaded into electronic health records, there was no inventory record for this resident. Staff also reported a lack of a system for documenting clothing added or removed during the resident's stay, and the facility did not have a missing items policy. The administrator confirmed that the family requested a refund for the missing clothing but was told a receipt was required. The facility's policy on misappropriation of resident property was reviewed, but there was no evidence of its effective implementation in this case.
CNA Takes Unauthorized Photo of Resident
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA took a private photo of the resident without consent. The incident occurred when the resident, who was cognitively intact with a BIMS score of 15, required assistance with incontinence care. The resident reported that the CNA was upset about having to perform the care and took a photo of the resident's private area, allegedly to show the DON that the day shift should have changed the resident. This action was taken without the resident's consent and caused significant distress to the resident. The resident did not initially report the incident to the facility but informed a family member, leading to police involvement. The DON and Administrator were informed of the incident, and the CNA admitted to taking and subsequently deleting the photo. Interviews with other staff and residents indicated awareness of the policy against taking photos of residents. The facility's policy on abuse, revised in 2017, states that residents have the right to be free from abuse, neglect, and exploitation.
Inadequate Infection Control During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinence care for two residents. Resident #1, who was cognitively intact and had a history of hip fracture and diarrhea, required maximum assistance with toileting due to bowel and bladder incontinence. During an observation, CNA B did not change gloves or perform hand hygiene after cleaning the resident's peri-area and buttocks before applying a clean brief. CNA B believed that hand hygiene was only necessary before and after care, not during the process. Resident #2, who was severely cognitively impaired with diagnoses including diabetes, stroke, and non-Alzheimer's dementia, was completely dependent on staff for toileting. During incontinence care, CNA C changed gloves but did not perform hand hygiene after cleaning the resident's peri-area and buttocks. CNA C stated that hand hygiene was only necessary if there was visible bowel movement on the gloves. The facility's Director of Nursing confirmed that staff were expected to change gloves and perform hand hygiene during incontinence care to minimize infection risk. The facility's handwashing policy, dated 2012, emphasized the importance of frequent handwashing.
Staffing Shortages Lead to Inadequate ADL Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in three residents who required assistance with ADLs, including showers, bed baths, and timely incontinent care. The lack of consistent care was attributed to staffing shortages, which were acknowledged by both the staff and management. Resident #1, a female with multiple health conditions including local infection of the skin, obesity, and incontinence, reported delays in receiving incontinent care, sometimes waiting 2-3 hours after using the call light. Despite being well-groomed at the time of observation, the resident expressed concerns about the facility's staffing issues, which were known to management but not addressed. Resident #2, a 96-year-old female with moderate cognitive impairment and dependency on assistance for showers and toileting, also reported not receiving scheduled showers due to insufficient staffing. Resident #3, who required extensive assistance with ADLs and had a history of traumatic subdural hemorrhage and kidney disease, stated that care was often delayed, and bed baths were not provided as scheduled. Interviews with staff, including a CNA and an LVN, confirmed that the facility was understaffed, leading to incomplete ADL care and documentation. The Assistant Director of Nursing (ADON) and the Administrator acknowledged the staffing issues and their impact on resident care, with the ADON admitting to failing to follow up on shower completions as planned.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the experiences of three residents. Resident #1, a female with multiple diagnoses including morbid obesity and muscle weakness, reported waiting 2-3 hours for incontinent care despite using her call light. She indicated that staffing issues were known to management but remained unaddressed. Resident #2, a 96-year-old female with a history of stroke and other neurological conditions, required maximum assistance with daily activities. She reported not receiving scheduled showers, attributing this to insufficient staffing. Resident #3, who had a traumatic subdural hemorrhage and other health issues, also experienced delays in care, including missed bed baths, and noted that staffing shortages had been a long-standing problem. Interviews with staff members corroborated the residents' accounts of inadequate staffing. CNA A, who was often assigned to 15 to 22 residents, confirmed that not all tasks were completed due to the lack of staff, resulting in missed showers and incomplete documentation. LVN B also acknowledged that daily living activities were not consistently completed, citing insufficient staff to meet residents' needs. Both staff members expressed that the lack of care could negatively impact residents' self-esteem and lead to potential health issues such as skin breakdown. The facility's management, including the ADON and the Administrator, were aware of the staffing deficiencies. The ADON admitted to not following up on shower completions and acknowledged the ongoing staffing issues. The Administrator, who had been in the facility for two months, recognized the impact of staffing shortages on residents' quality of life but had not yet provided a sufficient nursing staff policy. Resident advisory council minutes further highlighted concerns about delayed call light responses, missed showers, and insufficient staff in the dining room, underscoring the widespread nature of the staffing problem.
Resident Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's needs were reasonably accommodated, specifically regarding the resident call system. On a specific date, a resident's call light was found on the floor and out of reach, preventing the resident from requesting assistance. The resident, who was cognitively intact with a BIMS score of 14, expressed difficulty in calling for help due to the call button being inaccessible. The resident had a history of being at risk for falls, and the care plan included ensuring the call light was within reach as an intervention. During an interview, the Director of Nursing (DON) acknowledged that staff should have been checking to ensure call lights were within reach during rounds. The DON also mentioned that maintenance checks were conducted monthly to ensure call lights were functioning properly. Despite a request for the call light policy, it was not provided before the surveyor's exit.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to protect the confidentiality of a resident's personal health care information during a medication pass. An LVN left a laptop unlocked and open on a medication cart, exposing the resident's personal information, including medications, to staff and residents in the hallway. This incident occurred while the LVN was responding to a call light in the resident's room, leaving the computer unattended for approximately 1-2 minutes. The medication cart was positioned two doors down from the resident's room, with the screen facing the hallway, making the information visible to passersby. The resident involved was a male with a history of acute combined systolic and diastolic heart failure, type 2 diabetes mellitus with unspecified complications, and high blood pressure. The Director of Nursing confirmed that the facility's policy requires computer screens to be locked or minimized when not in sight during medication passes to prevent unauthorized access to patient information. The failure to adhere to this policy resulted in a breach of the resident's right to secure and confidential personal and medical records.
Inadequate Handling of Gastrostomy Tube by CNA
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a gastrostomy feeding tube. A CNA, identified as CNA C, was observed handling the resident's leaking G tube without proper hygiene practices, such as washing hands or wearing gloves initially. CNA C attempted to manage the situation by closing the end of the G tube to prevent further leaking, but did not alert a nurse to assess the resident's condition. This action was outside the CNA's scope of practice and posed a risk of complications for the resident. The resident involved was a male with a history of acute combined systolic and diastolic heart failure, type 2 diabetes mellitus, high blood pressure, and an infection related to an indwelling urethral catheter. The resident was cognitively intact, as indicated by a BIMS score of 12. The facility's policy on gastrostomy tube care did not address the competency required for such care, and the CNA's job description did not include G tube care. The Director of Nursing confirmed that CNA C should have notified a nurse and not attempted to assess the G tube, acknowledging the risk of unrecognized complications.
Inaccurate Documentation of Physician Notes
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, resulting in inaccurate documentation for one of the residents reviewed. Specifically, the physician visit notes for one resident were mistakenly documented in the file of another resident. This error was discovered during a review of the electronic nursing notes, which revealed that the physician notes for several dates contained information pertaining to a different resident, including their name, date of birth, vital signs, history, reason for visit, assessment, and plan. Interviews with the Director of Nursing, Corporate Nurse, and Administrator revealed a lack of awareness regarding the documentation error. The Administrator attributed the mistake to the physician being new to the system and stated that the nursing staff did not verify the accuracy of physician notes, as they were not responsible for ensuring their accuracy. The facility's policy on documentation emphasizes the importance of accuracy and completeness in clinical records, yet this incident highlights a failure to adhere to these standards, potentially placing residents at risk for medication and treatment errors.
Infection Control Lapse in G-Tube Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to proper infection control procedures while tending to a resident's G-tube. The resident, a male with a history of acute combined systolic and diastolic heart failure, type 2 diabetes mellitus, and high blood pressure, experienced a leaking G-tube. The CNA, identified as CNA C, responded to the situation without washing her hands or wearing gloves, which are essential practices to prevent cross-contamination and infection. She picked up the G-tube with bare hands, placed gloves on the resident's bed, and later discarded the gloves after capping the G-tube. The Director of Nursing (DON), who was new to the facility, was unaware of the last infection control training for staff. The DON acknowledged that CNA C should have washed her hands and worn gloves before handling the G-tube and should have informed a nurse about the leak. The facility's infection control policy, dated 2019, emphasizes the importance of hand hygiene to prevent the spread of infections. Despite previous infection control training sessions, the incident highlights a lapse in adherence to these protocols, potentially putting residents at risk of infection.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, which could place residents at risk of not receiving necessary care and services. Specifically, the call light for a resident was not functioning on the date of observation. The resident, who was cognitively intact with a BIMS score of 14, had a care plan indicating a risk for falls and required assistance with personal care. The care plan included interventions such as ensuring the call light was within reach and encouraging its use for assistance. However, during an interview and observation, the resident attempted to use the call light to call staff for assistance but found it was not working. The Director of Nursing (DON) was informed of the issue and confirmed that the call light was not operational. The Maintenance Director later revealed that call lights were checked monthly, and Resident #3's call light had been checked at the beginning of the month. Despite this, the call light was not functioning when needed. The DON acknowledged that staff should have been checking the call lights during rounds to ensure they were working and within reach. A call light policy was requested from the Administrator but was not provided before the survey exit.
Failure to Repair Resident's Walker
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards by not repairing or replacing a damaged walker used by a resident for mobility. The resident, who was cognitively intact and had diagnoses including cellulitis, lymphedema, and morbid obesity, reported that the padded backrest of his walker was broken during transport in February 2024. Despite informing the social worker and the therapy department, the walker remained unrepaired, leading the resident to attempt a temporary fix using zip ties. However, the walker continued to malfunction, making it unsafe and frightening for the resident to use. Interviews with facility staff revealed a lack of communication and action regarding the broken walker. The social worker acknowledged being informed of the issue but did not perceive it as a risk due to the resident's limited mobility. The Director of Rehabilitation was unaware of the problem and was focused on obtaining a motorized wheelchair for the resident. The Director of Nursing only became aware of the issue after the surveyor's inquiry and recognized the increased risk of falls associated with a malfunctioning walker. The facility did not have a policy for the repair of assistive devices, as confirmed by the administrator during the exit conference.
Failure in Gastrostomy Tube Management
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not provide the correct water flushes before and after medication administration through a gastrostomy tube for a resident. The resident, an elderly male with type 2 diabetes, dysphagia, and major depressive disorders, required a feeding tube due to swallowing problems. The resident's care plan and physician orders specified that the feeding tube should be flushed with 30 ml of water before and after medication and feedings, and with at least 5 ml of water between each medication. During an observation, a Licensed Vocational Nurse (LVN) administered medications via the resident's feeding tube but failed to flush the tube between each medication, contrary to the physician's orders. The LVN initially stated that she did not need to flush between medications and was unaware of the specific order to do so. Upon review, she acknowledged the oversight. The Director of Nursing (DON) confirmed that the nurse was expected to follow the physician's orders to prevent medication interactions and ensure proper administration. The facility did not have a specific policy for medication administration via feeding tubes, which contributed to the deficiency.
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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