Legacy Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bryan, Texas.
- Location
- 2817 Kent Street, Bryan, Texas 77802
- CMS Provider Number
- 455351
- Inspections on file
- 31
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction with frontal lobe deficit, psoas abscess, and aphasia was admitted without a baseline care plan being completed within 48 hours, contrary to facility policy. Record review showed no baseline care plan in the EMR and an incomplete MDS, while interviews with the DON and MDS Coordinator confirmed that the MDS Coordinator was responsible for baseline care plans, acknowledged the omission, and could not explain why the plan was not completed. Staff reported that in the absence of a baseline care plan, CNAs were expected to obtain needed care information from the nurse supervisor.
A resident with dementia, severe cognitive impairment, depressed mood, and a history of trauma-related beliefs and behaviors did not receive trauma-informed, culturally competent care. The resident’s record lacked a trauma screening, and the comprehensive care plan contained no focus area or interventions addressing his trauma history, fears, or behavioral triggers, despite multiple documented notes of paranoid beliefs, conflicts with a roommate, and repeated allegations involving staff and other residents. Social services, MDS staff, and the DON all acknowledged that such behaviors and triggers should be included in the care plan so staff could respond appropriately, but this was not done, resulting in a failure to follow professional standards and the facility’s own care planning policy.
A resident with dementia, prior hip fracture, and significant assistance needs for mobility and toileting experienced right leg pain during incontinence care, which was assessed by an LVN who found no visible abnormalities and administered PRN acetaminophen but did not document the event, notify the NP, or reliably communicate it to the next shift. Over the following days, staff reported being unaware of the prior pain episode, did not perform focused right leg assessments, and documented minimal or no pain until one day when a CNA observed the resident shivering in pain and an RN noted right leg pain without swelling, treated with acetaminophen, and reported to the oncoming nurse. Later that same day, another CNA found the resident in severe pain with marked swelling of the right leg, which the oncoming LVN assessed as significant edema and warmth before arranging transfer to the ED, where imaging revealed a distal right femur fracture from an unwitnessed ground-level fall. The absence of documentation, incomplete shift-to-shift communication, and lack of ongoing focused assessment of the resident’s right leg pain and condition led surveyors to cite a deficiency for failure to ensure adequate supervision and accident prevention.
Three residents with Parkinson's disease and other complex conditions did not receive their Carbidopa-Levodopa medications within the required timeframe, with doses administered late or missed entirely. Staff did not consistently document or report these late administrations, and interviews revealed that the informal practice of a one-hour administration window was not clearly outlined in facility policy. Leadership and clinical staff were unaware of the specific incidents at the time of the survey.
A resident with multiple medical conditions was left with dried blood splatters on the floor of her room following IV therapy. The blood was not cleaned up promptly, and neither housekeeping nor supervisory staff were notified, despite facility policy requiring immediate cleanup and disinfection of blood spills. Both the resident and a family member expressed concerns about the cleanliness and potential for contamination.
A resident with Parkinson's disease and autism did not receive recommended OT and PT services for several months after an IDT meeting due to the facility's failure to submit the required NFSS request form within the mandated timeframe. Staff interviews revealed a lack of training and understanding of PASRR documentation requirements, and the facility did not have a PASRR policy or protocol in place. Despite the delay, the resident's ADLs remained at baseline during this period.
Two residents with indwelling catheters did not have timely physician orders for catheter care after admission, resulting in a lack of documented catheter care orders for several days to over a month. Although staff reported providing catheter care as part of routine duties, the absence of formal orders was identified during order reviews and acknowledged by nursing and administrative staff.
A resident with significant mobility and cognitive impairments was left in a Geri-chair for approximately nine hours without being repositioned or provided with incontinent care, resulting in soiled clothing and skin redness. Staff did not perform required two-hour rounds or report care refusals to nursing, contrary to care plans and facility expectations.
Two residents with chronic pain did not receive consistent and effective pain management, including missed pain assessments, delays in medication administration, and lack of care plan documentation. One resident did not have her prescribed Fentanyl patch available due to delayed ordering, while another went without daily pain assessments for over a month. Nursing staff did not consistently document pain levels or monitor pain as required by facility policy.
Dietary staff prepared pureed foods by adding unmeasured amounts of liquid to carrots and roast, relying on estimation rather than following standardized recipes. The staff member had not received training on proper measurement and did not use the available recipe book, and no written protocol for pureeing food was provided by the dietary supervisor. This practice affected all residents receiving pureed diets.
Surveyors found that food items in the kitchen were not consistently labeled, dated, or discarded when expired, and cooking equipment such as the deep fryer and ovens were not properly cleaned. Dietary staff were observed working without required hair and beard restraints, and interviews revealed gaps in training and policy awareness. These failures in food storage, sanitation, and staff hygiene were directly observed and documented by surveyors.
A newly admitted resident with chronic pain and multiple bone disorders did not have a baseline care plan developed within 48 hours that addressed her pain management needs. Despite physician orders and documented pain assessments, the care plan lacked instructions for pain control, leading to delays and issues in medication administration as reported by the resident and confirmed by staff interviews.
A resident with a history of intracranial injury, spastic hemiplegia, and contractures did not have a comprehensive care plan addressing management of right hand and neck contractures. Observations showed the resident without appropriate positioning devices or splints, and staff interviews revealed uncertainty and lack of individualized interventions in the care plan. The care plan only included basic ADL assistance and did not reflect therapy recommendations or address all contracture needs.
A resident with severe cognitive impairment and a history of falls, including a hip fracture, did not have her care plan updated to include effective fall prevention interventions such as fall mats or a low bed after multiple falls. Despite repeated incidents and staff awareness of her high fall risk and inability to use the call light appropriately, the care plan remained limited to encouraging call light use and did not reflect additional safety measures.
A resident with a history of spastic hemiplegia and contractures in the right hand and neck was not provided with individualized interventions or devices to manage these conditions. The care plan lacked specific contracture management, and staff were unclear about appropriate measures, resulting in the resident being observed multiple times without splints, hand rolls, or positioning devices as recommended by therapy and facility policy.
A resident with severe cognitive impairment and a history of falls, including a hip fracture, did not have effective fall prevention interventions such as a low bed or fall mats in place. Despite repeated falls and documented difficulty using the call light, the care plan and physician orders lacked appropriate fall precautions, and staff confirmed that interventions were limited to encouraging call light use. Observations showed the resident's bed was not kept low and no fall mats were present, contrary to facility policy for high-risk individuals.
A resident with chronic pain syndrome did not receive a timely replacement of a physician-ordered Fentanyl patch due to delays in obtaining the required order and lack of follow-up by the admitting nurse. The resident experienced a gap in pain management, and staff interviews revealed confusion about the process for ordering controlled substances, with facility policy lacking guidance on ordering timelines for narcotics.
A resident with severe cognitive impairment and a PEG tube was given the wrong dose and route of Aspirin, and did not have vital signs checked before receiving multiple antihypertensive medications. Staff failed to clarify medication orders or monitor blood pressure as required, resulting in a medication error rate above 5%.
Expired multivitamins and nicotine patches were found in a medication storage room, with the ADON confirming and removing the expired items during an observation. The DON and Administrator stated that monitoring for expired products is expected, and facility policy requires checking expiration dates before administration. This failure could result in residents not receiving the intended therapeutic benefits of their medications.
Staff and hospice personnel did not follow Enhanced Barrier Precautions when providing care to two residents with indwelling medical devices, such as a PEG tube and a urinary catheter. Despite clear care plans and signage requiring the use of gowns and gloves, staff were observed omitting gowns during medication administration and device care, and acknowledged not following the required precautions.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and complete a baseline care plan within 48 hours of admission for one newly admitted resident, as required by facility policy. Record review showed that this resident, a female with diagnoses including frontal lobe and executive function deficit following cerebral infarction, psoas abscess, and aphasia, was admitted on an identified date, but no baseline care plan was present in the electronic medical record as of 02/05/2026. The resident’s MDS assessment was also noted to be incomplete. The facility’s written Care Planning Policy and Procedure states that a baseline care plan will be completed within 48 hours of admission to provide a comprehensive plan of care addressing the resident’s needs, strengths, goals, and approaches. During interviews, the DON confirmed that a baseline care plan should be completed within 48 hours after admission and stated that the MDS Coordinator was responsible for completing these plans. The DON acknowledged that Resident #1 did not have a baseline care plan and stated she did not know why it had not been completed. The MDS Coordinator (LVN A) also confirmed responsibility for baseline care plans, acknowledged that the baseline care plan for this resident was missed, and stated she did not know why it was not completed. She indicated that baseline care plans are important for staff to follow for new admissions and that, in the absence of such a plan, CNAs were expected to ask the nurse supervisor if they needed to know what care a resident required.
Failure to Provide Trauma-Informed, Culturally Competent Care for a Resident With Severe Cognitive Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma-informed, culturally competent care to a resident with a known history of trauma and severe cognitive impairment. The resident was an elderly male with dementia and altered mental status, with a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. His Minimum Data Set (MDS) assessment documented that he felt down, depressed, or hopeless nearly every day and that he was receiving an antidepressant. Despite these indicators of psychological vulnerability, review of his electronic medical record showed that no trauma screening assessment had been completed, and his care plan contained no focus area or interventions related to trauma history, behaviors, or triggers. Nursing and social services documentation reflected ongoing behavioral and psychological concerns that were not incorporated into the care plan. A nursing progress note described the resident making inappropriate verbal comments after medication administration and an episode where he accused a nurse of withholding medications, ranted at her, and threw a medication cup against the wall after taking his medication. A social services note documented that the resident believed other residents were out to get him, thought someone had a gun and was following him, and accused staff of showing him naked elderly women. The note indicated that he truly believed these allegations, that a psychologist had been notified, and that he refused to speak with the psychologist and was mean to her. None of these behaviors, beliefs, or potential triggers were reflected in the resident’s care plan. During interviews, the resident reported multiple distressing experiences and allegations involving his former roommate and various staff members, including threats from the roommate, seeing another resident unclothed, being pushed on the bed by an LVN, having his walker kicked by a male staff member, and having a male staff member run a finger across his back and put a finger in his ear. He also reported a background as an assistant warden in a prison and expressed strong feelings about men who hurt or kill women and children. The Social Services Director identified his family member as a trigger, described family conflict and restrictions on his visiting another family member before her death, and noted that the former roommate was large, bossy, and that the resident feared people having guns and believed the roommate had a gun. The Social Services Director, MDS Coordinators, and DON all stated that resident behaviors, fears, and triggers should be on the care plan so staff would know how to respond and monitor progress, and the DON specifically stated that this resident’s history of making allegations, fears, and triggers should absolutely be in his care plan. Despite this, the resident’s care plan and Kardex did not contain trauma history, behaviors, or triggers, and no trauma screening was present in the record, resulting in a failure to provide trauma-informed care in accordance with professional standards and the facility’s own care planning policy.
Failure to Assess and Communicate Right Leg Pain Leading to Unwitnessed Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assessment to prevent an accident and to identify and respond appropriately to a change in condition related to a resident’s right leg pain, which was later associated with a right femur fracture. The resident was an elderly female with dementia, a history of left femur fracture with surgical repair and left artificial hip joint, and other diagnoses including hypotension, iron deficiency, and pain. Her MDS showed severely impaired cognition (BIMS score of 01) and extensive physical assistance needs for bed mobility, transfers, and toileting, with full dependence for toilet transfer and incontinence care. Her care plan addressed pain related to a hip fracture with surgical repair, with interventions focused on administering ordered pain medication and observing for worsening pain symptoms to report to the physician. On one morning, a CNA observed the resident moaning and grimacing in pain when her right leg was moved during incontinence care and reported this to an LVN. The LVN assessed the resident and noted no visible abnormalities, deformities, swelling, or redness in the lower extremities, but confirmed that the resident moaned when the right leg was grasped during perineal care. The LVN administered PRN acetaminophen for pain but did not document the incident in the EHR, did not notify the NP, and was unsure if the information was communicated to the oncoming nurse at shift change. As a result, there was no documented follow-up assessment or monitoring of the right leg pain, and subsequent nurses and CNAs working the following shifts reported they were not aware of the prior pain episode and did not perform focused assessments of the right leg. Over the next several days, staff who provided care on various shifts reported no observed swelling, redness, or pain in the resident’s lower extremities during incontinence care, and there was no documentation in the EHR of ongoing pain assessment specific to the right leg. On a later date in the afternoon, a CNA observed the resident shivering and in apparent pain during lunch and reported this to an RN, who noted signs of pain in the right leg but no swelling or deformity, administered PRN acetaminophen, and reported the situation to the oncoming nurse. Later that same day, another CNA observed the resident moaning and grimacing in severe pain with significant swelling of the right leg from thigh to knee and reported this to the oncoming LVN, who assessed marked edema, warmth, and pain with palpation and movement, administered acetaminophen, and obtained an order to transfer the resident to the emergency department. Hospital records documented a distal right femur fracture from an unwitnessed ground-level fall at the facility, with radiology showing a dynamic hip screw in place and a midshaft comminuted impacted angulated spiral fracture below the implant. The NP and DON later stated they had not been informed of the initial right leg pain episode, and the DON acknowledged there was no evidence of continued assessment or communication regarding the resident’s right leg pain between the initial complaint and the later discovery of swelling and fracture. The facility’s abuse prevention and prohibition policy defined injuries of unknown origin and required a licensed nurse to examine the resident and notify the physician of any injuries noted when the source of injury was not observed or could not be explained by the resident. In this case, the hospital record identified the fracture as resulting from an unwitnessed ground-level fall at the facility, and staff interviews and record review showed no documented fall episodes for the resident in the month in question and no clear explanation from staff for how the injury occurred. The RP reported being informed by the hospital that the swelling might have been present for several hours before discovery and believed the fracture might have occurred during repositioning or care, while facility staff were unable to provide a definitive explanation. The lack of documentation, incomplete communication between shifts, absence of timely notification to the NP, and failure to conduct and document focused, ongoing assessments of the resident’s right leg pain and condition contributed to the deficiency in ensuring adequate supervision and accident prevention for this resident.
Failure to Administer Medications Within Required Timeframe
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for three out of five residents reviewed. Specifically, medications, including Carbidopa-Levodopa prescribed for Parkinson's disease, were not administered within the required timeframe for three residents. Medication administration records showed that doses were given outside the facility's stated one-hour window before or after the scheduled time, with some doses being administered significantly late. There were no supporting progress notes or documentation explaining the late administration for these instances. For one resident with severe cognitive impairment and multiple diagnoses including Parkinson's disease, hemiplegia, dysphagia, COPD, and dementia, Carbidopa-Levodopa was administered late on multiple occasions, with no documentation or notes to justify the delay. Another resident, with diagnoses including Parkinson's disease, urinary tract infection, hypertension, and soft tissue cancer, also received late administration of the same medication, again without supporting documentation. A third resident, who had Parkinson's disease, anxiety disorder, hypothyroidism, depression, and chronic pain syndrome, experienced both late and missed doses of Carbidopa-Levodopa, with no care plan in place and no documentation of the reasons for the missed or late doses. Interviews with medication aides and the DON revealed that staff followed an informal practice of administering medications within a one-hour window before or after the scheduled time, although this was not explicitly stated in the facility's policy. Staff admitted to giving medications late due to workload or being occupied on other halls, and often did not notify the charge nurse or document the late administration in the MAR. The DON, administrator, and nurse practitioner all expressed expectations that medication orders be followed as written and that any deviations be communicated to clinical staff, but were not aware of the specific late administrations at the time of the survey.
Failure to Clean Blood Spill After IV Therapy
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the presence of blood splatters on the floor of a resident's room following IV therapy. The resident, an elderly female with multiple medical diagnoses including metabolic encephalopathy, hypertension, atrial fibrillation, hypothyroidism, and vitamin deficiency, had received IV medications and fluids. Despite orders for monitoring signs of infection and maintaining a clean environment, several areas of dried blood were observed on the floor near the resident's bed the day after the IV was administered. Interviews revealed that the resident was aware of the blood on the floor and expressed concern about tracking it around the room with her wheelchair. A family member also noticed the blood and voiced concerns about cleanliness and the potential for spreading contaminants. The Housekeeping Supervisor stated she was not notified of the blood spill and confirmed that rooms are cleaned daily, but emphasized that blood spills should be cleaned immediately and reported to housekeeping for proper disinfection. The Director of Nursing and the Administrator both stated that their expectation is for blood spills to be cleaned up right away by staff and reported to the appropriate personnel. A review of the facility's policy on cleaning blood and body fluid spills indicated that all such spills should be cleaned and disinfected as soon as practical, with staff required to use appropriate personal protective equipment and approved disinfectants. The policy also states that all exposures should be reported to the infection control coordinator. In this instance, the failure to promptly clean and disinfect the blood spill and notify housekeeping was a direct violation of facility policy and infection control standards.
Failure to Timely Implement PASRR Recommendations and Submit Required Documentation
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, after an Interdisciplinary Team (IDT) meeting determined that a resident required occupational therapy (OT) and physical therapy (PT), the required Nursing Facility Specialized Services (NFSS) request form was not submitted within the mandated 20 business days. As a result, the resident did not receive the recommended therapies for several months following the IDT meeting. Record reviews showed that the resident had diagnoses including Parkinson's disease and autistic disorder, with intact cognition and independence in most activities of daily living (ADLs), requiring only supervision for showers. The care plan was updated to reflect the need for specialized therapies, and the IDT meeting included relevant staff and the resident's responsible party. However, the PASRR Comprehensive Quarterly Service plan form was not provided, and the NFSS request was not submitted in a timely manner, delaying the initiation of therapy services. Interviews with facility staff revealed a lack of understanding and training regarding the NFSS process and the required documentation for PASRR services. The MDS Coordinator and Director of Therapy were unaware of the need to submit the NFSS forms, and the Director of Nursing did not follow up to ensure the paperwork was completed. The facility also lacked a policy or protocol for PASRR, contributing to the delay. Despite the delay, staff and the resident reported no decline in the resident's ADLs during the period in question.
Failure to Ensure Timely Catheter Care Orders for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling catheters had appropriate physician orders for catheter care during specific periods. For one resident, there were no catheter care orders from the time of admission until over a month later, despite the resident being admitted with a Foley catheter in place. The resident's care plan eventually included interventions for catheter care, but this was not reflected in the physician orders or the medication administration record (MAR) during the initial period. Documentation showed that catheter care was provided only after the appropriate orders were entered, and prior to that, there was no documentation of catheter care orders in the MAR. Another resident was admitted with a Foley catheter and was incontinent of bowel and bladder, but did not have catheter care orders for several days following admission. The care plan for this resident included interventions related to the presence of an indwelling medical device, but the physician orders for catheter care were not entered until several days after admission. Documentation of catheter care and monitoring only began after the orders were in place. Interviews with staff revealed that catheter care was generally provided as part of routine care and that CNAs and nurses were aware of the need for such care, even if it was not triggered in the resident's plan of care. However, the absence of formal physician orders for catheter care was acknowledged by nursing and administrative staff, who indicated that orders should have been entered upon admission. The lack of timely catheter care orders was identified during order reviews and audits, and staff recognized that this omission could result in inadequate monitoring and care for residents with catheters.
Failure to Provide Timely Repositioning and Incontinent Care
Penalty
Summary
A deficiency occurred when a male resident with a history of intracranial injury, spastic hemiplegia, contracture of the left hand, and moderate cognitive impairment was not provided with necessary assistance for activities of daily living, specifically repositioning and incontinent care. The resident was assessed as dependent on staff for transferring, bed mobility, and toileting, and was incontinent of bowel and bladder. His care plan included interventions for skin integrity, incontinence, and the need for regular repositioning and perineal care. On the day in question, the resident was observed in a Geri-chair from early morning until late afternoon, remaining in the same soiled clothing for several hours. Staff interviews revealed that the resident was not repositioned or provided with incontinent care every two hours as required. When finally assisted into bed, the resident was found to have a saturated brief with both urine and feces, and his skin showed slight redness. The CNAs and LVN assigned to his care admitted that rounds and care were not performed as scheduled, and that refusals of care were not reported to nursing staff as required by facility protocol. The facility's policy on incontinence care emphasized the importance of keeping skin clean and dry to prevent breakdown and infection, but did not specify the frequency of care. The Director of Nursing confirmed that it was expected for nurses and CNAs to make rounds and provide care every two hours, and that refusals should be reported and documented. However, on this occasion, the required care and monitoring were not provided, resulting in the resident being left in soiled conditions for an extended period.
Failure to Provide Consistent and Effective Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents requiring such services, resulting in deficiencies related to the evaluation, administration, and documentation of pain management. For one resident, a female with chronic pain syndrome and multiple bone disorders, the facility did not evaluate the effectiveness of her current pain medications and failed to have her prescribed pain medications available for administration. Upon admission, her pain was assessed at a level of 4/10, and she was prescribed a Fentanyl patch, Baclofen, and PRN oxycodone. However, the Fentanyl patch was not reordered in a timely manner due to a lack of follow-up by the admitting nurse, resulting in a period where the resident did not have access to her prescribed pain management. The resident reported severe pain, delays in receiving PRN medication, and expressed a preference for routine rather than PRN administration. Additionally, her baseline care plan did not include any entries related to pain or pain management, and staff interviews confirmed that the lack of a care plan could lead to inadequate pain management. For the second resident, a male with metabolic encephalopathy, dementia, pain, and a history of right shoulder surgery, the facility failed to conduct at least daily assessments of pain for 34 out of 49 days. Although his care plan identified the presence of pain and included interventions to evaluate pain using a 1-10 scale, it did not specify the frequency of assessments. There was no physician order for pain monitoring, and documentation of pain assessments was missing for numerous days. Observations and interviews revealed that the resident experienced ongoing pain, reported that pain medications were not effective, and was unable to recall details of conversations about his pain. Nursing staff confirmed that pain monitoring was not consistently documented and that there was no standing order to monitor pain, despite the resident's chronic pain condition. The facility's own pain management policy required pain assessments every shift and as needed, with documentation of pain levels and effectiveness of interventions. However, both residents experienced lapses in pain assessment, documentation, and timely administration of pain medications, contrary to professional standards of practice, the comprehensive person-centered care plan, and the residents' expressed choices. These failures were confirmed through record reviews, staff and resident interviews, and direct observations.
Failure to Measure Liquids in Pureed Food Preparation
Penalty
Summary
Dietary staff failed to prepare pureed foods according to measured recipes, as observed during meal service. Specifically, a dietary staff member added unmeasured amounts of liquid from cooked carrots and pan juices to pureed carrots and roast, respectively, without following any standardized measurement or recipe. The staff member admitted to guessing the amount of liquid to add and stated she had not received training on proper measurement for pureed diets. She was also unaware of the exact number of servings being prepared, only estimating the amount needed for all residents on pureed diets. Further review revealed that while a recipe book was available in the kitchen, the dietary staff member had not been utilizing it for preparing pureed foods. The dietary supervisor confirmed the existence of the recipe book but was unable to provide a written policy or protocol for pureeing food at the time of the survey. This lack of adherence to standardized recipes and absence of a clear protocol had the potential to affect all residents receiving pureed diets prepared in the facility's kitchen.
Deficiencies in Food Storage, Sanitation, and Staff Hygiene in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and sanitation. During several tours, food items in the walk-in refrigerator and dry food pantry were found to be unlabeled, undated, and in some cases, expired. Specific items such as coleslaw, scrambled egg mix, dessert cups, bread, rolls, rice, corn syrup, and Italian dressing were not properly labeled or dated, and expired items remained in storage even after initial findings were communicated to staff. The facility's own policies required all time and temperature control for safety (TCS) leftovers to be labeled, covered, and dated, and for expired foods to be discarded, but these procedures were not consistently followed. In addition to food storage issues, the kitchen's cooking equipment, including the deep fryer and ovens, was found to be unclean, with excessive grease, food debris, and charred residue present. The cleaning schedule provided by the Dietary Supervisor indicated that equipment should be cleaned regularly, but interviews revealed inconsistencies in cleaning frequency and adherence to the schedule. The Dietary Supervisor acknowledged that unclean equipment could pose fire hazards and increase the risk of illness for residents. Surveyors also noted that dietary staff were not consistently wearing required hair and beard restraints while working in the kitchen. Several staff members with beards were observed without beard restraints, and interviews revealed confusion and lack of training regarding the requirement for beard restraints. Some staff stated they had not been provided with beard restraints or were unaware of the policy, despite the facility's written procedures mandating hair restraints for all kitchen staff. These lapses in food safety and sanitation practices could place residents at risk of foodborne illness, as directly stated in the report.
Failure to Develop Baseline Care Plan Addressing Pain Management Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted female resident with chronic pain syndrome and multiple bone disorders. Upon admission, the resident was assessed with a pain level of 4/10 and had physician orders for pain management, including a Fentanyl patch, Baclofen, and PRN oxycodone. Despite these documented needs, the baseline care plan did not include any entries related to pain or pain management. The resident reported experiencing significant pain, delays in receiving pain medication, and issues with medication administration, such as the removal of her Fentanyl patch without timely replacement and receiving Baclofen at undesired times. Interviews with the resident, MDS Coordinator, and DON confirmed that the baseline care plan was not completed as required and did not address the resident's immediate needs, particularly pain management. The facility's care planning policy did not specifically address baseline care plans, and staff acknowledged that the lack of a comprehensive baseline care plan could result in staff not knowing how to manage the resident's pain effectively.
Failure to Develop and Implement Comprehensive Care Plan for Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting individualized interventions for contractures in the resident's right hand and neck. The resident, a male with a history of intracranial injury, spastic hemiplegia, and contractures, was assessed to have functional limitations in range of motion in both upper and lower extremities. Despite these documented conditions, the care plan only included basic interventions for assistance with activities of daily living and did not address specific contracture management for the right hand or the neck. Multiple observations revealed that the resident was consistently without appropriate positioning devices or splints for his right hand and neck contractures while in his Geri-chair and bed. Staff interviews confirmed that the resident previously had a pillow for his neck and a splint or hand roll for his hand, but these were no longer in use. A CNA reported uncertainty about whether to use a rolled-up washcloth in the resident's hand due to the lack of an order, and the MDS Coordinator acknowledged that the care plan lacked individualized interventions for the contractures, particularly for the neck, which she had not considered a contracture. Therapy staff indicated that the resident had not received therapy since the previous year, and the occupational therapy discharge summary had recommended the use of a palmar guard for the right hand. The Director of Nursing stated that staff are expected to identify contractures and develop individualized care plans, but this had not occurred for the resident's neck contracture. The facility's care planning policy requires comprehensive plans that address all resident needs, but this was not followed in this case.
Failure to Update Care Plan with Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to review and update the care plan for a resident with a history of falls and severe cognitive impairment. The resident, an elderly female with diagnoses including dementia, diabetes, hypertension, and a history of fractures, experienced multiple falls during her stay. Despite these incidents, the care plan was not revised to include appropriate safety interventions such as fall mats or a low bed, even after unwitnessed and witnessed falls occurred on several occasions. Clinical records and progress notes indicated that the resident had at least three falls, including one resulting in a hip fracture and others without injury. Observations over several days confirmed that the resident's room did not have fall mats and the bed was not kept in a low position. Staff interviews revealed that interventions prior to the most recent fall were limited to encouraging call light use and keeping the call light within reach, despite the resident's severe cognitive impairment and inability to use the call light appropriately. Physical therapy assessments noted the resident's high fall risk and difficulty with transfers but did not recommend specific fall precautions. The facility's care planning policy requires that care plans remain current and address residents' needs, but the care plan for this resident was not updated with effective fall prevention interventions after repeated falls, as confirmed by staff and record review.
Failure to Provide Contracture Management for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decrease in range of motion (ROM) for a resident with documented contractures. The resident, who had a history of intracranial injury, spastic hemiplegia, and contractures affecting both the right hand and neck, was observed multiple times without any splint, hand roll, or positioning device in place for his contractures. The care plan for the resident did not include individualized interventions for contracture management of the right hand or address the neck contracture, despite clear evidence of these conditions. Staff interviews revealed a lack of awareness and guidance regarding the management of the resident's contractures. A CNA reported that devices previously used for the resident's neck and hand were no longer available, and she was unsure whether to use alternatives like a rolled-up washcloth due to the absence of specific orders. The MDS Coordinator acknowledged that the care plan contained only basic interventions and did not address the resident's specific contracture needs, particularly for the neck, which she had not considered a contracture. Therapy staff confirmed that the resident had not received therapy for his contractures since the previous year, and the occupational therapy discharge summary had recommended the use of a palmar guard for the right hand. Facility policy required assessment and appropriate treatment for loss of voluntary movement and limitation in ROM, including the neck, but these were not implemented for the resident. Observations consistently showed the resident without necessary devices to manage his contractures, indicating a failure to follow policy and provide individualized care.
Failure to Implement Adequate Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of appropriate assistance devices to prevent accidents for a resident with a history of multiple falls and significant cognitive impairment. The resident, an elderly female with diagnoses including dementia, diabetes, hypertension, and a history of fractures, experienced three falls—two unwitnessed and one witnessed—over a three-month period. Despite these incidents, the care plan did not include interventions such as fall mats or a low bed, and physician orders lacked fall precautions or increased monitoring. The only intervention added after the second fall was education and encouragement to use the call light for assistance, despite documentation and staff interviews indicating the resident was unable to use the call light appropriately due to severe cognitive impairment. Observations conducted over several days revealed that the resident's bed was not kept in the low position and no fall mats were present in her room, even after multiple falls. Staff interviews confirmed that prior to the most recent fall, interventions were limited to encouraging call light use and keeping the call light within reach. Both nursing and CNA staff expressed that the resident was not capable of using the call light effectively and that fall mats would have been an appropriate intervention given her fall history. Physical therapy assessments noted the resident's high fall risk and difficulty with transfers but did not recommend specific fall precautions or interventions. The facility's fall prevention policy requires that all residents at high risk for falls have individualized care plans with appropriate interventions, yet this was not followed for the resident in question. The incident log lacked detailed outcomes for the falls, and the care plan was not updated with effective interventions after repeated incidents. The lack of timely and appropriate fall prevention measures contributed to the resident experiencing multiple falls, including one resulting in a hip fracture.
Failure to Ensure Timely Availability of Physician-Ordered Fentanyl Patch
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with chronic pain syndrome and other bone disorders by not ensuring the timely availability of a physician-ordered Fentanyl patch. Upon admission, the resident had a Fentanyl patch in place, but it was removed when it expired, and a replacement was not available due to delays in ordering the medication. The admitting nurse did not follow up with the physician to obtain the required triplicate order for the Fentanyl patch, and the nurse practitioner clarified that only the physician could order this medication. As a result, the resident went without the prescribed Fentanyl patch for an extended period, during which time she reported severe neck pain related to her medical condition. Documentation in the electronic medical record and medication administration record confirmed the gap in Fentanyl administration, with nursing notes indicating the medication was not available and was pending delivery from the pharmacy. Interviews with nursing staff and the director of nursing revealed a lack of clarity and training regarding the process for ordering controlled substances, specifically the need for physician involvement and timely follow-up to ensure medication availability. The facility's medication ordering policy did not address timelines or procedures for ordering narcotics, contributing to the delay in the resident receiving her prescribed pain management.
Medication Error Rate Exceeds 5% Due to Incorrect Dose, Route, and Lack of Monitoring
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with four errors identified in 35 opportunities, resulting in an error rate of 11.43%. One staff member, an LVN, administered 325 mg of Aspirin crushed via PEG tube to a resident, despite the order specifying 81 mg chewable Aspirin to be given by mouth. The same resident, who had a history of cerebral infarction, dysphagia, aphasia, and essential hypertension, was also not assessed with vital signs such as blood pressure and pulse prior to receiving multiple antihypertensive medications, as required by accepted standards and the resident's care plan. The resident involved was severely cognitively impaired, non-verbal, and on an NPO diet due to dysphagia, requiring all medications to be administered via PEG tube. Despite this, the medication order for Aspirin was not clarified or updated to reflect the appropriate route, and the incorrect dose was given. Staff interviews revealed that nurses did not consistently check or document vital signs before administering blood pressure medications, and there was a lack of clarity among staff and pharmacy regarding the need for blood pressure parameters and monitoring for such residents. Facility policy required staff to verify medication orders, be aware of contraindications, and consult with prescribers if there were concerns about medication administration. However, these procedures were not followed, as staff failed to review and clarify the medication orders, did not monitor vital signs as indicated, and did not communicate concerns to the physician or pharmacy. The failure to adhere to these protocols resulted in medication errors involving incorrect dose, route, and lack of necessary monitoring for a resident with significant medical vulnerabilities.
Expired Medications Found in Medication Storage Room
Penalty
Summary
Expired and/or discontinued medications were found in one of two medication storage rooms during an observation and interview. Specifically, six bottles of multivitamins with an expiration date of 01/2024 and one box of nicotine patches with an expiration date of 04/2024 were present in the medication storage closet on Hall 100. The ADON present at the time confirmed the presence of these expired medications and removed them from the room. Interviews with the DON and Administrator revealed that the facility's expectation is for the supply person to monitor expiration dates when restocking supplies, and that expired products should be disposed of. The facility's Medication Administration Policy and Procedure requires that the individual administering medication ensures the expiration date has not been exceeded before administration. The failure to remove expired medications from storage could result in residents not receiving the intended therapeutic benefits of their medications.
Failure to Follow Enhanced Barrier Precautions During Device Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not ensuring that staff and hospice personnel followed Enhanced Barrier Precautions (EBP) during care of residents with indwelling medical devices. Observations revealed that licensed vocational nurses (LVNs) and a hospice registered nurse (RN) did not wear required personal protective equipment (PPE), such as gowns, when providing care involving a PEG tube and a urinary catheter, despite clear signage and care plans indicating the need for EBP. One resident, a male with severe cognitive impairment, cerebral infarction, dysphagia, and a PEG tube, had physician orders and a care plan requiring EBP, including the use of gowns and gloves during device care. On two separate occasions, LVNs administered medications and tube feeding through the PEG tube while only wearing gloves, omitting the gown. Both the signage on the resident's door and the care plan specified the need for both gown and gloves during such care. The LVNs acknowledged in interviews that they did not follow the required precautions and recognized the importance of doing so. Another resident, also with severe cognitive impairment and a suprapubic catheter, was observed receiving catheter care from a hospice RN who wore gloves but not a gown, contrary to facility policy and posted instructions. The hospice RN stated that this was not standard practice for hospice in home settings, but the facility's contract and policies required adherence to facility infection control protocols. Interviews with facility leadership confirmed that hospice staff are expected to follow facility policies regarding infection control when providing care within the facility.
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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