Legend Oaks Healthcare And Rehabilitation Garland
Inspection history, citations, penalties and survey trends for this long-term care facility in Garland, Texas.
- Location
- 2625 Belt Line Road, Garland, Texas 75044
- CMS Provider Number
- 676413
- Inspections on file
- 52
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation Garland during CMS and state inspections, most recent first.
Two residents with cognitive impairment and complex medical/psychiatric histories were seated near each other in the dining area when one resident, upset that the other was coughing over and reaching for food on her tray, threw an empty plastic bowl that struck the other resident’s upper body. The injured resident, who had dementia and required extensive assistance with ADLs and mobility, was assessed with no injuries or pain reported. The resident who threw the bowl, who had a history of CVA, schizoaffective disorder, and bipolar disorder, acknowledged the behavior and stated she acted because the other resident would not stop reaching for her food. This incident occurred despite a facility policy stating residents must be free from abuse, neglect, exploitation, and mistreatment by anyone, including other residents.
A resident with dementia, morbid obesity, CKD, overactive bladder, and bowel/bladder incontinence, who required substantial assistance with ADLs and was dependent for mobility, was left in a urine-soiled brief for several hours after requesting help via the call light. A CNA responded, found that the preferred brief size was not in the room, went to another hall to obtain the correct size, and then chose not to wake the resident upon return when the resident was asleep, leaving the brief unchanged despite the resident’s expressed desire to be awakened for changing. The resident’s responsible party reported multiple unsuccessful attempts to reach staff by phone while the resident remained soiled and crying. This conduct was inconsistent with the resident’s care plan and facility policies requiring provision of toileting and hygiene services and maintenance of resident dignity and cleanliness.
Surveyors found that a crash cart containing emergency supplies and medications was left unlocked and unattended in a hallway, making its contents accessible to residents. Additionally, a resident with severe cognitive impairment was found with a tube of topical analgesic cream in her room, despite having no physician order or assessment for self-administration. Staff were unaware of the medication's presence, and facility policy required all medications to be securely stored and accessible only to authorized personnel.
A resident with chronic respiratory failure was found to have a sleep apnea mask, nebulizer mask, and nasal cannula left unbagged and improperly stored when not in use, despite physician orders and facility policy requiring proper storage to prevent infection. Facility staff confirmed that these devices should have been bagged when not in use.
The facility failed to adhere to professional standards for food safety by not labeling opened food items with dates in the kitchen's walk-in refrigerator. Two jars of spaghetti sauce were found without open or discard dates, posing a risk of food-related illnesses to residents. Despite staff having up-to-date food safety certificates, this oversight occurred, highlighting a lapse in following the facility's food storage policy and FDA guidelines.
The facility reported a medication error rate of 13.33%, exceeding the acceptable 5% threshold. Three residents did not receive their medications within the prescribed timeframes, as observed on a specific date. The errors involved late administration of Glipizide, Benzonatate, Carvedilol, and Metformin. The staff acknowledged the delays, and the facility's policy requires medications to be administered as prescribed.
A LTC facility failed to protect a resident's personal and medical records when a resident's representative was mistakenly given another resident's face sheet containing sensitive information. The DON confirmed the breach, which likely occurred two years ago, and emphasized the importance of adhering to PHI management policies to prevent unauthorized disclosure.
The facility failed to maintain a clean and safe environment for 11 residents, with issues such as dirty air-condition units, soiled linens, and inadequate housekeeping services. Residents reported that their rooms were not cleaned regularly, and some faced health issues due to the lack of cleanliness. Housekeeping staff acknowledged oversight, and the Housekeeping Supervisor confirmed that daily checks were conducted, but these practices were not consistently followed.
The facility failed to ensure that three residents were free from unauthorized physical restraints, including scoop mattresses and a positioning wedge, without physician orders or assessments. This oversight involved residents with severe cognitive impairments and histories of falls, potentially putting them at risk of injury.
The facility failed to provide scheduled showers to two dependent residents, leading to concerns about personal hygiene and skin integrity. One resident with bilateral leg amputations and another with severe cognitive impairment received bed baths instead of showers, despite being scheduled for showers three times a week. Interviews revealed inconsistencies in documentation and communication among staff.
The facility failed to provide appropriate respiratory care for several residents, including not changing nebulizer tubing, not cleaning BiPAP machines, improperly storing nebulizer masks, and not maintaining humidifiers. These deficiencies were confirmed through observations and interviews with staff and residents.
The facility failed to re-order medications in a timely manner for four residents, resulting in low or depleted supplies of essential medications. This issue was observed during medication preparation and administration, and staff interviews revealed inconsistencies in following the re-ordering procedure. The DON and ADON acknowledged the problem and emphasized the importance of timely re-ordering to ensure residents receive necessary medications.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards. Observations revealed rust on the ice machine's door hinges, improperly labeled dill pickle relish, and unsealed frozen chicken nuggets. Interviews confirmed these issues, and the facility's policy mandates proper storage and labeling.
The facility failed to obtain a signed informed consent for a resident before administering Lamictal, a medication for bipolar disorder. The resident was unaware of taking the medication or the diagnosis it was treating. The ADON admitted to overlooking the need for consent, and the DON confirmed that obtaining consent is required by facility policy.
The facility failed to ensure the call light system in the rooms of two residents was accessible, which could prevent them from obtaining assistance when needed. One resident's call light was found on the floor behind the headboard, and another's was hanging on the headboard out of reach. Staff acknowledged the issue and moved the call lights within reach.
A resident reported that staff had called her a liar but did not file a grievance because she did not know how. Interviews revealed that it was the Social Worker's responsibility to inform residents about the grievance process, but this was not effectively communicated to the resident.
The facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and a history of falls. The care plan required a low bed with a fall mat, but the mat was missing after the resident moved rooms. Both the ADON and DON confirmed the necessity of the fall mat to prevent injuries.
The facility failed to ensure a resident with a feeding tube had a clear physician order specifying the downtime, leading to potential risks of underfeeding, overfeeding, aspiration, and fluid overload. The nursing staff was confused about when to stop and resume the feeding due to the lack of a specific downtime order.
The facility failed to ensure proper hand hygiene practices were followed by staff, leading to potential infection risks for two residents. An ADON did not wash her hands before applying a splint, and a CNA did not perform hand hygiene during incontinence care. Both staff members acknowledged their lapses, and the DON emphasized the importance of handwashing in preventing infection transmission.
Resident-to-Resident Abuse During Dining
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse by another resident when one resident threw an empty plastic bowl at another during a meal. Resident #1 was an 85-year-old female with dementia, reduced mobility, chronic pain, and multiple other medical conditions, and required setup assistance for all ADLs and was dependent for mobility. Her MDS indicated she was unable to complete the interview and had no documented physical or verbal behaviors. Her care plan identified her as at risk for impaired cognitive function/dementia and included interventions such as consistent routines, step-by-step instructions, and monitoring for changes in cognitive status. Resident #2 was a female with a history of nontraumatic intracerebral hemorrhage, hemiplegia/hemiparesis, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, and other medical conditions. Her MDS showed a BIMS score of 12 (moderate cognitive impairment), dependence or need for setup with all ADLs, and no documented physical or verbal behaviors. Her care plan identified risk for impaired cognitive function related to CVA, schizophrenia, and bipolar disorder, and a potential for mood problems related to schizophrenia and bipolar disorder, with interventions focused on communication, psychosocial support, and monitoring mood and cognitive changes. On the morning of 03/03/26 during dining, Resident #2 threw an empty plastic cup/bowl at Resident #1, striking Resident #1 on the upper body/shoulder after Resident #1 reportedly reached for or attempted to take food from Resident #2’s tray and coughed over her food. Staff interviews indicated that Resident #2 told staff she threw the cup because Resident #1 tried to take food from her tray and did not stop when told to. The nurse’s progress note documented a resident-to-resident incident in which Resident #1 was struck by a cup thrown by Resident #2, with no injuries or distress observed and Resident #1 denying pain. The facility’s policy stated that each resident has the right to be free from abuse, neglect, exploitation, and mistreatment by anyone, including other residents. Despite this policy, the incident occurred, and the facility failed to ensure Resident #1 was free from abuse by Resident #2.
Failure to Provide Timely Incontinent Care and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and assistance with activities of daily living (ADLs) to a resident who was dependent on staff for toileting and hygiene. The resident was an older female with multiple diagnoses, including COPD, dementia with mood disturbance, type 2 diabetes, morbid obesity, chronic kidney disease, overactive bladder, and bowel and bladder incontinence. Her MDS assessment showed moderate cognitive impairment, substantial assistance needs for most ADLs, wheelchair use, and dependence on all mobility tasks. Her care plan identified bowel/bladder incontinence related to decreased mobility, deconditioning, activity intolerance, weakness, unsteady gait, and impaired cognition, with interventions that included use of disposable briefs, checking for incontinence as required, washing and drying the perineum, changing clothing as needed after incontinence episodes, monitoring for UTI, and observing the peri-area for redness or excoriation. On the day of the incident, the resident used her call light to request assistance with changing her clothes and a soiled brief. A CNA responded, and the resident requested to be changed. The CNA reported that when she checked the resident’s closet, only smaller briefs were available and not the XXXL size the resident preferred, so she went to a storage area on another hall to obtain the correct size. The CNA stated that when she returned to the resident’s room, the resident was asleep, and the CNA decided not to wake her and did not change the soiled brief at that time. The CNA acknowledged that she made the decision not to change the resident and that the expectation was to wake the resident to change her if requested. The resident and her responsible party reported that the resident remained in a soiled brief for several hours despite repeated attempts to obtain assistance. The responsible party stated she received a call from the resident crying and reporting she had been waiting since early morning for her soiled brief to be changed. The responsible party described multiple unsuccessful attempts to reach facility staff by phone and reported that, during follow-up calls with the resident over the next several hours, the resident stated she still had not been changed and had fallen asleep while waiting. The resident later stated that staff told her they had not changed her because she was asleep when they returned, and she expressed confusion and upset because staff routinely woke her for other reasons and she wanted to be awakened to be changed. The facility’s policies on Quality of Care and Resident Rights required that residents unable to perform ADLs receive necessary services for toileting and hygiene and that residents be treated with dignity and be appropriately groomed and in clean clothing.
Failure to Secure Medications and Lock Emergency Cart
Penalty
Summary
Surveyors observed that the facility failed to store all drugs and biologicals in locked compartments as required by state and federal regulations. On the morning of the survey, a crash cart containing emergency supplies, equipment, and medications was found unlocked and unattended in a hallway outside the nurse's station. The drawers of the cart, which were accessible to passing residents, contained items such as scissors, syringes, tubing, and a first aid kit. Staff interviews confirmed that the crash cart should have been locked when not in use, and that its contents could be harmful if accessed by residents. Additionally, a tube of topical analgesic cream was found on the overbed table of a resident diagnosed with dementia, depression, and low back pain. The resident had a severe cognitive impairment and no physician order for the analgesic cream. There was no assessment for self-administration of medications, nor any documentation indicating the resident was competent to manage her own medications. Staff were unaware of the presence of the cream in the resident's room and acknowledged that it should have been stored securely and administered by nursing staff. Facility policy required that all drugs and biologicals be stored in locked compartments and accessible only to authorized personnel. The policy also specified that medication rooms, carts, and supplies must be locked or attended by authorized staff. The observed failures to lock the crash cart and to prevent unauthorized medications from being present in a resident's room were in direct violation of these policies and regulatory requirements.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure who required multiple respiratory devices, including a sleep apnea mask, nebulizer mask, and nasal cannula. On the date of observation, all three respiratory devices were found unbagged and not properly stored when not in use, contrary to professional standards of practice and the facility's own policy. The resident's care plan included oxygen therapy, and physician orders specified the use of oxygen, nebulizer treatments, and BiPAP/CPAP at night. During observations and interviews, the DON and an RN confirmed that all breathing devices should have been bagged when not in use to prevent infection. The failure to properly store these respiratory devices was directly observed and acknowledged by facility staff. The resident involved had an intact cognitive status and a diagnosis of chronic respiratory failure, requiring consistent adherence to respiratory care protocols.
Improper Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety in its only kitchen. During an observation, two 48-ounce plastic jars of opened spaghetti sauce were found on a shelf in the walk-in refrigerator without any dates indicating when they were opened or when they should be discarded. The Dietary Manager confirmed that all food in the walk-in refrigerator should have an open and discard date, acknowledging that foods past their discard dates could become spoiled and potentially expose residents to food-related illnesses. Despite the staff having up-to-date food safety certificates, this oversight occurred. Interviews with staff, including a dietary aide and the Director of Nursing (DON), highlighted the importance of proper food storage practices. The dietary aide emphasized the necessity of labeling leftover foods with opened and discard dates to prevent residents from consuming spoiled foods, which could lead to illness. The DON also noted that ingesting spoiled foods could cause food-borne illnesses or discomfort to residents. The facility's policy on frozen and refrigerated food storage, as well as the FDA Food Code, requires that refrigerated, ready-to-eat foods be clearly marked with the date they were opened and a discard date if held for more than 24 hours, which was not adhered to in this instance.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 13.33% due to four errors out of 30 opportunities. These errors involved three residents who did not receive their medications within the prescribed timeframes. Resident #28, a female with diabetes and chronic respiratory failure, did not receive her Glipizide and Benzonatate as ordered between 7:00 a.m. and 10:00 a.m. Resident #74, a male with hypertension and coronary artery disease, did not receive his Carvedilol within the scheduled timeframe. Resident #89, a male with diabetes, did not receive his Metformin as prescribed. The medication administration errors were observed on 2/18/2025, when MA A administered medications to the residents outside the scheduled timeframes. The medications appeared in red on the Medication Administration Record (MAR), indicating they were late. MA A acknowledged the delay, attributing it to running behind schedule, and expressed an understanding that medications should not be given too close together. The Assistant Director of Nursing (ADON) and Clinical Resource Nurse confirmed that medications should be administered within the designated window or the physician should be contacted to adjust the timing. Interviews with the Director of Nursing (DON) and the Medical Doctor (MD) highlighted the expectation that medications be administered within the scheduled window to avoid potential adverse events. The facility's policy, revised in 2015, mandates that medications be administered as prescribed by the attending physician. However, the medication error policy was not provided at the time of the survey exit, indicating a possible gap in policy adherence or availability.
Breach of Resident Confidentiality in LTC Facility
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, specifically for one resident involved in a privacy investigation. The incident occurred when a resident's representative, assisting with the discharge of another resident, was inadvertently handed a document containing another resident's personal information. This document, identified as a face sheet, included sensitive details such as the resident's name, birthdate, social security number, and medical diagnoses. The Director of Nursing (DON) confirmed the breach after reviewing the documents in question, acknowledging that the incident likely occurred two years prior. Despite the DON's assertion that no similar incidents had occurred in the past 12 months, the facility's policy on Protected Health Information (PHI) management emphasizes the responsibility of all personnel to prevent unauthorized disclosure of resident information. The facility's failure to adhere to these policies resulted in the potential risk of exposure and misuse of the resident's personal information.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 11 residents. Observations revealed that multiple rooms had air-condition units with black dirt stains and thick dust build-up on the filters. Additionally, some rooms had stained mini-fridges, heavily soiled linens, and missing air filters. Interviews with residents indicated that housekeeping services were inadequate, with some residents reporting that their rooms had not been cleaned for several days. One resident mentioned that the lack of cleanliness exacerbated their sinus and allergy problems. Another resident reported that their sleep apnea machine was not being cleaned properly, despite previous complaints to the Director of Nursing (DON). Housekeeping staff acknowledged that certain areas might have been overlooked and that they faced challenges cleaning rooms of residents who exhibited aggressive behavior. The Housekeeping Supervisor confirmed that staff were trained to clean thoroughly, including air-condition units and mini-fridges, and that he conducted daily checks known as Angel rounds to ensure cleanliness. However, the observations indicated that these practices were not consistently followed, leading to an environment that could pose infection control concerns.
Failure to Ensure Residents Were Free from Unauthorized Physical Restraints
Penalty
Summary
The facility failed to ensure that three residents were free from physical restraints that were not required to treat their medical symptoms. Resident #14, who has quadriplegia and a history of falls, was observed with a scoop mattress without a physician's order or assessment. The Licensed Vocational Nurse (LVN) was unaware of the need for a physician's order or assessment for the scoop mattress, which was intended to assist with fall prevention. The Assistant Director of Nursing (ADON) also confirmed the absence of a physician's order and assessment for the scoop mattress, which was provided at the family's request without proper documentation or evaluation. Resident #63, who has Alzheimer's disease and severe cognitive impairment, was also observed with a scoop mattress without a physician's order or assessment. The LVN and ADON were unsure of the need for a physician's order or assessment, and the mattress was provided based on a family request. The Director of Nursing (DON) confirmed the lack of physician orders and assessments for the scoop mattress, indicating a misunderstanding of the facility's policy on restraint use. Resident #49, who has a history of repeated falls and severe cognitive impairment, was observed with a positioning wedge without a physician's order or assessment. The ADON and DON both confirmed the absence of proper documentation and evaluation for the use of the positioning wedge. The facility's policy on restraints requires a physician's written order and assessment, which were not followed in these cases, potentially putting the residents at risk of injury.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, two residents, one with bilateral leg amputations and another with severe cognitive impairment, did not receive their scheduled showers consistently. Records for January 2024 and December 2023 showed that both residents were scheduled to receive showers three times a week but were instead given bed baths on multiple occasions. Interviews with staff revealed inconsistencies in documentation and communication regarding the residents' refusal of showers and the subsequent actions taken by the nursing staff. Resident #1, a cognitively intact female with bilateral leg amputations, was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. However, records indicated that she only received bed baths on the scheduled days. The resident expressed concerns about not receiving proper care and mentioned a fear of retaliation if she complained. Interviews with CNAs and LVNs revealed that the resident had refused showers on some occasions, but there was confusion about the proper documentation and follow-up procedures. The ADON confirmed that the resident was at risk of skin breakdown due to not receiving her scheduled showers. Resident #36, a male with severe cognitive impairment and on hospice care, was also scheduled to receive showers three times a week. However, records showed that he only received bed baths. The resident's family expressed concerns about the lack of showers and were told that a special shower chair was needed, which contradicted the facility's available resources. Interviews with hospice staff and facility administrators revealed a breakdown in communication and documentation, leading to the resident not receiving his scheduled showers. The DON acknowledged the issue and mentioned that the resident was at risk of skin breakdown due to the lack of proper hygiene care.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, leading to deficiencies in their treatment. Resident #14's nebulizer tubing was not changed within the facility's policy of 7 days, and there was no date indicating the last change. This oversight was confirmed during an observation on January 17, 2024, and was acknowledged by the Assistant Director of Nursing (ADON), who admitted that the tubing should have been changed on Wednesday nights by the night nurse and checked by the staff on Thursdays. The ADON also noted that missing the scheduled change could result in an infection. Resident #15's BiPAP machine was not properly cleaned and sanitized. The mask and tubing lacked a date indicating the last cleaning, and the resident's family member had previously raised concerns about the machine's maintenance. The Licensed Vocational Nurse (LVN) and ADON both confirmed that the machine should be cleaned nightly, and the lack of proper cleaning could lead to infection. Additionally, the resident's humidifier was found empty, which could cause nasal irritation. Resident #55's nebulizer mask was improperly stored and not dated, as observed during an interview with the resident. The mask was left on top of the nebulizer machine, which was not always clean. The Registered Nurse (RN) and ADON both acknowledged that the mask should be cleaned, bagged, and dated to prevent contamination. Similarly, Resident #67's humidifier was found without water, which could lead to nasal dryness and irritation. The Director of Nursing (DON) and ADON both confirmed that the humidifier should have water to moisten the nasal linings and prevent dryness. These deficiencies highlight the facility's failure to adhere to professional standards of practice and the residents' comprehensive care plans.
Failure to Re-Order Medications Timely
Penalty
Summary
The facility failed to ensure that four residents were provided medications and pharmaceutical services to meet their needs. Specifically, the facility did not re-order medications in a timely manner for Resident #3 (Clopidogrel Bisulfate 75 mg), Resident #12 (Gabapentin capsule 100 mg), Resident #56 (Oxcarbazepine 300 mg), and Resident #58 (Levothyroxine Sodium 25 mcg). This failure was observed during medication preparation and administration, where it was noted that the blister packs for these medications were either completely out or running low, indicating a lack of timely re-ordering by the staff responsible for medication management. Resident #3, a female with hemiplegia and hemiparesis following a cerebral infarction, was found to have no remaining Clopidogrel Bisulfate 75 mg tablets in her blister pack. Resident #12, a female with severe cognitive impairment and chronic pain due to osteoporosis and neuropathy, had only three Gabapentin capsules left. Resident #56, a female with major depressive disorder and bipolar disorder, had only one Oxcarbazepine 300 mg tablet left. Resident #58, a female with chronic kidney disease and hypothyroidism, had only two Levothyroxine Sodium 25 mcg tablets left. Interviews with CMA B and LVN N revealed that medications should be re-ordered when they reach the blue portion of the blister pack, but this procedure was not consistently followed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the issue, stating that medications must be re-ordered in a timely manner to ensure residents have the necessary medications. The facility's policy requires medications to be re-ordered seven days in advance to maintain an adequate supply. The DON and ADON emphasized the importance of following this procedure to prevent residents from running out of essential medications, which could adversely affect their health. The facility planned to audit the medication carts and in-service the staff to reinforce the importance of timely medication re-ordering.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed that the ice machine in the facility's kitchen had rust on and inside the door hinges. Additionally, a gallon container of dill pickle relish in the walk-in refrigerator was dated but lacked a visible expiration date, and a large box of frozen chicken nuggets in the walk-in freezer was not sealed, exposing it to air-borne contaminants. These issues were identified during a survey conducted on 01/19/24 from 09:17 AM to 09:21 AM. Interviews with the Dietary Manager, Dietician, and Housekeeping Supervisor confirmed the deficiencies. The Dietary Manager and Dietician acknowledged the issues with the ice machine and food storage, stating that the cleaning of the ice machine was the responsibility of maintenance. The Housekeeping Supervisor confirmed that maintenance was responsible for cleaning the ice machine and admitted uncertainty about how to address the rust issue. The facility's policy on food storage and supplies, dated 2012, mandates that all storage areas be maintained in an orderly manner, with air-tight containers or bags for all opened packages of food, and accurate labeling with the item and date opened. The U.S. Food and Drug Administration (FDA) Code (2022) also requires that packaged food be labeled as specified in law and protected from contamination.
Failure to Obtain Informed Consent for Medication
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain a signed informed consent for Resident #28 before administering Lamictal, a medication used to treat seizures and bipolar disorder. The resident, an [AGE] year-old female with Alzheimer's disease, was alert and oriented but was unaware that she was taking Lamictal or that it was being used to treat bipolar disorder. This oversight was identified during a review of the resident's medical records and confirmed through interviews with the resident and facility staff. The Assistant Director of Nursing (ADON) responsible for reviewing pharmacy recommendations admitted to overlooking the need for consent for Lamictal. The Director of Nursing (DON) confirmed that residents are supposed to give consent for medications and that it is the ADONs' responsibility to ensure these consents are obtained. The facility's policy on psychoactive medications consent, dated July 2014, requires that the use of such medications be explained to the resident or their legal representative and that consent be obtained. However, this policy was not followed in the case of Resident #28, leading to a violation of the resident's rights to be informed and to participate in their treatment decisions.
Failure to Ensure Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure the call light system in the rooms of two residents was accessible, which could prevent them from obtaining assistance when needed. Resident #68, a male with secondary Parkinsonism and ataxic gait, was found with his call light on the floor behind the headboard, covered by a box. A CNA who entered the room did not notice the misplaced call light until it was pointed out, after which she cleaned it and placed it within the resident's reach. The resident's care plan specifically mentioned the importance of having the call light within reach due to his risk of falls and unsteady gait. Resident #236, a female with osteoarthritis and idiopathic neuropathy, was found with her call light hanging on the headboard, out of her reach. The resident was unaware of the call light's location. An ADON who observed the situation acknowledged that the call light was not accessible and moved it within the resident's reach. The resident's care plan also emphasized the need for the call light to be within reach due to her fall risk and muscle weakness. Interviews with the DON and ADON confirmed that the facility's policy required call lights to be within residents' reach to ensure they could communicate their needs. The DON stated that all staff were responsible for ensuring call lights were accessible and mentioned plans to audit the call light system. The facility's policies on accommodation of needs and call light procedures were reviewed, both of which mandated that call lights be within residents' reach before staff left the room.
Failure to Inform Resident on Grievance Filing Process
Penalty
Summary
The facility failed to ensure that Resident #71 knew how to file a grievance. Resident #71, a [AGE] year-old female with intact cognitive status and diagnoses including stroke and diabetes, reported that staff had called her a liar. She did not file a grievance about the issue because she did not know how to do so. This indicates that the facility did not provide adequate information to the resident on how to file a grievance, as required by their policy. Interviews with the Social Worker (SW) and the Operations Manager revealed that it was the SW's responsibility to ensure residents knew how to file grievances. The SW stated that she completed quarterly assessments with residents to inform them about the grievance process but was unaware of why Resident #71 did not know how to file a grievance. The facility's policy indicated that residents and/or families are informed of the grievance policy during the admission process, but this was not effectively communicated to Resident #71.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #44, who had severe cognitive impairment and a history of falls. The care plan, dated 05/16/23, specified that the resident should have a low bed with a fall mat due to her poor balance, unsteady gait, and poor safety awareness. However, during an observation and interview on 01/17/24, it was noted that while the resident's bed was low, there was no fall mat present. The resident was confused and unable to answer questions coherently. Further interviews revealed that the fall mat was left behind when the resident moved rooms. Both the ADON and DON confirmed that the fall mat was necessary to prevent injuries and that its absence posed a risk of increased severity of injury in the event of a fall. The DON mentioned that the facility was in the process of ordering a new mat as the one provided by Hospice was dirty. The facility's policy on care plans was reviewed, but it was not dated and did not provide specific guidance on ensuring the presence of fall mats as per individual care plans.
Failure to Ensure Clear Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that Resident #76, who required enteral feeding due to dysphagia following a cerebrovascular accident, had a clear physician order specifying the downtime for the feeding tube. The resident's care plan indicated the need for tube feeding, but the physician order only specified the duration of feeding (16 hours) without mentioning the specific downtime. This omission led to confusion among the nursing staff, as they were unsure when to stop and resume the feeding, potentially risking underfeeding, overfeeding, aspiration, and fluid overload for the resident. During an observation and interview, LVN N confirmed the absence of a downtime order and highlighted the risks associated with this lack of clarity. The Director of Nursing (DON) acknowledged the issue, stating that a clear order for downtime was necessary to ensure consistent care and prevent complications. The facility's policies on gastrostomy tube care and physician orders were reviewed, revealing that the orders should be accurately transcribed and verified, which was not adhered to in this case.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff, leading to potential infection risks for two residents. In the first instance, the Assistant Director of Nursing (ADON) did not wash or sanitize her hands before applying a resting hand splint to a resident's right hand. The resident, a male with a history of cerebral infarction and hemiplegia, confirmed that he was supposed to wear the splint. The ADON acknowledged the lapse in hand hygiene and admitted that being busy was not an excuse for neglecting this critical practice. The Director of Nursing (DON) emphasized the importance of handwashing in preventing infection transmission and stated that staff are expected to wash their hands before and after every care activity. In the second instance, a Certified Nursing Assistant (CNA) failed to perform hand hygiene during incontinence care for a female resident with dementia and chronic kidney disease. The CNA did not change her gloves or wash her hands after cleaning the resident's peri-area and buttocks, and before applying cream and handling a clean brief. When questioned by the surveyor, the CNA admitted she should have performed hand hygiene but did not. The DON confirmed that staff are required to perform hand hygiene and change gloves during incontinence care to prevent infection spread. The facility's policy on hand hygiene underscores its importance in infection prevention and control.
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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