Legend Oaks Healthcare And Rehabilitation - New Br
Inspection history, citations, penalties and survey trends for this long-term care facility in New Braunfels, Texas.
- Location
- 2468 Fm 1101, New Braunfels, Texas 78130
- CMS Provider Number
- 676392
- Inspections on file
- 35
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation - New Br during CMS and state inspections, most recent first.
Several residents, including those with cognitive and physical impairments, were served burnt bread during meals, leading them to refuse the food or request alternatives. Direct observations and resident interviews confirmed the issue, while staff either did not notice the problem or had no response when questioned.
A resident with multiple comorbidities and a history of COVID-19 did not have documentation in the medical record showing that education about the COVID-19 vaccine was provided to the resident or their representative, despite facility policy requiring this step. Staff interviews indicated confusion about vaccine administration, and although consent was obtained, the vaccine was not given and education was not documented.
The facility failed to provide adequate respiratory care for three residents requiring oxygen therapy. Two residents had dusty oxygen concentrators, risking respiratory complications, while a third resident received oxygen without physician orders. The facility's policy on oxygen administration was not followed, leading to these deficiencies.
A resident with multiple health conditions did not receive their ordered PRN hydrocodone for nine days due to a prescription error, despite staff attempts to resolve the issue. The resident was given acetaminophen instead, which was effective for lower pain levels, but the stronger medication was unavailable when needed.
The facility failed to maintain proper food handling and hygiene standards in the kitchen. A dietary staff member handled diet tickets and prepared plates without proper hand hygiene, risking cross-contamination. Additionally, a grilled cheese sandwich was served on a wet divided plate, which was not properly dried, potentially leading to cross-contamination. The dietary supervisor and resource acknowledged these issues, which could make residents sick.
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. One resident's depression was not coded in the annual assessment, and another resident's use of oxygen therapy was omitted. The MDS Coordinator acknowledged these oversights, highlighting the importance of accurate documentation for appropriate care.
The facility failed to include the use of side rails in the care plans of two residents, despite physician orders and observations confirming their use for repositioning and mobility. This omission could lead to staff not monitoring associated risks, potentially resulting in accidents or injuries.
A resident experienced unplanned weight loss due to the facility's failure to follow physician orders for weekly weight monitoring and implement dietary interventions. The resident, admitted with serious medical conditions, was at high risk for nutritional issues. Despite this, the nursing staff did not weigh the resident as required, and there was a lack of communication regarding his reduced appetite. The facility's dietician was not informed of the weight loss in a timely manner, delaying necessary interventions.
The facility failed to assess and document the use of bed rails for two residents before installation. One resident with chronic respiratory failure and another with encephalopathy and moderate cognitive impairment were using side rails without documented assessments or discussions of risks and benefits. The facility's policy requires informed consent and documentation for restraint use, which was not followed.
The facility failed to properly secure drugs and biologicals in two medication carts, with loose, unidentified pills found in the carts. Staff interviews revealed that CMAs are responsible for ensuring carts are clean and free of loose pills, but the presence of these pills could risk residents not receiving their medications as ordered.
The facility failed to maintain an effective training program for staff, specifically for one employee, Cook D, who did not receive required annual trainings. The HR Manager and Administrator rely on the Relias program to track training needs, but Cook D was not identified for overdue trainings. The facility's policy outlines mandatory training topics, but a policy for required annual training was not provided.
The facility failed to provide mandatory effective communication training for an employee, Cook D, as required by their policy. Cook D's training log showed no evidence of annual communication training being completed prior to March 2025, with the last recorded training in January 2024. The HR Manager and Administrator acknowledged the oversight, which could potentially affect residents by leaving them uninformed due to the lack of staff training.
The facility failed to provide mandatory annual dementia management training to an employee, Cook D, as required. Despite being hired in December 2023, Cook D's training log showed no evidence of annual dementia training before March 2025. The HR Manager, responsible for identifying staff needing training, did not include Cook D in the reports. The Administrator confirmed the responsibility of ensuring staff training but could not provide a policy on required training.
The facility failed to provide mandatory QAPI training to an employee, Cook D, as part of its annual training requirements. The training log showed no evidence of QAPI training being provided annually before March 2025, with the last recorded training in January 2024. The HR Manager and Administrator acknowledged their responsibility to ensure staff received annual trainings, but Cook D was not identified in the training program reports. A policy on required annual training was not provided before the survey exit.
The facility failed to provide mandatory annual infection control training to an employee, Cook D, as required by its infection prevention and control program. The HR Manager and Administrator relied on the Relias training program to track compliance but did not identify Cook D as needing training. This oversight could increase the risk of staff errors and potential harm to residents.
The facility failed to provide mandatory ethics training for an employee, Cook D, as required annually. The training log showed no evidence of ethics training being provided prior to March 2025, with the last training completed in January 2024. The HR Manager and Administrator acknowledged their responsibility in ensuring staff received annual trainings, but a policy addressing required training was not provided.
The facility failed to provide required annual behavioral health training for an employee, Cook D, as per regulatory requirements and the facility's assessment. The HR Manager and Administrator relied on the Relias training program to track training needs, but Cook D was not identified for training. Despite requests, no policy on required annual training was provided.
A registered nurse in a long-term care facility diverted narcotic pain medications from two residents, one of whom had been discharged. The facility failed to remove the discharged resident's medication, allowing the nurse to access and misuse it. Additionally, the nurse diverted medication from another resident without proper documentation. The facility's procedures for handling controlled medications for discharged residents were not followed, leading to the oversight.
A resident with dementia and osteomyelitis experienced a change in condition with the onset of diarrhea and a red rash, which was not reflected in her care plan. Despite being at risk for pressure ulcers, the care plan was not updated to address these acute changes. The resident's condition was reported by CNAs, and the NP ordered probiotics and a high fiber diet, but the care plan remained unchanged due to the MDS Nurse's absence.
A resident with severe cognitive impairment and respiratory conditions was not provided adequate oxygen therapy as ordered. Observations revealed the resident with low oxygen saturation levels and an empty oxygen tank. Staff interviews indicated lapses in monitoring and managing the resident's oxygen needs, contrary to the facility's policy and physician's orders.
A facility failed to accurately document the administration of PRN Hydrocodone-Acetaminophen for a resident with dementia and chronic pain. The MAR did not reflect the administration of the medication, despite entries on the Narcotic Count Sheet. This discrepancy was confirmed by the DON, who noted the correct process involves documentation on both the MAR and the Narcotic Count Sheet.
A resident with an abrasion on her elbow did not receive wound care as ordered by the physician, due to a lapse by the Wound Care Nurse who documented the care as completed before performing it and then forgot to administer the treatment. This failure was identified through observations and interviews, revealing that the bandage had not been changed since admission, posing a risk of infection.
A resident's wound care was inaccurately documented as completed in the facility's records, despite the care not being administered. The Wound Care Nurse marked the treatment as done before attempting it and forgot to perform it after failing to locate the resident. The facility lacked a specific policy on clinical record accuracy, leading to this oversight.
Failure to Provide Palatable Food During Meals
Penalty
Summary
Surveyors found that the facility failed to provide palatable food to residents, as evidenced by multiple instances where residents were served burnt bread during meals. Specifically, three residents with varying medical conditions, including hemiplegia, dysphagia, dementia, diabetes, Alzheimer's disease, and muscular dystrophy, were observed during lunch receiving Italian rolls that were burned at the bottom. Two residents directly stated they would not eat the bread due to it being burnt, and another resident reported that burned food was a recurring issue, often leading them to forgo eating or request alternatives. These findings were based on direct observation, resident interviews, and review of medical records and care plans, which indicated that all affected residents were on regular diets and, in some cases, required assistance with meal setup or supervision. When the issue was brought to the attention of facility staff, the DON had no response regarding the burnt bread, and the Food Service Manager, who assisted with the meal, stated she did not notice any burnt bread or receive complaints. The facility's policy provided to surveyors referenced the Texas Food Establishment Rules. The deficiency was identified as a failure to provide food that was palatable and met the needs of each resident, as required.
Failure to Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to implement its COVID-19 immunization policies and procedures by not ensuring that a resident's medical record included documentation that the resident or their representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. Record review showed that the resident had a history of heart failure, acute respiratory failure, dementia, cognitive communication deficit, and required personal assistance. The resident had previously contracted COVID-19 and had received her last COVID-19 vaccination in late 2023. However, there was no documentation in the care plan or medical record indicating that education about the COVID-19 vaccine was provided to the resident or her representative during the relevant period. Interviews with facility staff, including the DON and previous ADON, revealed uncertainty about the ongoing administration of COVID-19 vaccines to residents. The resident's responsible party confirmed that consent for vaccination had been given, but the vaccine was not administered, and no education was provided. The facility's policy required that education be provided and documented before offering the vaccine, but this was not followed for the resident in question.
Inadequate Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen therapy. For two residents, the nursing staff did not regularly clean the oxygen concentrators, which were observed to be covered in dust, including the vent ports where filters are located. This lack of maintenance could lead to the residents inhaling dust particles, potentially causing infections or respiratory complications. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the concentrators were not being cleaned as required, and there was uncertainty about whether the rental company serviced the equipment. For the third resident, the facility did not have physician orders for the use of oxygen, despite the resident being observed with oxygen therapy on multiple occasions. The resident's care plan did not include any focus or interventions for oxygen therapy, and the nursing staff was unaware of the need for a physician's order. The DON acknowledged that the resident should have had orders for oxygen use, as it had been administered without proper documentation or guidance. The facility's policy on oxygen administration requires that oxygen therapy be administered as ordered by a physician or as an emergency measure until an order can be obtained. However, this policy was not followed, leading to the deficiencies observed. The lack of proper maintenance and documentation for oxygen therapy placed the residents at risk of respiratory complications.
Failure to Provide Ordered PRN Hydrocodone for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not having the ordered PRN hydrocodone available for nine days from admission to discharge. The resident, a male with diagnoses including metabolic encephalopathy, acute pulmonary edema, and a stage III pressure ulcer, was moderately cognitively impaired and required PRN pain medication. Despite having an order for hydrocodone, the medication was not available, and the resident did not receive it during his stay. The deficiency was identified through interviews and record reviews, which revealed that the facility did not have an active prescription for the hydrocodone on file with the pharmacy. Attempts by nursing staff to obtain the medication from the emergency kit were denied due to the lack of a prescription. The physician had sent the prescription multiple times, but it was not received by the pharmacy due to an error in the submission process. As a result, the resident was given acetaminophen instead, which was effective for lower pain levels, but the stronger medication was unavailable when requested by the family. Interviews with staff indicated that there were ongoing issues with obtaining the hydrocodone, and the resident was observed to be in pain on at least one occasion. The Director of Nursing stated that the expectation was for nurses to notify the physician and pharmacy if a medication was unavailable. The facility's policy emphasized the importance of providing pharmaceutical services to meet residents' needs, but this was not achieved in this case, leading to the deficiency.
Improper Food Handling and Hygiene in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. A dietary staff member, after washing hands, handled diet tickets and then proceeded to prepare resident plates without maintaining proper hand hygiene. The staff member was seen placing fingers inside bowls and plates, which could lead to cross-contamination. The dietary supervisor acknowledged that meal tickets are not considered clean items and that improper handling of bowls and plates could cause cross-contamination. Additionally, a divided plate was observed with water droplets and pooling water, which was not properly dried before a grilled cheese sandwich was served on it. The dietary supervisor and resource acknowledged that serving food on wet plates could lead to cross-contamination and potentially make residents sick. The facility's policy on handling clean equipment and utensils was reviewed, which stated that clean items should be handled to prevent contamination, and dishes should be air-dried and inspected for cleanliness and dryness before use.
Inaccurate Resident Assessments Lead to Deficiencies
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. For one resident, the nursing staff did not code a diagnosis of depression on the resident's annual assessment, despite documentation in the psychiatric initial assessment and reports from the resident's family indicating the resident was experiencing depression. The MDS Coordinator acknowledged the oversight and emphasized the importance of accurately reflecting the resident's status to ensure appropriate care and services. In another case, the nursing staff failed to document that a resident was receiving oxygen therapy on her annual assessment, even though physician orders and the care plan indicated the use of oxygen due to a respiratory illness. Observations confirmed the resident was using oxygen, and the MDS Coordinator admitted the omission in the assessment. This failure to accurately document the resident's status could lead to inadequate care and services being provided.
Failure to Include Side Rails in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical and nursing needs. For one resident, who was admitted with chronic respiratory failure and chronic pulmonary edema, the care plan did not reflect the use of side rails for repositioning and mobility, despite physician orders indicating their use. Observations confirmed the presence of side rails, and interviews with the MDS Coordinator revealed that the omission could lead to staff not monitoring associated risks, potentially resulting in accidents or injuries. Similarly, another resident, admitted for orthopedic aftercare following a surgical amputation, also had physician orders for the use of side rails for mobility and repositioning. However, the care plan failed to document this need. Observations and interviews confirmed the resident's use of side rails, and the MDS Coordinator acknowledged that the care plan should have included this information to ensure staff awareness and risk monitoring. The facility's policy mandates that care plans include measurable objectives and timeframes to address residents' needs, which was not adhered to in these cases.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by the case of a resident who experienced unplanned weight loss. The nursing staff did not follow physician orders to weigh the resident weekly for four weeks, which was crucial for monitoring his nutritional status. Additionally, dietary interventions were not implemented when the resident's weight began to trend downward, despite the resident being identified as at risk for weight loss. The resident, who had been admitted with diagnoses including encephalopathy, respiratory failure, and sepsis, was at risk for nutritional issues due to his medical condition. His nutritional risk evaluation indicated a high risk, necessitating immediate preventive protocols. However, the resident's care plan and progress notes did not reflect adequate monitoring or intervention, as his weight decreased from 129.58 pounds to 124.9 pounds within a short period. The resident's meal intake varied, and there was a lack of communication between the CNA and nursing staff regarding his reduced appetite and meal consumption. Interviews with facility staff revealed systemic issues in communication and protocol adherence. The LVN was unaware of the resident's high risk for weight loss and did not realize the resident's weight was trending down until it was too late. The facility's dietician was not informed of the resident's weight loss in a timely manner, delaying necessary dietary interventions. The DON acknowledged broken systems within the facility, including the failure to audit resident records and discuss significant events like weight loss. The facility's policy required regular weight monitoring and intervention, but these procedures were not followed, leading to the resident's unplanned weight loss.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for two residents, Resident #85 and Resident #95, prior to their installation. Resident #85, who was admitted with chronic respiratory failure and pulmonary edema, had an order for mobility bars to aid in repositioning but lacked an assessment for the use of side rails. There was no documentation indicating that the risks and benefits of using side rails were discussed with the resident, who had no cognitive impairment as per her BIMS score. Interviews with facility staff confirmed the absence of an assessment and discussion regarding the use of side rails. Resident #95, admitted with encephalopathy, respiratory failure, and sepsis, also had an order for mobility bars. His admission MDS assessment indicated moderate cognitive impairment. Observations revealed that he used quarter side rails, but he did not recall any discussion about their use. The facility's Director of Nursing confirmed that staff were required to conduct assessments and discuss the risks and benefits of side rails with residents or their representatives, which was not done in this case. The facility's policy mandates that residents have the right to be free from restraints unless necessary to treat medical symptoms, and requires a physician's order and informed consent for their use. The policy also emphasizes the need for ongoing assessments and documentation of medical symptoms warranting restraint use. The failure to adhere to these procedures could potentially lead to avoidable injuries for residents using side rails.
Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly secured within two of the four medication carts observed for medication storage. Specifically, one unidentified small round white pill was found in the bottom drawer of the medication cart on the 400 hall, and two unidentified small round white pills were found in the top drawer of the medication cart on the 300 hall. These pills were loose, unlabeled, and lacked identifying markers, although the medication carts themselves were locked and secured. Interviews with staff revealed that the Certified Medication Aide (CMA) could not identify the loose pills and stated that facility policy requires staff to dispose of any loose pills found in medication carts. The Director of Nursing (DON) confirmed that medications are to be stored in their original packaging and that CMAs are responsible for checking the carts daily to ensure cleanliness and the absence of loose pills. Despite this, the presence of loose pills in the medication carts was observed, which could potentially lead to residents not receiving their necessary medications as ordered.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, specifically for one employee, Cook D, out of 28 employees reviewed for training requirements. The personnel records for Cook D showed a hire date of December 16, 2023, but the training log provided by the HR Manager revealed no evidence of required annual trainings being completed prior to March 25, 2025. The missing trainings included communication, resident rights, QAPI, infection control, ethics, behavior health, dementia, HIV, falls, restraint, and emergency preparedness training. The last recorded completion of these trainings was in early 2024, indicating a lapse in maintaining the annual training schedule. Interviews with the HR Manager and Administrator revealed that the facility relies on the Relias training program to identify staff needing annual trainings within 30 days. However, Cook D did not appear on any weekly reports generated by the HR Manager, who acknowledged it was his responsibility to run these reports and provide them to department heads. The Administrator confirmed that it is the responsibility of HR and department heads to ensure staff complete their trainings to maintain quality care. The facility's policy on in-service training, dated April 2004, outlines mandatory training topics, but a policy addressing required annual training for specific areas was not provided upon request.
Failure to Provide Mandatory Communication Training
Penalty
Summary
The facility failed to provide mandatory effective communication training for one of its employees, Cook D, as required by their training policy. Cook D was hired on December 16, 2023, and a review of their training log from the previous 15 months showed no evidence of annual communication training being completed prior to March 25, 2025. The last recorded completion of this training was on January 25, 2024. This oversight in training could potentially affect residents by leaving them uninformed due to the lack of staff training. Interviews with the HR Manager and the Administrator revealed that the facility relied on the Relias training program to identify staff who needed to complete annual trainings. The HR Manager was responsible for running weekly reports to identify employees with upcoming training due dates and providing these reports to department heads. However, Cook D did not appear on any of these reports, leading to the missed training. Both the HR Manager and the Administrator acknowledged that failing to train staff annually increased the risk of staff errors, potentially putting residents in harm's way. The facility's policy mandates that all employees attend training on various topics, including communication skills, to ensure quality care is provided.
Failure to Provide Annual Dementia Training
Penalty
Summary
The facility failed to provide mandatory dementia management training to one of its employees, Cook D, as required annually. Cook D was hired on December 16, 2023, and a review of their training log from the previous 15 months showed no evidence of dementia training being provided annually before March 25, 2025. The last recorded dementia training for Cook D was completed on January 26, 2024. This oversight was identified during an interview with the HR Manager, who stated that the facility relied on the Relias training program to identify staff needing annual training within 30 days. However, Cook D did not appear on any of the weekly reports generated by the HR Manager, who acknowledged it was his responsibility to run these reports and provide them to department heads to ensure staff completed their required training. The Administrator confirmed that both HR and the Administrator were responsible for ensuring staff received their annual training. The Administrator also stated that department heads were tasked with ensuring their staff completed the necessary training to maintain quality care. Despite requests, a policy addressing required annual training, including dementia training, was not provided by either the HR Manager or the Administrator before the exit. The lack of training could potentially place residents at risk due to staff being uninformed.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to include mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for one of its employees, Cook D, as part of its annual training requirements. The personnel records for Cook D showed a hire date of December 16, 2023, and a review of the training log for the previous 15 months revealed no evidence of QAPI training being provided annually before March 25, 2025. The last recorded QAPI training for Cook D was completed on January 26, 2024. Interviews with the HR Manager and the Administrator revealed that the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. The HR Manager stated that Cook D did not appear on any of the weekly reports generated to track training compliance. Both the HR Manager and the Administrator acknowledged their responsibility to ensure staff received their annual trainings, emphasizing that failure to do so could increase the likelihood of staff errors and put residents at risk. Despite requests, a policy addressing required annual training, including QAPI training, was not provided by either the HR Manager or the Administrator before the survey exit.
Failure to Provide Annual Infection Control Training
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training to one of its employees, Cook D, as part of its infection prevention and control program. The personnel records for Cook D showed a hire date of December 16, 2023, and a review of the training log for the previous 15 months revealed no evidence of annual infection control training being provided prior to March 25, 2025. The last recorded annual infection control training for Cook D was completed on January 26, 2024. Interviews with the HR Manager and the Administrator revealed that the facility relied on the training program Relias to identify staff who needed to complete annual trainings. The HR Manager stated that Cook D did not appear on any of the weekly reports generated by Relias, which are used to track training compliance. Both the HR Manager and the Administrator acknowledged their responsibility in ensuring staff received their annual trainings, emphasizing that failure to do so could increase the risk of staff performing tasks incorrectly and potentially harming residents.
Failure to Provide Mandatory Ethics Training
Penalty
Summary
The facility failed to provide mandatory ethics training for one of its employees, Cook D, as required annually. The personnel records for Cook D showed a hire date of December 16, 2023, and a review of the training log from the previous 15 months revealed no evidence of ethics training being provided annually prior to March 25, 2025. The last recorded ethics training for Cook D was completed on January 25, 2024. This lapse in training was identified during an interview with the HR Manager, who stated that the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. However, Cook D did not appear on any of the weekly reports generated by Relias, which the HR Manager was responsible for running and distributing to department heads. The HR Manager acknowledged that it was his responsibility to ensure that department heads were informed of staff needing to complete their trainings. The Administrator confirmed that both HR and the Administrator were responsible for ensuring staff received their annual trainings. The Administrator emphasized that staff were required to complete trainings to stay updated on policies and procedures to ensure quality care. Despite requests, a policy addressing required annual training, including ethics training, was not provided by either the HR Manager or the Administrator before the exit interview.
Failure to Provide Required Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training consistent with regulatory requirements and the facility's own assessment for one employee, Cook D, out of 28 employees reviewed. Cook D's personnel records showed a hire date of December 16, 2023, and a training log review revealed that the last annual behavioral health training was completed on January 26, 2024. There was no evidence of the required annual training being provided prior to March 25, 2025. This oversight was identified during an interview with the HR Manager, who acknowledged the reliance on the Relias training program to track and notify staff of upcoming training requirements. The HR Manager admitted that Cook D did not appear on any of the weekly reports generated by Relias, which are used to identify employees needing to complete annual trainings. The HR Manager and the Administrator both stated that it was their responsibility to ensure staff received their annual trainings, and that department heads were responsible for ensuring their staff completed these trainings. Despite requests, a policy addressing required annual training, including behavioral health training, was not provided by either the HR Manager or the Administrator before the survey exit.
Medication Diversion by RN in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically involving the diversion of narcotic pain medications by a registered nurse (RN-B). After a resident was discharged, the facility did not remove the resident's medication blister pack of Hydrocodone/Acetaminophen from the medication cart, which allowed RN-B to divert eight tablets for personal use. This oversight occurred despite the resident being discharged, and the medication continued to be documented as administered by RN-B. Another resident's medication was also misappropriated by RN-B, who diverted five tablets of Hydrocodone/Acetaminophen for personal use. The narcotic count sheets indicated that these medications were signed off by RN-B, but they were not documented on the resident's Medication Administration Record (MAR). The resident, however, did not report any pain or issues with receiving pain medication when needed. The facility's process for handling controlled medications for discharged residents was not followed correctly, as the medications remained in the cart and were not removed by the Director of Nursing (DON) as required. The narcotic counts were conducted at shift changes, but discrepancies were not identified, and the discharged status of the resident was not recognized. This failure in procedure allowed RN-B to continue accessing and diverting the medications without detection until an audit revealed the issue.
Failure to Update Care Plan for Resident with Diarrhea and Skin Breakdown
Penalty
Summary
The facility failed to review and revise the care plan for Resident #4 after a change in her condition, specifically regarding her bowel incontinence and increased risk for skin breakdown. Resident #4, an elderly woman with dementia, pleural effusion, and osteomyelitis, was initially assessed as being at risk for pressure ulcers. Despite this, her care plan was not updated to address the development of diarrhea and a red rash in her peri-area, buttocks, and sacrum. The resident experienced a change in condition with the onset of diarrhea, which was reported by CNAs to the nursing staff. The diarrhea was attributed to antibiotic therapy, and despite the administration of Imodium, the condition persisted. The resident developed a red rash and was in significant discomfort, which was noted by the CNAs and reported to the nursing staff. The NP was aware of the diarrhea and ordered probiotics and a high fiber diet, but was not informed of the pressure ulcer development. The Wound Care Nurse was aware of the moisture-associated skin damage and was treating it with Triad paste, but the care plan was not updated to reflect these acute changes. The Director of Nursing acknowledged that the care plan should have been updated to address the resident's acute changes, but the MDS Nurse responsible for updating care plans was on vacation and unaware of the rapid onset of the resident's condition.
Inadequate Respiratory Care for Resident
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required oxygen therapy, as evidenced by multiple observations and interviews. The resident, who had severe cognitive impairment and a history of metabolic encephalopathy, severe sepsis with septic shock, and pneumonia, was observed with an oxygen saturation level of 83% on room air, which is below the preferred level of 90% or higher. Despite having a physician's order for oxygen therapy at 2-4 liters per minute as needed, the resident was found without oxygen in the dining room and later with an empty oxygen tank in her room. Interviews with the resident's family and staff revealed inconsistencies in the administration of oxygen therapy. The family member reported that the resident was found without oxygen and had a low oxygen saturation level, prompting staff to provide an oxygen tank. A Licensed Vocational Nurse (LVN) acknowledged that the resident's oxygen tank was empty and should have been replaced or the resident should have been connected to the oxygen concentrator upon returning to her room. The LVN admitted to not paying sufficient attention to the oxygen tank levels and stated that oxygen saturation levels were checked only once per shift. The Director of Nursing (DON) and a nurse practitioner confirmed the importance of maintaining oxygen saturation levels above 90% to prevent poor oxygenation and altered mental status. The facility's policy on oxygen administration emphasized the need for oxygen therapy to be administered as ordered by the physician. However, the failure to consistently monitor and manage the resident's oxygen therapy led to inadequate treatment, as evidenced by the resident's low oxygen saturation levels and the use of an empty oxygen tank.
Inaccurate Documentation of PRN Medication Administration
Penalty
Summary
The facility failed to maintain accurate clinical records for a resident regarding the administration of PRN medication, Hydrocodone-Acetaminophen, over five instances in February and March 2024. The medication administration records (MAR) did not reflect the administration of this medication, despite entries on the Narcotic Count Sheet indicating that the medication was given. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who noted that the correct process involves documenting the administration of PRN medication on both the MAR and the Narcotic Count Sheet. The resident involved was a woman with a history of dementia, spinal fractures, and chronic pain, who was prescribed Norco for severe pain. The lack of documentation on the MAR could lead to improper medication administration and hinder accurate tracking of the resident's pain management needs. The DON acknowledged the issue and noted that the problem of inaccurate documentation had been identified previously, leading to the implementation of a new auditing process by the Assistant Directors of Nursing (ADONs).
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, specifically in administering wound care as ordered by the physician. The resident, who was admitted with conditions including atherosclerotic heart disease, high blood pressure, and cognitive communication deficit, had an abrasion on her right elbow that required dressing changes every Monday, Wednesday, and Friday. However, the wound care was not performed as scheduled. On one occasion, the Wound Care Nurse documented that the care was completed before actually performing it, and subsequently forgot to administer the treatment after being unable to locate the resident. This oversight was confirmed through interviews and observations, where it was noted that the bandage on the resident's elbow had not been changed since the date of admission. The Wound Care Nurse admitted to checking off the wound care in the electronic clinical record prematurely and acknowledged forgetting to return to complete the task. The Director of Nursing and the Administrator both recognized the potential harm of not providing wound care as ordered, which could disrupt the healing process and increase the risk of infection.
Inaccurate Wound Care Documentation
Penalty
Summary
The facility failed to maintain accurate clinical records for a resident, specifically regarding wound care documentation. The resident, who was admitted with conditions including atherosclerotic heart disease, high blood pressure, and cognitive communication deficit, had an order for wound care on her right elbow. The treatment administration record inaccurately documented that wound care was completed when it had not been provided. This discrepancy was discovered when the resident was observed with a bandage dated several days prior, indicating the wound care had not been performed as documented. Interviews revealed that the Wound Care Nurse had preemptively marked the wound care as completed in the electronic record before attempting to perform the care. The nurse was unable to find the resident in her room and subsequently forgot to administer the treatment. The Director of Nursing and the Administrator acknowledged the failure to follow the facility's standard of practice, and it was noted that the facility lacked a specific policy on the accuracy of clinical records. The existing guidance from the corporate manual emphasized timely and accurate documentation, which was not adhered to in this instance.
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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