Longmeadow Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Justin, Texas.
- Location
- 120 Meadowview Dr, Justin, Texas 76247
- CMS Provider Number
- 675185
- Inspections on file
- 46
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Longmeadow Healthcare Center during CMS and state inspections, most recent first.
Several residents with cognitive or physical impairments did not receive necessary assistance with nail care, resulting in long, dirty fingernails that were not cleaned or trimmed as required. Staff interviews and observations indicated a lack of consistent monitoring and unclear responsibilities among CNAs and nurses, despite facility policy mandating regular nail care to prevent infection and injury.
The facility did not ensure that food items in the kitchen were properly labeled, dated, or covered, and served hot food below the required holding temperature. Multiple perishable items were found without dates or labels, and a pureed burger was served at 133.7°F, below the required standard. Staff interviews revealed inconsistent knowledge of proper procedures, and facility policies were not followed, affecting all residents receiving meals, including a resident on dialysis.
Staff failed to follow infection control protocols during incontinence and catheter care for two residents, including not changing gloves or performing hand hygiene between dirty and clean tasks, and not donning required PPE for a resident on Enhanced Barrier Precautions. Staff also improperly disposed of used linens and trash, and did not consistently sanitize hands after glove removal, despite being aware of facility policies and procedures.
The facility failed to provide accessible and working call lights in two shower rooms, with one lacking a reachable cord and the other having a nonfunctional call light. Interviews and observations confirmed that staff were responsible for checking and reporting issues, but maintenance checks were infrequent and the Administrator was unaware of the deficiencies until the survey.
A resident who was incontinent of bladder and dependent on staff for personal hygiene did not receive complete perineal care after an incontinent episode. An LVN failed to clean the resident's penis and scrotum as required by facility policy, despite the resident's care plan indicating the need for such care to prevent complications like UTIs and skin breakdown.
A resident with severe cognitive impairment and on hospice care was subjected to verbal abuse by a CNA, as reported by a roommate. The incident was reported internally but the resident's physician and representative were not notified, contrary to facility policy. Staff interviews and record review confirmed the lack of required notifications following the event.
A resident with severe cognitive impairment and on hospice care did not have their care plan reviewed or revised after a CNA was reported to have used inappropriate language while providing care. Although the incident was reported and investigated, the care plan was not updated to address the resident's psychosocial or emotional needs as required by facility policy.
A resident with significant cognitive and physical impairments sustained burns after spilling hot coffee on himself due to the facility's failure to provide a screw-on lid cup and adequate supervision as outlined in his care plan. The resident, who required extensive assistance and supervision, was left unsupervised, leading to the incident.
The facility failed to provide proper respiratory care for four residents by not labeling or dating oxygen supplies and improperly storing nasal cannulas. Staff interviews confirmed these oversights, which posed an infection risk. The facility lacked a formal policy on these procedures.
The facility's kitchen failed to meet professional food safety standards, with issues such as improper storage of ice scoops, unsealed and undated food items, and expired products. Observations included dried residues on containers and lack of visible expiration dates, posing contamination risks. Interviews with staff highlighted the importance of cleanliness and proper dating to ensure food safety.
A resident with mobility issues was found with an inaccessible call light, which is crucial for requesting assistance. Despite staff awareness of the importance of call lights, the resident's call light was not consistently placed within reach, leading to a deficiency. Interviews with staff highlighted the need for accessible call lights, but the facility lacked a specific policy to ensure this.
A resident experienced delays in accessing her trust fund at a facility, sometimes waiting days for money and being required to provide receipts for purchases. The facility limited withdrawals to $75 per month, citing the need to ensure funds for other residents. The Business Office Manager and Administrator confirmed these practices, which contradicted the facility's policy on residents' rights to manage their financial affairs.
The facility failed to ensure a homelike environment for two residents in the secure unit, both with impaired cognitive status and non-Alzheimer's dementia. One resident's room was bare, with only a comforter and baby dolls, while the other lacked decorations and a TV. The facility discouraged personal items due to theft concerns, and the DON was unaware of the residents' desires for a more homelike setting.
The facility failed to develop comprehensive care plans for three residents, including one requiring oxygen administration, another undergoing dialysis, and a third with behavior issues towards female residents. This lack of care planning could lead to inadequate care and safety concerns.
A resident with a G-tube did not receive appropriate care as the facility failed to follow protocols for enteral feeding. Medications were not administered one by one, remnants were left in the medication cup, and the feeding tube was not capped when detached. The syringe used for medication administration was not cleaned after use, increasing the risk of infection. The ADON acknowledged these failures, and the DON confirmed the importance of following the facility's policy.
A facility failed to document necessary physician orders for a resident undergoing dialysis, despite the resident's dependence on the treatment due to end-stage renal disease. The absence of orders, including dialysis type, schedule, and site assessments, was acknowledged by the ADON and DON, who stressed the importance of these orders for effective care. The facility's policy requiring confirmation of dialysis orders was not adhered to.
A facility failed to maintain accurate records for controlled drugs, specifically Fentanyl patches, for a resident with severe cognitive impairment and chronic pain. A box of patches went missing, and staff interviews revealed that the practice of counting medication cards during narcotic counts had been discontinued, contributing to the oversight. The incident was reported, but the alleged perpetrator was not identified.
A resident was administered Paliperidone ER, an antipsychotic medication, without a proper diagnosis of schizophrenia. The resident, who had severe cognitive impairment and a diagnosis of bipolar disorder, was prescribed the medication for schizophrenia related to bipolar disorder, despite not exhibiting schizophrenia symptoms. Facility staff, including the DON, were unaware of the reason for the medication order, and a request for diagnosis clarification was not addressed, violating the facility's policy on psychotropic medications.
Two CNAs failed to adhere to infection control protocols during incontinence care for two residents, leading to potential cross-contamination. One CNA did not wash hands before donning gloves and failed to change gloves after handling soiled briefs. The other CNA initially performed hand hygiene but did not change gloves or sanitize hands after cleaning a resident's buttocks, contaminating various items in the process. Interviews with facility leadership confirmed that these actions violated the facility's infection control policies.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene for four residents who were unable to perform these tasks independently. Observations and interviews revealed that these residents had long, dirty fingernails that had not been cleaned or trimmed as required. In each case, the residents either expressed discomfort with the condition of their nails or were unable to recall when they were last trimmed, and staff were either unaware of the issue or had not addressed it. Resident assessments and care plans indicated that these individuals had significant cognitive or physical impairments, such as hemiplegia, dementia, or other conditions requiring staff assistance with personal hygiene. Despite these documented needs, staff did not ensure that nail care was performed regularly. Interviews with CNAs, nurses, and administrative staff confirmed that there was a lack of consistent monitoring and follow-through regarding nail care, with some staff unaware of their responsibilities or the current condition of the residents' nails. Facility policy required regular nail care to prevent infection and injury, with specific instructions for staff roles based on resident diagnoses such as diabetes. However, observations showed that these policies were not consistently implemented, as evidenced by the presence of long, discolored, and dirty fingernails on multiple residents. Staff interviews further revealed gaps in communication and accountability regarding nail care duties.
Failure to Properly Store and Serve Food According to Professional Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen. During an observation of the facility's reach-in refrigerator, multiple food items were found not dated, labeled, or properly covered. These included a cup of cut mixed fruit, three plates of cut salad, six small cups of white dressing, cheese slices left uncovered and loosely wrapped, and a snack bag with a half sandwich and apple. Staff interviews confirmed that all kitchen personnel were responsible for labeling, dating, and covering food items, but several items were not properly managed, and staff were unsure of their preparation dates or who prepared them. Additionally, the facility failed to ensure that hot food was held at the required temperature during meal service. During lunch service, a pureed burger intended for residents on a pureed texture diet was measured at 133.7°F, below the required holding temperature. Despite this, the food was served to residents. Staff interviews revealed confusion and inconsistency regarding the correct holding temperature, with some staff stating it should be 160°F, others 140°F, and the facility dietitian stating 135°F. The Dietary Manager acknowledged that the food was served below the facility's policy requirement and that it was not reheated due to time constraints. Record reviews of facility policies and the FDA Food Code confirmed the requirements for labeling, dating, and covering food items, as well as maintaining hot food at safe temperatures. Staff interviews consistently indicated awareness of these requirements, but the observed practices did not align with policy or regulatory standards. The deficiencies were observed to potentially affect all residents receiving meals from the facility's kitchen, including a resident on dialysis who received an improperly labeled snack bag.
Failure to Follow Infection Control Protocols During Incontinence and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during incontinence and catheter care for two residents. In the case of one resident with severe cognitive impairment and total dependence for personal hygiene, both an LVN and a CNA performed peri care without changing gloves or performing hand hygiene between dirty and clean tasks. The staff also failed to sanitize their hands after glove removal, and one staff member left the resident's room without performing hand hygiene. Both staff acknowledged during interviews that they did not follow proper procedures, including not bringing hand sanitizer into the room. For another resident with intact cognition and a Foley catheter, a CNA provided catheter and incontinence care without donning the required gown for Enhanced Barrier Precautions (EBP), despite signage and supplies being available outside the room. The CNA changed gloves multiple times without performing hand hygiene and placed used linens and trash bags on the floor, contrary to infection control protocols. The CNA admitted to forgetting to wear the required PPE and recognized the importance of hand hygiene and proper disposal of contaminated materials. Record reviews confirmed that both residents required assistance with personal hygiene and were at risk for infection due to their medical conditions. Facility policies required hand hygiene after glove removal and the use of appropriate PPE for residents on EBP, especially those with indwelling medical devices. Staff interviews further confirmed awareness of the correct procedures, but these were not followed during the observed care activities.
Inaccessible and Nonfunctional Call Lights in Shower Rooms
Penalty
Summary
The facility failed to ensure that resident shower rooms were adequately equipped with functioning call systems. Specifically, in the 100 hall shower room, the call light in the shower area was missing a cord, making it inaccessible to residents. In the 200 hall shower room, the call light in the shower area was not working. These deficiencies were identified through resident interviews, which revealed ongoing complaints about the lack of an accessible call light cord, and through direct observations with facility staff confirming the missing and nonfunctional call lights. Interviews with staff indicated that CNAs and nurses were responsible for checking the functionality of call lights during cleaning and were expected to report issues to maintenance using a QR code system. However, the Maintenance Director was unaware of the nonfunctional call light in the 200 hall shower room until it was brought to his attention during the survey. The facility did not have a specific policy regarding call lights, and maintenance checks of shower rooms occurred infrequently, sometimes as seldom as once a month. The Administrator was not aware of the deficiencies until the survey and expected staff to report maintenance concerns as they arose.
Failure to Provide Complete Perineal Care for Incontinent Resident
Penalty
Summary
A deficiency occurred when a male resident who was incontinent of bladder did not receive appropriate perineal care following an incontinent episode. During an observed care episode, an LVN and a CNA provided peri care to the resident, who was dependent on staff for toileting and personal hygiene due to severe cognitive impairment and impaired mobility. The LVN cleaned the resident's front pubic area but failed to clean the penis and scrotum, which is required per the facility's perineal care policy. The LVN then completed care of the anal area and buttocks, and the resident was assisted with dressing and transferred to a chair. The resident's care plan indicated a need for monitoring and providing incontinent care to prevent complications such as urinary tract infections and skin breakdown. The LVN later confirmed in an interview that she did not clean the scrotum and penis and acknowledged that this was not adequate incontinent care. The facility's policy specifically directs staff to clean the penis and scrotum for male residents during perineal care.
Failure to Notify Physician and Representative After Verbal Abuse Incident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was protected from verbal abuse and that appropriate notifications were made following an incident. A certified nursing assistant (CNA) was reported by a roommate to have loudly used inappropriate language, specifically saying 'shut the fuck up,' while providing care to a resident who was on hospice and had severe cognitive impairment. The incident was overheard by the roommate, who then reported it to the Assistant Director of Nursing (ADON). The resident involved was dependent on staff for most self-care needs, had a BIMS score of 00 indicating severe cognitive impairment, and was unable to communicate effectively due to her condition and hearing impairment. Following the report of the incident, there was no documentation that the resident's attending physician or representative was notified, as required by facility policy. Interviews with staff, including the Director of Nursing (DON), ADON, and a Licensed Vocational Nurse (LVN), confirmed that the incident was reported internally but not communicated to the resident's family or physician. The resident's family member, who visited daily, stated she was not informed of the incident by the facility and only learned of it through the survey process. The social worker was also unaware of any facility report involving the resident. Record review and staff interviews further revealed that the facility's policy required immediate notification of the physician and family in the event of a significant change in status, but this protocol was not followed in this case. The roommate who reported the incident did not observe any changes in the resident's behavior following the event, and there was no documentation of any changes in medication or care. The failure to notify the appropriate parties after the incident constituted a deficiency in protecting the resident from abuse and ensuring proper communication as outlined in facility policy.
Failure to Update Care Plan After Staff-to-Resident Verbal Incident
Penalty
Summary
The facility failed to review and revise the comprehensive, person-centered care plan for a resident after an incident in which a certified nursing assistant (CNA) raised her voice and used inappropriate language while providing care. The incident was reported by the resident's roommate, who overheard the CNA loudly using profane language during care. Despite this report, the resident's care plan was not updated to address the incident or to ensure that the resident's needs were being met in light of the event. The resident involved had significant medical and cognitive impairments, including senile degeneration of the brain, epilepsy, and unspecified psychosis, and was dependent on staff for most self-care needs. The resident was also on hospice care and had a BIMS score indicating severe cognitive impairment. Observations and interviews confirmed that the resident was unable to communicate effectively and relied on staff for emotional, intellectual, physical, and social needs. The care plan in place prior to the incident included general interventions for staff interaction but was not revised following the reported event. Interviews with staff and review of records revealed that although the incident was reported to facility leadership and investigated, there was no documentation of a care plan update or new interventions to address the resident's psychosocial or emotional needs after the incident. The facility's policy required ongoing review and revision of care plans to reflect changes in residents' needs and preferences, but this was not followed in this case.
Failure to Prevent Resident Burn Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, resulting in the resident spilling hot coffee on himself and sustaining burns. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, aphasia, and lack of coordination, required extensive assistance for most activities of daily living and supervision while eating. Despite these needs, the facility did not provide a cup with a screw-on lid as specified in the resident's care plan, nor did they ensure one-person supervision while the resident was eating. On the day of the incident, the resident spilled coffee on himself, which went unwitnessed and unassessed for an undetermined amount of time. The resident sustained burns to his forearm, hip, and waist. The coffee was served in a water cup with a lid, straw, and handle, which the resident had been using since his admission in 2017. The resident reported that the lid fell off when he dropped the cup, leading to the spill. The facility's failure to adhere to the care plan and provide the necessary supervision and equipment directly contributed to the incident. The resident's care plan had identified a risk of burns due to hot liquids, with specific interventions to prevent such injuries. However, these interventions were not followed, as evidenced by the use of an inappropriate cup and lack of supervision. The facility's oversight in implementing the care plan and ensuring the resident's safety measures were in place led to the resident's injury.
Failure to Ensure Proper Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who required oxygen therapy. Specifically, the facility did not ensure that the nasal cannula tubing and humidity bottles for two residents were labeled or dated, which is a part of the nursing protocol to prevent infection. Observations revealed that the oxygen supplies for these residents were not dated or labeled, and interviews with staff confirmed that this was a responsibility of the night shift nurses, as per the facility's protocol. Additionally, the facility did not properly store the nasal cannula for two other residents. Observations showed that the nasal cannulas were not bagged when not in use, which could lead to contamination and infection. Staff interviews indicated that the nasal cannulas should be bagged to maintain cleanliness, but this procedure was not followed, resulting in the nasal cannulas being exposed to potentially unclean surfaces. The Director of Nursing (DON) and other staff members acknowledged the importance of dating, labeling, and properly storing oxygen supplies to prevent infection. However, the facility did not have a formal policy regarding these procedures, which contributed to the oversight. The lack of adherence to these protocols posed a risk of infection to the residents receiving oxygen therapy.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The deficiencies included improper storage of ice machine scoops, with one scoop found inside the ice machine and another placed on a shelf next to it. This improper storage could lead to contamination of the ice. Additionally, several food items in the dry goods pantry were not properly sealed or dated, including opened bags of potato chips, tortillas, cornbread mix, and grits, which were not marked with an opened date. These practices exposed the food to air-borne contaminants and potentially compromised their freshness. Further observations revealed that several containers, such as those holding chocolate syrup, red food coloring, and various sauces, had dried product residue on their lids and sides, which could attract insects and compromise cleanliness. Many of these containers lacked visible expiration or use-by dates, including items like Worcestershire sauce, apple cider vinegar, cooking wine, and pancake syrup. The presence of expired food items, such as jars of sliced pepperoncini peppers, was also noted, which could affect the taste and safety of the food served to residents. Interviews with the Dietary Manager and the Administrator confirmed the importance of maintaining cleanliness and proper dating of food items to ensure safety and freshness. The facility's policy on food storage emphasized the need for orderly maintenance of storage areas, proper sealing and dating of opened packages, and the discarding of expired products. The U.S. FDA Code was also referenced, highlighting the requirement for proper labeling and protection of food from contamination.
Inaccessible Call Light Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light system was accessible, which is a critical component for residents to obtain assistance and communicate their needs. Resident #76, an elderly female with muscle wasting, unsteadiness of feet, and abnormalities of gait, was observed to have her call light hanging on the wall near the privacy curtain, out of her reach. Despite being informed of this, LVN A did not reposition the call light within the resident's reach, leaving the resident unable to call for help. Interviews with staff, including CNA A, ADON B, HA A, and the DON, consistently highlighted the importance of having the call light within reach for residents to communicate their needs and request assistance. CNA A and HA A both took action to place the call light within reach after being informed of its inaccessibility. The staff acknowledged that without the call light, residents might attempt to stand up, risking falls and other injuries, and their needs would not be addressed. The facility's policy on resident rights emphasizes the right to reasonable accommodation of needs and preferences, yet there was no specific policy for ensuring call lights are within reach. The Administrator and DON both recognized the importance of the call light as a lifeline for residents and expressed the expectation that staff should ensure call lights are accessible. However, the lack of a specific policy and consistent monitoring led to the deficiency observed in Resident #76's case.
Failure to Provide Timely Access to Resident Trust Funds
Penalty
Summary
The facility failed to honor a resident's right to manage her financial affairs, specifically regarding access to her trust fund. The resident, who was cognitively intact and had diagnoses including diabetes and cerebral ischemia, reported delays in accessing her funds, sometimes waiting days to receive money. She was also required to provide receipts for purchases made with her own money, which she felt violated her privacy. The facility limited her withdrawals to $75 per month, citing the need to ensure other residents could also access funds. Interviews with the Business Office Manager (BOM) and the Administrator revealed that the facility had a policy of writing checks for amounts over $100, which the resident had difficulty cashing. The BOM confirmed that the facility only kept $500 on hand and replenished it every other day, leading to instances where residents were asked to wait for their funds. The Administrator acknowledged that residents were sometimes asked to wait until staff went to the store to access their money. The facility's policy stated that residents have the right to manage their financial affairs, but the practice of requiring receipts and limiting access to funds contradicted this policy.
Failure to Provide Homelike Environment in Secure Unit
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents residing in the secure unit. Resident #14, a female with severely impaired cognitive status and diagnosed with non-Alzheimer's dementia, was observed to have a room lacking personal effects, with only a comforter and two baby dolls present. A family member reported being discouraged from bringing personal items due to concerns about theft by other residents. Similarly, Resident #40, a female with moderately impaired cognitive status and diagnosed with non-Alzheimer's dementia, was found in a room devoid of decorations, personal effects, or a TV, expressing a desire for decorations. Interviews with the DON and Corporate Nurse revealed a lack of awareness regarding the residents' desires for a more homelike environment. The facility's policy on resident rights allows for personal possessions unless they infringe on others' rights or safety. However, the facility discouraged families from bringing items that might be taken by other residents, as residents often wandered into each other's rooms. The facility did not provide locks on closets, contributing to the issue of personal items being taken.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which could potentially place them at risk of not receiving necessary care and services. Resident #100, a male with cerebral infarction and anemia, was not care planned for oxygen administration despite having a history of acute respiratory failure and ongoing oxygen supplementation. The resident's progress notes indicated multiple instances of low oxygen saturation and the need for oxygen therapy, yet no care plan was in place to address this critical need. Resident #30, a male with end-stage renal disease and acute kidney failure, was undergoing dialysis but did not have a care plan for this treatment. Despite the resident's dependence on dialysis and the presence of a port and fistula for the procedure, the facility failed to document a care plan outlining the goals and interventions necessary for managing his condition. Interviews with staff revealed a lack of awareness and communication regarding the resident's dialysis needs, leading to the oversight in care planning. Resident #49, a male with cerebrovascular disease and dementia, exhibited inappropriate behavior towards female residents, yet there was no care plan to address these behavior concerns. Despite reports from staff and residents about the resident's inappropriate touching, the facility did not document or implement a care plan to manage and monitor his behavior. This lack of documentation and intervention could result in female residents feeling unsafe and violated within the facility.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. The resident, a cognitively intact male with a history of gastrostomy and dysphagia, was observed receiving medications via a G-tube in a manner inconsistent with facility policy. The Assistant Director of Nursing (ADON) prepared and administered the resident's medications by crushing them together and not dissolving them fully before administration, which left remnants in the medication cup. This was contrary to the policy that requires medications to be administered one by one with a flush of water between each. Additionally, the ADON did not cap the feeding formula tubing when it was detached from the G-tube port, allowing it to touch the enteral feeding pump, which could lead to contamination. The syringe used for medication administration was not cleaned after use, which is against the facility's policy that requires syringes to be cleaned after each use to prevent infection. These actions were acknowledged by the ADON during an interview, where she admitted to not following the correct procedures. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered separately unless there is an order for them to be given together. The DON also emphasized the importance of capping the feeding tube to prevent contamination and ensuring medications are fully dissolved to avoid blockages. The Administrator was unaware of the specific procedures for tube feeding but stated that the facility's policy should be followed to meet the medical needs of the residents.
Failure to Document Dialysis Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident undergoing dialysis had the necessary physician orders in place, which is a requirement for providing safe and appropriate dialysis care. The resident, a male with end-stage renal disease and acute kidney failure, was dependent on dialysis. Despite being cognitively intact and aware of his dialysis needs, the resident's records lacked essential orders related to his dialysis treatment. These missing orders included the type and schedule of dialysis, as well as specific instructions for monitoring and assessing the dialysis site, such as checking for bleeding, bruits, and thrills, and weighing the resident before and after dialysis. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that there was an awareness of the missing orders and the importance of having them documented. The ADON acknowledged the absence of orders and emphasized their necessity for assessing the effectiveness of dialysis. The DON confirmed that staff should ensure dialysis orders are entered into the system to guide care. The facility's policy on dialysis care, which outlines the need for reviewing and confirming physician orders, was not followed, leading to this deficiency.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain a system of records for the receipt and disposition of controlled drugs, specifically Fentanyl patches, for a resident. On November 30, 2023, it was discovered that a box of five Fentanyl patches was missing from the narcotic box when a medication aide attempted to change the resident's patch. The narcotic count sheet and the box of patches were not accounted for, leading to a discrepancy in the controlled drug records. Interviews with staff revealed that the facility's practice of counting medication cards during narcotic counts had been discontinued, which contributed to the oversight. The resident involved was an elderly male with severe cognitive impairment and multiple diagnoses, including neurocognitive disorder with Lewy Bodies, Parkinson's disease, and chronic pain. The incident was reported to the medical director, DON, administrator, and police department, but the alleged perpetrator was not identified. The facility's policy required a narcotic audit at each shift change, but the lack of a system to account for medication cards and narcotic count sheets per shift led to the failure in maintaining accurate records.
Inappropriate Use of Antipsychotic Medication Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was administered Paliperidone ER, an antipsychotic medication used to treat schizophrenia and schizoaffective disorder, without an appropriate diagnosis of schizophrenia. The resident's admission MDS assessment indicated severe cognitive impairment and diagnoses of bipolar disorder and non-Alzheimer's disease, but not schizophrenia. Despite this, the resident was prescribed Paliperidone ER for schizophrenia related to bipolar disorder, and there was no care plan addressing the use of this antipsychotic medication. Interviews with facility staff, including LVNs and the DON, revealed that the resident did not exhibit behaviors associated with schizophrenia and primarily displayed wandering behavior. The DON acknowledged the absence of a schizophrenia diagnosis and was unaware of the reason for the medication order specifying schizophrenia. Additionally, the March Pharmacy Consultant Nursing Summary Report had requested clarification of the diagnosis, which was not addressed by the facility. The facility's policy on psychotropic medications mandates that such drugs should only be administered when necessary to treat a specific condition as diagnosed and documented, which was not adhered to in this case.
Infection Control Deficiencies in Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of two CNAs during incontinence care for two residents. The first incident involved a CNA who did not wash hands before donning gloves and failed to change gloves or perform hand hygiene after handling a soiled brief and before applying a clean one. This CNA acknowledged the importance of hand hygiene and glove changes to prevent contamination but did not adhere to these practices. The second incident involved another CNA who performed hand hygiene initially but failed to change gloves or perform hand hygiene after cleaning a resident's buttocks and before applying a clean brief and gown. This CNA also contaminated various items in the resident's room and the hallway with soiled gloves and hands, including the bed controller, call light, and door handles. The CNA admitted to not performing hand hygiene at critical points and recognized the importance of doing so for infection control. Interviews with the ADON, DON, and Administrator confirmed that the facility's policy required staff to perform hand hygiene before and after glove use and when moving from soiled to clean areas during care. The facility's hand hygiene policy and personal care procedures were not followed, leading to potential risks of cross-contamination and infection for the residents involved.
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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