Mcallen Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcallen, Texas.
- Location
- 600 N Cynthia St, Mcallen, Texas 78501
- CMS Provider Number
- 455560
- Inspections on file
- 37
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mcallen Nursing Center during CMS and state inspections, most recent first.
Two residents with significant cognitive and physical impairments had documented falls that were not incorporated into their comprehensive care plans. Although both residents were care planned for fall risk with various interventions, incident reports showed one resident had an unwitnessed fall and another had multiple witnessed falls that were never added or dated in the care plans. The MDS/RN reported that, following corporate direction, staff stopped updating care plans with dated post-fall interventions and instead relied on incident reports, progress notes, post-fall evaluations, neuro checks, and 24-hour reports, while the DON stated that changes were communicated via in-services and incident reports despite policy requiring each fall to be documented and reflected in the care plan.
A resident with multiple chronic conditions did not have the administration of clonazepam and insulin properly documented by two LVNs on several occasions. Although the medications were reportedly given, the MAR lacked required entries, and there was no supporting documentation in progress notes. Both LVNs acknowledged the omission and confirmed the resident did not refuse medications, contrary to facility policy requiring complete and accurate records.
Two residents were not included in care plan meetings and their care plans were not updated to reflect current smoking status or discharge planning, despite completed smoking evaluations and changes in their needs. Staff confirmed that care plans for smoking and discharge were not implemented in a timely manner, contrary to facility policy.
Surveyors found 17 loose, unlabeled tablets and capsules in each of two medication carts, mixed with blister packs for residents' medications. Nursing staff, including an LVN, ADON, and DON, confirmed there was no official policy on how often to clean medication carts, and could not identify the medications or their intended recipients. Facility policy required removal of medications with missing labels, but this was not consistently followed.
Nursing staff failed to consistently and accurately document blood pressure readings prior to administering blood pressure-altering medications to two residents with complex medical conditions, including heart failure and chronic kidney disease. Multiple instances were found where the same blood pressure values were recorded for several administrations in a row, and required documentation was missing from the clinical record. Staff interviews confirmed that blood pressure readings were sometimes copied from previous entries rather than measured at the time of medication administration, contrary to facility policy and physician orders.
Two residents with significant medical conditions did not have their weekly weights consistently obtained and documented as ordered by their physicians, despite care plans specifying this intervention. Staff interviews revealed inconsistencies in the process for weighing and recording, and nursing leadership confirmed that the required weekly weights were not always completed.
A resident with a stage 4 sacral pressure ulcer and a catheter did not receive proper infection control during wound care, as both the WCN and a CNA failed to wear required gowns and did not perform hand hygiene after removing gloves, despite clear orders and facility policy. Both staff acknowledged forgetting the procedures, and the DON confirmed the lapses.
Two residents with cognitive and behavioral impairments were involved in an incident where one physically struck the other on the head. The aggressive resident, who had a history of behavioral issues and was on one-to-one monitoring, was able to assault another resident in the dining room. The incident was not immediately reported or investigated, and facility policy requiring notification of law enforcement was not followed.
A resident with severe cognitive impairment and behavioral issues struck another resident on the head twice. Although the incident was eventually reported to the state agency, it was not reported to local law enforcement as required by policy and regulation. The administrator chose not to notify law enforcement based on the victim's request, despite facility policy and state law mandating immediate reporting of such abuse allegations.
A resident with cognitive impairments eloped from a facility due to inadequate supervision and failure to follow elopement procedures. The resident, assessed as a low elopement risk, left unnoticed and was found by police nearby. Staff in the break room did not hear the alarm, and the facility's elopement protocols were not properly implemented, leading to the incident.
A resident with a history of exit-seeking behavior and cognitive impairment eloped from the facility unnoticed, despite having a wander guard and previous one-to-one supervision. The resident was found at a nearby apartment complex after being out of the facility for approximately 30 minutes. Staff had redirected the resident earlier in the day but failed to maintain adequate supervision, leading to the incident.
A facility failed to implement a comprehensive care plan for a resident, omitting critical elements such as a wander guard, IV antibiotics for a bacterial infection, and interventions for multiple falls. Despite protocols for incidents, these were not reflected in the care plan, leading to a deficiency in addressing the resident's medical and psychosocial needs.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed unlabeled food, personal items in a resident's refrigerator, and expired milk. The Dietary Manager and Administrator acknowledged the issues.
The facility failed to maintain hand sink hot water temperatures at a comfortable level of at least 100 degrees F in several resident rooms, with temperatures ranging from 67.6 degrees F to 86.5 degrees F. Residents confirmed they only had access to cold water, and the Maintenance Supervisor acknowledged the issue, noting that staff had to let the water run for 15 to 20 minutes to achieve the desired temperature. This failure compromised the residents' right to a safe, clean, comfortable, and homelike environment.
The facility failed to maintain safe water temperatures in the women's shower room, with observed temperatures reaching 121.4 degrees F. Staff interviews and record reviews confirmed that the hot water was not properly circulated due to empty halls, and there was no policy in place to ensure safe water temperatures, placing residents at risk of burns.
The facility failed to establish an effective infection prevention and control program, leading to deficiencies in sanitizing equipment between residents and improper incontinent care procedures. Staff interviews confirmed the failure to follow established protocols, increasing the risk of infection.
The facility failed to maintain accurate medical records for a resident with multiple serious health conditions, including missing documentation for post-dialysis weight, PEG site care, anticoagulant monitoring, SpO2 saturation, pain assessment, and infection monitoring over several shifts.
The facility failed to complete initial comprehensive MDS assessments within 14 days of admission for two residents, impacting the development of necessary care plans. The DON and a PRN RN acknowledged the oversight, citing the lack of a permanent MDS Coordinator and time constraints as contributing factors.
The facility failed to develop and implement a comprehensive care plan for a resident administered Keppra for mood disorder and psychotic symptoms. Despite physician orders to monitor and document behavioral episodes and adverse drug events, the care plan did not reflect the use of Keppra. Interviews revealed that the oversight was due to the absence of a permanent MDS Coordinator and shared responsibilities among staff.
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. One resident's oxygen concentrator displayed a warning light, and the nasal cannula was not in place, while another resident received incorrect oxygen levels via a trach mask. Staff interviews revealed a lack of understanding and adherence to oxygen administration protocols.
The facility failed to establish an effective pain management program for a resident with multiple diagnoses, including dementia and a right femur fracture. Staff did not consistently assess or manage the resident's pain, leading to unnecessary discomfort and decreased quality of life. LVNs failed to assess pain levels before administering medication, and the facility's pain management policies were not followed.
The facility failed to maintain a safe environment, with dark discoloration observed on the bathroom ceiling in A Hall and the ceiling in E Hall. Maintenance checks were conducted, but the issues persisted.
The facility failed to ensure a resident's call light was within reach, despite the resident's severe cognitive impairment and functional quadriplegia. Observations and staff interviews confirmed the call light was repeatedly placed out of reach, contrary to the resident's care plan and facility policy.
The facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for two of the three days reviewed. The daily staffing forms for 2/27/24 and 2/28/24 were not posted in a prominent location and lacked census information. The DON and ADON acknowledged the omissions, and the Administrator confirmed the absence of a policy related to staff posting.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were periodically reviewed and revised by a team of qualified persons after each assessment and after falls, as required. For one resident with Alzheimer’s disease, dementia, muscle weakness, reduced mobility, joint stiffness, and bone density disorder, the comprehensive care plan identified fall risk and included multiple fall-related interventions with various initiation and revision dates. However, facility incident/accident reports showed this resident sustained an unwitnessed fall on 11/27/2025 that was not reflected or updated in the resident’s care plan. A second resident, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contractures, muscle weakness, lack of coordination, dementia, and mood disorder, also had a care plan identifying fall risk related to CVA, dementia, and right-sided weakness. The care plan contained general fall-prevention interventions and showed an initial date and a revision date. Review of the facility’s incident/accident reports revealed that this resident experienced three witnessed falls on 11/14/2025, 12/16/2025, and 12/30/2025, none of which were reflected or updated in the resident’s care plan. In interviews, the MDS/RN stated that, per direction from a corporate consultant, care plans were no longer updated with dated interventions after each fall, and that staff instead relied on incident reports, progress notes, post-fall evaluations, neuro check forms, the 24-hour report, and previous progress notes for information on interventions and updates. The MDS/RN reported that care plan reviews were done quarterly, annually, and with significant changes in condition, and that dated interventions were not routinely added after each fall, especially when there was no injury or significant change. The DON stated that staff learned of changes to interventions through in-services and incident reports and that care plans were updated when incidents occurred or as needed, but acknowledged, after hearing the facility’s Fall Management System policy, that each fall should be documented, reviewed, and reflected with dates and interventions in the care plan.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, two LVNs did not document the administration of prescribed clonazepam and insulin on multiple occasions, as evidenced by missing check-offs on the Medication Administration Record (MAR) for several dates. There was no documentation in the progress notes to indicate whether the medications were administered, held, or refused on those dates. The resident involved was an adult male with multiple diagnoses, including Parkinson's disease, type 2 diabetes, intellectual disabilities, autistic disorder, anxiety disorder, and depression. Physician orders required the administration of clonazepam three times daily for anxiety and insulin as per a sliding scale for diabetes. Review of the MAR for the relevant month showed that doses of both medications were not documented as given at several scheduled times. Interviews with the LVNs responsible revealed that they administered the medications as ordered but failed to document the administration on the MAR, attributing the omission to forgetfulness. Both LVNs acknowledged their responsibility to ensure accurate documentation and confirmed that the resident did not refuse medications and was not out of the facility. The facility's policies required documentation of all administered medications and specific procedures for documenting refusals, which were not followed in these instances.
Failure to Update and Involve Residents in Care Planning for Smoking and Discharge
Penalty
Summary
The facility failed to ensure that each resident and/or their representative, as well as the interdisciplinary team (IDT), were invited to participate in care plan meetings for both comprehensive and quarterly review assessments. Specifically, two residents were not included in these meetings as required. Additionally, the care plans for these residents were not revised in a timely manner to accurately reflect their current smoking status, despite both having completed smoking evaluations indicating they were independent and safe smokers. For one resident, the care plan did not include any information about smoking, even though a smoking evaluation had been completed and indicated the resident had recently started smoking. The other resident's care plan also lacked documentation of smoking status and did not address discharge planning, despite the resident having a completed smoking evaluation and being admitted for several months. Both residents' Minimum Data Set (MDS) assessments did not reflect tobacco use or smoking, and their care plans were not updated to include this information until much later. Interviews with facility staff, including the MDS coordinator, DON, and administrator, confirmed that the care plans for smoking were not implemented until after the residents had already begun smoking. Staff acknowledged that discharge planning should have been included in the care plan for one resident but was not. The facility's policy requires comprehensive, person-centered care plans that address all identified needs, but this was not followed in these cases.
Loose and Unlabeled Medications Found in Medication Carts
Penalty
Summary
Surveyors observed that two medication carts, one on B-hall and one on D/E-halls, contained 17 assorted loose tablets and capsules each, stored in the same drawers as blister packs for residents' medications. These loose medications were not labeled, and staff could not determine which residents they belonged to or how long they had been in the carts. The facility's policy required routine inspection and removal of medications with missing labels, but this was not consistently followed. Interviews with nursing staff, including an LVN, the ADON, and the DON, revealed that there was no official policy on how often medication carts should be cleaned, and each nurse was responsible for their own cart. Staff stated that loose medications should be disposed of properly, but there was no documentation or evidence that this was being done regularly. The staff were unable to identify the medications or their intended recipients, and acknowledged that the presence of loose medications could result in residents losing their prescribed doses.
Failure to Accurately Document Blood Pressure Prior to Administration of BP-Altering Medications
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents who were receiving blood pressure-altering medications. Licensed vocational nurses (LVNs) did not consistently document blood pressure readings as required by physician orders and facility policy prior to administering medications such as amiodarone, hydralazine, metoprolol, midodrine, and amlodipine. In multiple instances, the same blood pressure readings were documented for several medication administrations in a row, which is not consistent with normal physiological variation and suggests that actual measurements may not have been taken each time. For one resident with diagnoses including chronic heart failure, hypertension, hypotension, and end-stage renal disease, LVNs failed to correctly document blood pressure readings on numerous occasions when administering medications that required such monitoring. The electronic medication administration record (eMAR) often showed repeated or identical blood pressure values for different times and dates, and in some cases, there were no corresponding entries in the blood pressure summary. Interviews with staff revealed that at times, blood pressure values were copied from previous entries if the nurse misplaced the original documentation, rather than being measured and recorded at the time of medication administration. Another resident with hypertension and chronic kidney disease also had repeated blood pressure values documented for consecutive days when receiving antihypertensive medication, with missing entries in the blood pressure summary. Staff interviews confirmed that the practice of documenting without actual measurement occurred, and that this was not in accordance with facility policy or physician orders. The facility's own guidelines required blood pressure to be checked and documented immediately prior to administration of such medications, but this was not consistently followed.
Failure to Implement Comprehensive Care Plans for Weekly Weights
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included measurable objectives and timeframes to meet the medical, nursing, mental, and psychosocial needs of two residents. Specifically, the care plans for both residents did not ensure that weekly weights, as ordered by their physicians, were consistently obtained and documented. For one resident with morbid obesity and chronic systolic heart failure, the care plan included a goal to maintain stable weight and interventions to provide a specific diet, but there was no evidence of weekly weights being recorded between two documented dates over a month apart. For another resident with mild protein-calorie malnutrition and dementia, the care plan addressed unplanned weight loss and included interventions such as weekly weights and monitoring for further weight loss. However, weight records showed that weekly weights were not consistently documented, with a gap of over a month between recorded weights. Both residents had active physician orders for weekly weights, but the facility did not ensure these orders were followed. Interviews with staff revealed inconsistencies in the process for weighing residents, with some CNAs stating they always weighed residents as required, while others described weighing residents monthly or passing information between shifts if weights were missed. Nursing leadership acknowledged that residents were not being weighed as ordered and described the process for assigning and recording weights, but the documentation did not support that weekly weights were consistently obtained as required by the care plans and physician orders.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for a resident requiring enhanced barrier precautions due to a stage 4 sacral pressure ulcer and the presence of a catheter. During wound care, both the wound care nurse (WCN) and a certified nursing assistant (CNA) did not wear the required personal protective equipment (PPE), specifically gowns, despite clear physician orders and signage indicating the need for enhanced barrier precautions. Both staff members also failed to perform hand hygiene after removing gloves during the procedure, contrary to facility policy and established infection control protocols. The resident involved had significant medical conditions, including a stage 4 pressure ulcer, hypertension, and type 2 diabetes, and required daily wound care with specific instructions for PPE use. Interviews with the WCN and CNA revealed that both were aware of the correct procedures but forgot to follow them during the observed wound care. The Director of Nursing confirmed that the staff should have worn gowns and performed hand hygiene as required by the facility's infection control policy, which was last reviewed in a recent in-service.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. One resident, who had a history of moderate cognitive impairment, dementia, and muscle weakness, was struck twice on the head by another resident with severe cognitive impairment, behavioral symptoms, and a history of aggression. The incident occurred in the dining room as the aggressive resident was being escorted in a wheelchair and began swinging her arms, making contact with the other resident. The assaulted resident initially denied being hit but later admitted to the incident during the investigation, stating he did not want to report it due to fear of escalation and concerns about his probation status. The aggressive resident had documented behavioral issues, including hallucinations, delusions, and a pattern of physical and verbal aggression toward others. She was already on one-to-one monitoring and awaiting transfer to a psychiatric hospital due to her escalating behaviors. Despite these interventions, the resident was able to physically assault another resident. Staff present during the incident did not immediately report the event, and the facility's investigation was only initiated after a witness reported the incident two days later. No injuries were found on assessment, but the delay in reporting and investigation was evident. The facility's policies required prevention, investigation, and reporting of abuse, neglect, and exploitation. However, the incident was not reported to law enforcement as required by policy, and there was a lack of immediate documentation and witness statements. The failure to promptly identify, report, and investigate the abuse incident, as well as to protect the resident from ongoing verbal abuse, constituted a deficiency in ensuring residents' rights to be free from abuse and neglect.
Failure to Timely Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, to the administrator and appropriate authorities, including local law enforcement. Specifically, an incident occurred in which a female resident with severe cognitive impairment and behavioral issues struck a male resident on the head twice. The male resident initially denied the incident but later admitted to being hit during the facility's investigation. The incident was not reported to local law enforcement as required by facility policy and state regulations. The male resident involved had a history of moderate cognitive impairment, dementia, and physical limitations, requiring assistance with activities of daily living. The female resident had severe cognitive impairment, hallucinations, delusions, and a documented history of aggressive behaviors. At the time of the incident, she was on one-to-one supervision and awaiting transfer to a psychiatric hospital due to escalating behavioral symptoms. The incident was eventually reported to the state agency, but not to local law enforcement, based on the male resident's expressed fear of legal repercussions due to his probation status. Interviews with facility staff, including the DON and Administrator, confirmed that the administrator was made aware of the incident two days after it occurred and initiated an investigation at that time. Both the DON and Administrator acknowledged that the facility's policy required reporting such incidents to both state and local authorities, but the administrator chose not to notify law enforcement, citing the resident's and his family's request. The facility's own policy and state law mandate immediate reporting of abuse allegations to all appropriate authorities, which was not followed in this case.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident, leading to an elopement incident. The resident, who had a history of Alzheimer's, Bipolar Disorder, PTSD, Major Depressive Disorder, and Unspecified Dementia, was moderately cognitively impaired but functionally independent. Despite being assessed as a low elopement risk, the resident managed to leave the facility unnoticed and was found by police approximately 0.2 miles away. On the night of the incident, the resident was last seen in his room at 11:15 p.m. but was discovered missing at 12:30 a.m. The staff, including CNAs and LVNs, were in the break room and did not hear the alarm when the resident exited through the front door. The alarm was turned off without confirming the resident's whereabouts, and a code silver was initiated only after the resident was found missing. Interviews with staff revealed a lack of awareness and implementation of the facility's elopement procedures. The facility's policy required staff to respond promptly to alarms and to follow systematic procedures for monitoring residents at risk of elopement. However, the staff's failure to adhere to these protocols resulted in the resident's unsupervised departure. The incident highlighted gaps in staff training and awareness regarding the facility's elopement procedures, as not all staff were informed or responsive to the alarms and the necessary protocols for managing such situations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was at risk of elopement. The resident, who had a history of exit-seeking behavior and cognitive impairment, managed to leave the facility unnoticed and was found at a nearby apartment complex. The resident's care plan indicated a risk for wandering and exit-seeking, and interventions such as a wander guard and redirection were in place. However, these measures were insufficient to prevent the elopement. On the day of the incident, the resident was seen attempting to exit the facility, triggering the door alarm. Staff redirected the resident to his room, but he later eloped through a window. The resident was out of the facility for approximately 30 minutes before staff became aware of his absence. Interviews with staff revealed that the resident had been taken off one-to-one supervision the day before the incident, despite ongoing exit-seeking behaviors. The resident's medical history included moderate cognitive impairment, mood disorder, and dementia, which contributed to his exit-seeking behavior. Despite the use of a wander guard and previous one-to-one supervision, the facility's failure to maintain adequate supervision and implement additional interventions led to the resident's elopement. Staff interviews indicated that while they were aware of the resident's behaviors, the existing protocols and supervision were not sufficient to prevent the incident.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. The care plan did not reflect the use of a wander guard, the administration of IV antibiotics for a bacterial infection, or the falls experienced by the resident on three separate occasions. This oversight could potentially place residents at risk of not receiving the necessary care and services as indicated in their comprehensive care plans. The resident in question was an elderly male with multiple diagnoses, including type 2 diabetes, hepatic encephalopathy, mood disorder, unspecified psychosis, hypertension, dementia with behavioral disturbances, alcohol abuse in remission, muscle weakness, lack of coordination, and cognitive communication deficit. The resident had a moderate cognitive impairment and required supervision for bed mobility and transfers. Despite these needs, the care plan did not adequately document the interventions and precautions necessary to address the resident's condition and incidents. Interviews with various staff members, including LVNs, RNs, the MDS Nurse, the ADON, and the DON, revealed inconsistencies and a lack of clarity regarding the responsibility for updating the care plan. Although the facility had protocols in place for falls and other incidents, these were not consistently reflected in the care plan. The staff acknowledged that the care plan should have included the wander guard, the IV antibiotics, and the interventions for each fall, but these were not documented, leading to a deficiency in the resident's care plan.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety. During an observation of the kitchen, it was found that refrigerator #1 contained a plastic container with beans that was not labeled, a personal 4 fl. oz. bottle of water, and an open 2-liter plastic bottle belonging to staff. Additionally, refrigerator #2 contained two gallons of expired milk. These issues were identified during a kitchen inspection at 10:15 a.m. on the specified date. In an interview, the Dietary Manager acknowledged the expired milk and unlabeled beans, stating that the kitchen staff knew the milk was expired but failed to discard it. The Dietary Manager also mentioned that she conducts quarterly or as-needed in-services regarding labeling and dating. The Administrator confirmed that the Dietary Manager had informed her of the issues and that all food items had been discarded. The facility's policy on Frozen and Refrigerated Foods Storage requires proper labeling of cooked foods, including the date placed in the refrigerator and an expiration or use-by date.
Failure to Maintain Adequate Hot Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment by not maintaining the hand sink hot water temperatures at a comfortable level of at least 100 degrees F. Observations revealed that the water temperatures in several resident rooms were significantly below the required temperature, with readings ranging from 67.6 degrees F to 86.5 degrees F. The Maintenance Supervisor acknowledged that the water heater used for both halls E and F took time to flow hot water to the back rooms, and staff had to let the water run for 15 to 20 minutes to achieve the desired temperature. However, it was noted that residents did not typically allow the water to run for that long, resulting in them only having access to cold water. Despite the Maintenance Supervisor's weekly log showing higher temperatures, these were taken after letting the water run for an extended period, which was not reflective of the residents' actual experience. Interviews with residents confirmed that they did not have warm or hot water when using their hand sinks and always received cold water. The Maintenance Supervisor admitted to testing random rooms and letting the water run for several minutes before taking temperature readings. He also mentioned the need for circulating pumps to draw hot water faster to the end rooms. The Administrator stated that staff would notify the Maintenance Supervisor to adjust the water heater valves when temperatures were not within the required range. However, the lack of immediate access to warm or hot water placed residents at risk of not having a comfortable and homelike environment.
Unsafe Water Temperature in Women's Shower Room
Penalty
Summary
The facility failed to maintain water temperatures at a safe level in the women's shower room, which could place residents at risk of injuries and burns. During an observation, the hot water temperature in the women's shower room was found to be 121.4 degrees F, exceeding the safe maximum of 110 degrees F. The Maintenance Supervisor acknowledged that the water heater in the B hall, which also served the C hall, was not circulating hot water properly due to the lack of residents in these halls, causing the water temperature to stay hot. The Logbook Documentation from earlier in the month showed a recorded temperature of 107.6 degrees F, indicating that the issue was not consistently monitored or addressed. The Administrator confirmed that there was no policy for water temperatures and that the Maintenance Supervisor was responsible for ensuring safe water temperatures. Interviews with staff, including a CNA and the DON, revealed that the hot water in the women's shower room would be instantly hot when turned on, and cold water was used to bring it to a comfortable temperature for residents. The CNA mentioned that some residents did not want assistance with their showers, but she would stay in the shower room with them. The DON reiterated that the water temperature should not exceed 110 degrees F to prevent the risk of skin burns. The deficiency was observed and confirmed through multiple interviews and record reviews, highlighting a lapse in maintaining a safe environment for residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, leading to multiple deficiencies. During medication administration, an LVN did not sanitize the blood pressure cuff between uses for three residents. This was observed during med pass sessions, where the LVN completed hand hygiene but neglected to disinfect the blood pressure cuff before and after use on each resident. Interviews with the LVN and other staff confirmed that the protocol requires sanitizing equipment between residents, and failure to do so could lead to infection control issues. The LVN admitted to not following the protocol and was unsure of the last time she attended an infection control in-service. Additionally, during incontinent care for a resident, a CNA failed to use appropriate cleaning procedures. The CNA used a wipe more than once to clean the resident's buttocks, which is against the protocol of using one wipe per swipe and disposing of it immediately. This improper technique was observed during an incontinent care session, and the CNA admitted to remembering this incorrect method from school. Interviews with other staff members, including another CNA and the ADON, confirmed that the correct procedure involves using one wipe per swipe to prevent contamination and infection. The facility's infection control guidelines and incontinence care procedures were reviewed, revealing that the staff did not adhere to established protocols designed to prevent the spread of infections. The guidelines clearly state the need for disinfecting reusable equipment and using proper techniques during incontinent care. The failure to follow these protocols was acknowledged by multiple staff members, including the DON, who emphasized the importance of these measures in preventing infection control issues.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for one resident. Specifically, the facility did not accurately document various critical health metrics for a resident with multiple serious health conditions, including dementia, type 2 diabetes mellitus, end-stage renal disease, and myocardial infarction. The resident's post-dialysis weight, PEG site care, anticoagulant monitoring, SpO2 saturation, pain assessment, and monitoring for signs of infection were not accurately recorded in the Medication Administration Record (MAR) on multiple shifts over several days. The report details that the resident's post-dialysis weight was not documented on the MAR for a specific date, which is crucial for monitoring potential fluid overload. Additionally, PEG site care was not recorded for one shift, and anticoagulant monitoring was missing for several shifts, which is essential for tracking potential adverse drug events. The resident's SpO2 saturation, pain assessment, and monitoring for signs of infection were also not documented for multiple shifts, which are critical for ensuring the resident's overall health and well-being. Interviews with facility staff, including an LVN, ADON, and DON, revealed that the failure to document these critical health metrics could lead to serious health risks for the resident, such as fluid overload and missed side effects of medications. The facility's policy on medication and treatment administration emphasizes the importance of accurate and timely documentation, yet these procedures were not followed, leading to the identified deficiencies.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete an initial comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity for two residents reviewed for comprehensive MDS assessment timing. Specifically, the facility did not complete the Admission MDS assessment within 14 days of admission for two residents. This failure was identified through record reviews and interviews with staff members, including the Director of Nursing (DON) and a PRN RN, who acknowledged the oversight and attributed it to the lack of a permanent MDS Coordinator since January 2024. The DON admitted that the assessments should have been completed within the required timeframe to ensure accurate information for developing care plans. Resident #14, who was admitted with diagnoses including Alzheimer's disease, mood disorder, delusional disorders, major depressive disorder, anxiety disorder, insomnia, and cognitive communication deficit, had an incomplete admission MDS assessment dated 02/13/2024. Similarly, Resident #275, admitted with diagnoses including diabetes, insomnia, schizophrenia, major depressive disorder, dementia, and cognitive communication deficit, also had an incomplete admission MDS assessment dated 02/14/2024. Interviews with the DON and RN F revealed that the assessments were not completed due to time constraints, which hindered the development of necessary care plans to address the residents' needs.
Failure to Develop Comprehensive Care Plan for Resident on Keppra
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #14, who was administered the medication Keppra for behaviors related to mood disorder and psychotic symptoms. Despite the physician's order to monitor the resident for episodes of anger, yelling, and delusions, and to document the interventions and outcomes, the care plan did not reflect the use of Keppra. This oversight was confirmed through record reviews and interviews with the Director of Nursing (DON), Licensed Vocational Nurse (LVN), and Registered Nurse (RN) responsible for care plans. The absence of a care plan for the use of Keppra meant that the resident's care was not individualized to address her specific needs related to the medication's administration and monitoring for adverse drug events (ADEs). Resident #14 had a history of severe cognitive impairment, Alzheimer's disease, mood disorder, delusional disorders, major depressive disorder, anxiety disorder, insomnia, and cognitive communication deficit. The resident's admission records and physician orders indicated the need for Keppra to manage her behavioral symptoms. However, the care plan only included general interventions for behavior problems without specific details on the use of Keppra. Interviews revealed that the facility had not had a permanent MDS Coordinator since January 2024, and the responsibility for updating care plans was shared among the DON, Assistant Director of Nursing (ADON), and RN. The RN admitted to overlooking the development of a care plan for Keppra, and the DON acknowledged that this failure did not provide individualized care for the resident.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. Resident #299's oxygen concentrator displayed a red warning light indicating a low oxygen flow rate or concentration. Despite the warning, the resident's nasal cannula was not in place, and the staff did not notice the issue during their rounds. The resident's oxygen saturation was checked and found to be within normal limits, but the oxygen concentrator was not immediately replaced, indicating a lapse in monitoring and equipment maintenance. Interviews with the staff revealed a lack of understanding of the warning light's significance and the necessary actions to address it promptly. Resident #177's oxygen was administered at 4.5 Lpm instead of the physician-ordered 5 Lpm via a trach mask. Observations showed that the oxygen setting was incorrect, and staff interviews confirmed that the oxygen levels were not set according to the physician's order. The staff demonstrated a misunderstanding of how to correctly set the oxygen levels, which could lead to insufficient oxygen delivery to the resident. The facility's policies on oxygen administration and safety were not adequately followed, as evidenced by the incorrect oxygen settings and the lack of proper equipment checks. Both residents had significant medical histories, including chronic respiratory conditions and cognitive impairments, which necessitated careful monitoring and adherence to prescribed oxygen levels. The deficiencies in oxygen administration and equipment maintenance could have led to serious respiratory complications for the residents. The staff's lack of knowledge and failure to follow established protocols contributed to the deficiencies observed during the survey.
Failure to Adequately Assess and Manage Pain for Resident
Penalty
Summary
The facility failed to establish an effective pain management program for Resident #9, who had multiple diagnoses including dementia, type 2 diabetes mellitus, hypertension, and pain in unspecified joints and the right knee. The resident was also suffering from a displaced subcapital fracture of the right femur and had a history of osteopenia, osteoarthrosis, osteoporosis, and degenerative arthritis. Despite these conditions, the facility did not adequately assess or manage the resident's pain, leading to unnecessary discomfort and decreased quality of life for the resident. One significant issue was that LVN B did not assess Resident #9's pain level before administering PRN pain medication. During a medication pass observation, Resident #9 complained of severe pain, rating it as 9 or 10 out of 10. However, LVN B administered acetaminophen-codeine without assessing the pain level. This failure to assess pain was confirmed in an interview where LVN B admitted to forgetting to ask due to nervousness from being observed by surveyors. Additionally, other staff members, including LVN C, also failed to properly assess and manage the resident's pain, as evidenced by an incident where regular Tylenol was given despite the resident's pain being at a level of 10 out of 10. Interviews with various staff members, including the ADON, DON, and other LVNs, revealed a lack of consistent practice in assessing and managing pain. Staff members acknowledged the importance of assessing pain levels and following up on the effectiveness of pain medication, but these practices were not consistently followed. The facility's pain management policies were not adhered to, resulting in Resident #9 experiencing ongoing severe pain without adequate relief. This deficiency highlights a significant lapse in the facility's pain management protocols and the need for better adherence to established procedures to ensure residents' well-being.
Ceiling Discoloration in Hallways
Penalty
Summary
The facility failed to provide a safe and functional environment for residents, staff, and the public in two of four hallways observed for environmental conditions. Specifically, the bathroom ceiling on A Hall and the ceiling in E Hall were found to have dark discoloration. Observations revealed multiple discolorations, including light brownish-yellow and black stains, with a smeared substance over some of the black discolorations. Interviews with the ADON and DON confirmed that maintenance checks for stains and issues with ceilings were conducted, but the discolorations were still present during the survey.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide services with reasonable accommodation of resident needs and preferences for one resident. Specifically, the staff did not ensure that the call light for a resident on hospice care was within reach. This resident, who had severe cognitive impairment, functional quadriplegia, and other significant medical conditions, was observed on multiple occasions with the call light placed out of reach. Interviews with various staff members, including an LVN, CNA, ADON, and DON, confirmed that the call light should be within reach of the resident to ensure they can call for assistance when needed. However, the call light was repeatedly found on the upper left-hand side of the resident's pillow, making it inaccessible. The resident's comprehensive care plan explicitly stated that the call light should be within reach to prevent falls and ensure timely assistance. Despite this, observations and staff interviews revealed a consistent failure to adhere to this requirement. The facility's policy on call light response also mandated that staff ensure the call light is within reach during each interaction with the resident. The failure to comply with this policy and the care plan placed the resident at risk of not having their needs met in a timely manner.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for two of the three days reviewed. Specifically, on 2/27/24 and 2/28/24, the daily staffing information was not posted in a prominent location, and the forms did not include the census. During a tour on 2/27/24, the Surveyor could not locate the daily staff form, and the Director of Nursing (DON) later showed the Surveyor that the form was in a binder tilted sideways in a basket in the hallway by the Administrator's office. The DON admitted that the form should be filled out completely and posted prominently but could not confirm if it was visible to residents or visitors in its current location. On 2/28/24, the DON stated that the staffing form is completed daily by herself, the Assistant Director of Nursing (ADON), or the night staff, but she could not ensure its visibility to residents or visitors. Record review revealed that the forms for 2/27/24 and 2/28/24 lacked census information. The ADON, who filled out the forms for those days, acknowledged the omission but could not explain why the census was not included. The Administrator confirmed that the daily staffing sheet should be posted every day, including weekends, but admitted there was no policy related to staff posting.
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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