Meridian Care Monte Vista
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 616 W Russell Pl, San Antonio, Texas 78212
- CMS Provider Number
- 455450
- Inspections on file
- 38
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 22 (2 serious)
Citation history
Health deficiencies cited at Meridian Care Monte Vista during CMS and state inspections, most recent first.
A resident with ALS, a tracheostomy, and a documented OOH DNR and DNR physician orders was found unresponsive by a CNA, who notified an LVN. After assessment by two LVNs revealed loss of pulse and respirations, a Code Blue was called, and RT staff initiated suctioning and ambu-bag ventilation while an LVN performed chest compressions. Staff were unsure of the resident’s code status, relied on an outdated crash cart binder that contained incorrect DNR information, and continued resuscitation while the LVN searched the EMR for verification. EMS arrived, continued CPR, and obtained a pulse before being informed by the LVN that the resident was actually a DNR, despite existing documentation and the responsible party’s prior completion of DNR forms. The facility lacked a specific policy for Out-of-Hospital DNRs, relying only on a general resident rights policy regarding refusal of treatment.
The facility did not update its Emergency Preparedness Plan annually, failed to correct a persistent fire alarm system trouble signal, and allowed overgrown vegetation and dead branches to accumulate near the building, including the smoking area. The Administrator was unaware of the annual review requirement for the emergency plan, and the Maintenance Director acknowledged ongoing issues with the fire alarm and grounds maintenance.
The facility did not report multiple allegations of abuse, neglect, or mistreatment involving four residents, including emotional distress, neglect of a G-tube dressing, rough incontinent care, and verbal abuse. These incidents were documented in grievance reports but were not reported to the state agency as required, despite residents having significant cognitive and physical impairments.
The facility did not thoroughly investigate or report multiple allegations of abuse, neglect, or mistreatment involving four residents, including incidents of poor treatment, neglect of care, rough handling, and verbal abuse. Despite documentation of grievances and internal discussions among leadership, required reporting to the state agency was not completed, and there was no evidence that further potential harm was prevented during the investigation process.
Medication carts containing drugs, including narcotics, were left unattended and unlocked in two separate hallways for several minutes, with staff unable to account for the responsible personnel. Facility policy requires carts to be locked when not attended, but in both instances, the carts were accessible to unauthorized individuals while residents and CNAs were present in the area.
A resident with complex medical needs, including a sacral pressure injury, did not have daily wound care consistently documented in the treatment administration record as required by physician orders and facility policy. Several dates lacked evidence of wound care being provided, and staff interviews confirmed the expectation for timely documentation. The resident's representative also reported inconsistent care and had to provide dressings personally.
A resident with intact cognition and multiple chronic conditions was repeatedly told by staff that his family member would be called if he refused to change clothes, a practice used to gain compliance with care. This approach, which was included in the care plan at the family member's request, made the resident feel threatened and sad, and was acknowledged by the DON and administrator as a violation of the resident's rights to self-determination and choice.
Two residents' rights were not protected when an LVN diverted Norco pain medication by being the sole staff member to call in refills and receive pharmacy deliveries, bypassing required verification procedures. Audits later revealed missing medication cards, and staff interviews confirmed that established protocols for receiving and securing narcotics were not consistently followed.
A resident with complex medical needs was discharged to a hospital without the facility sending the required discharge notice to the state LTC ombudsman. Interviews with the ombudsman, SW, DON, and administrator confirmed that no notification was made, and the facility's records did not contain evidence of such notice.
A facility exceeded the acceptable medication error rate with a 7.69% error rate due to late administration of medications to a resident with GERD and constipation. A new RN administered carafate and enulose over an hour late, citing unfamiliarity with the residents and procedures. The facility's policy mandates timely medication administration to ensure therapeutic effectiveness.
The facility's kitchen failed to meet food service safety standards by improperly storing plastic containers without air-drying, inadequately labeling and dating chopped beef brisket in the cooler, and failing to properly label and seal French fries in the freezer. These actions could lead to foodborne illness due to bacterial growth and deterioration in food quality.
A resident with severe cognitive impairment and multiple medical conditions was left exposed during catheter care when two CNAs failed to fully close the privacy curtain. The incident was observed by surveyors, and the CNAs admitted the oversight. The facility's DON confirmed that privacy should have been maintained, and staff had received training on resident rights.
A resident with a cognitive communication deficit did not have their needs fully addressed in their care plan, as required by facility policy. Despite having a history of hemiplegia, hemiparesis, major depressive disorder, and aphasia, the care plan lacked a focus on communication needs. Staff interviews confirmed the omission, and the resident used a communication card not documented in the care plan.
A resident with severe cognitive impairment and legal blindness was found to have hazardous cleaning supplies in their bathroom, posing a risk of contact with dangerous substances. Facility staff confirmed the presence of these materials, which were not supposed to be in resident rooms, as per facility policy.
A resident with a history of cancer, diabetes, and dementia displayed signs of depression and isolation but was not referred to mental health services, despite multiple documented reports of these symptoms. The facility's policy required providing behavioral health services to maintain residents' well-being, which was not followed.
A medication cart was left unlocked by an RN during medication administration, contrary to facility policy and training. The cart, containing various medications, was out of the RN's sight, posing a risk of misappropriation or accidental ingestion. The DON confirmed the breach of protocol, despite the RN having passed a proficiency checklist.
The facility failed to maintain an effective infection prevention and control program. An RN did not sanitize a blood pressure cuff between two residents, risking cross-contamination. Additionally, two CNAs did not wear gowns while caring for a resident on enhanced barrier precautions, despite signage. Both incidents occurred despite staff having received infection control training.
The facility failed to properly dispose of garbage in Dumpster #1, which was overflowing and missing a drainage plug, with trash scattered around the area. Interviews revealed that trash was picked up twice a week, and the dumpster had been recently replaced. The facility's waste disposal policy and the U.S. Public Health Service Food Code require sealed and covered waste containers with drain plugs, which were not followed.
A resident with severe cognitive impairment suffered a fracture to her left tibia, which was not reported to the state agency as required. The injury was discovered after the resident returned from an Adult Day Care program, and despite the presence of a significant bruise and swelling, the facility did not classify it as an injury of unknown origin. The facility's staff relied on the resident's limited communication about the bus, leading to a failure to report the incident within the required timeframe.
A resident with intellectual disabilities and diabetes did not have a comprehensive care plan, missing crucial details like LIDDA contact information, Adult Day Care specifics, and transportation arrangements. Interviews revealed a lack of communication and coordination among staff, with the MDS Coordinator unavailable and the DON acknowledging the oversight. The facility's policy required comprehensive care plans, but the necessary updates were not made.
Failure to Honor Resident’s Documented DNR Status During Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Out-of-Hospital Do Not Resuscitate (OOH DNR) order and documented DNR status when the resident was found unresponsive and staff initiated resuscitation. The resident was an older female with diagnoses including depression, anxiety disorder, ALS, and a tracheostomy, and had a BIMS score of 15, indicating she was cognitively intact. Her care plan, physician orders, and an OOH DNR form signed by the physician and two witnesses all documented that her code status was DNR. Despite this, when she was found unresponsive in her room, staff proceeded with CPR and other resuscitative measures after determining she had no pulse and had stopped breathing. According to interviews and record review, an agency CNA discovered the resident unresponsive and notified an LVN, who assessed the resident and noted she was pale but breathing, with a weak pulse. Another LVN entered, performed a sternal rub and other stimuli without response, while the first LVN rechecked pulses at multiple sites and then reported finding no pulse and that the resident had stopped breathing. At that point, a Code Blue was called. Respiratory therapy staff removed the breathing circuit from the tracheostomy, suctioned the airway, and began manual ventilation with an ambu bag. Another LVN began chest compressions. During this period, staff questioned whether the resident was a DNR or full code, and there was hesitation because the LVN leading the response was unsure of the resident’s code status. Staff reported that the crash cart binder, which they relied on to verify code status, was not up to date and contained DNR information for residents who were no longer in the facility. The LVN in charge stated she attempted to verify the resident’s status by checking the crash cart binder and then the electronic medical record, but resuscitation had already been initiated and continued while this verification was pending. EMS arrived and continued compressions, and a pulse was recovered before the LVN informed EMS that the resident was actually a DNR based on the documentation she eventually located. The resident’s responsible party later confirmed that a DNR had been completed at the hospital and again at the facility, and stated that the resident did not want CPR, including having her ribs cracked, and that the facility did not abide by the resident’s wishes. The facility did not have a specific policy for Out-of-Hospital DNRs, only a general resident rights policy stating that residents have the right to refuse treatment.
Removal Plan
- Provided in-service training to staff on resident rights, including: Timely Emergency Services & Professional Standards for CPR; How to Identify the Resident Code Status; and Abuse & Neglect.
- Required all new hires to complete the in-service trainings on resident rights, code status, and CPR-related standards.
- Implemented a process for night shift nurses to print the daily resident census, highlight residents with DNR status, and place the dated census sheet in each crash cart binder along with a copy of each resident’s DNR.
- Implemented a process for morning-shift ADONs to check crash cart binders for accuracy and needed DNR code status updates.
- Implemented DON review of resident code status and crash cart binder accuracy.
- Implemented use of a Standard of Care (SOC) spreadsheet that includes a DNR column and records the date of any code status change; tracked by the corporate nurse.
- Implemented audits of printed reports for new admissions to verify code status and ensure crash cart binders are updated accordingly.
- Implemented a process for the Social Worker to deliver newly executed DNR documentation to the DON for updating the electronic medical record and adding the DNR to the crash cart binder and SOC tracking.
- Implemented a DON audit of resident charts for DNR documentation.
- Implemented corporate nurse audits of SOCs.
Deficiencies in Fire Safety Systems, Emergency Preparedness, and Grounds Maintenance
Penalty
Summary
The facility failed to maintain a safe environment by not correcting impairments related to the fire alarm system, not maintaining outside areas free of fire hazards, and not ensuring the Emergency Preparedness Plan was evaluated and updated annually. During inspection, the Emergency Preparedness Plan was found to have last been reviewed and signed in 2005, with no documentation of a more recent review. The Administrator, newly employed for one week, was unaware of the requirement for annual review and update of the Emergency Preparedness Plan and had not yet reviewed it. The facility housed 52 residents, including 17 who were dependent on ventilators for maintaining oxygen levels. Observations revealed the fire alarm annunciator near the Nurse Station displayed a trouble signal indicating a low battery, and the Maintenance Director confirmed ongoing issues with the fire alarm control panel, including a DC battery charge failure. Service tags on the panel indicated recent attempts to address the issue, but the trouble signal persisted. Additionally, the outside inspection showed overgrown vegetation, dead tree branches, dead brush, and leaves along the rear of the building, particularly near the smoking area, with multiple trees leaning against the roof. The Maintenance Director acknowledged responsibility for grounds maintenance and awareness of the overgrown vegetation but cited workload as a reason for the delay in addressing these hazards.
Failure to Timely Report Allegations of Abuse, Neglect, or Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframes. Specifically, the facility did not report four separate allegations of abuse, neglect, or mistreatment involving four different residents. These allegations included a nurse allegedly treating a resident poorly and causing emotional distress, a nurse neglecting to change a gastric tube stoma dressing and instructing the resident to do it herself, rough incontinent care resulting in discomfort to an amputated leg, and verbal abuse where a staff member insulted a resident. Record reviews and interviews revealed that these allegations were documented in grievance reports but were not reported to the state agency as required by facility policy and state regulations. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the grievances were reviewed by the interdisciplinary team, including the previous administrator, but the allegations were not recognized or reported as abuse, neglect, or exploitation (ANE) to the state agency. The current administrator also confirmed that the grievances should have been reported but were not, either due to lack of recognition or assumption that another staff member had reported them. The residents involved had varying degrees of cognitive and physical impairment, including diagnoses such as cerebral vascular accident, seizures, end-stage renal disease, severe obesity, amputation, adjustment disorder with depressed mood, and Parkinson's disease. Their care plans indicated significant needs for assistance with activities of daily living and communication. Despite these vulnerabilities, the facility did not follow established procedures to report the allegations, as confirmed by the absence of corresponding reports in the state’s incident database.
Failure to Investigate and Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated and reported as required. For four out of ten residents reviewed, there was no evidence that allegations of abuse, neglect, or mistreatment were properly investigated or that further potential harm was prevented during the investigation process. The facility also did not report the results of these investigations to the state agency, as required by policy and regulation. One resident with severe cognitive impairment and a history of stroke and seizures was alleged by her representative to have been treated poorly by a nurse, resulting in the resident crying, which was noted as rare for her. Another resident, who was cognitively intact and dependent on a gastrostomy tube for nutrition, alleged that a nurse neglected to change her tube dressing and instructed her to do it herself, contrary to her care plan requiring staff assistance. In both cases, grievance reports were documented, but the DON stated she did not recall the reports and had not reported the investigation results to the state agency. A third resident, with end-stage renal disease, severe obesity, and an above-knee amputation, alleged rough incontinent care by a staff member, resulting in soreness to her amputated leg. The ADON recalled discussing the allegation but did not report the results to the state agency. A fourth resident, with severe cognitive impairment and a history of depression and Parkinson's disease, alleged verbal abuse by a CNA. The ADON and administrator discussed the allegation but did not recognize it as reportable. A review of the state incident database confirmed that none of these allegations were reported as required. The facility's policy mandates immediate reporting of such allegations, but this was not followed.
Unattended and Unlocked Medication Carts
Penalty
Summary
Facility staff failed to ensure that medication carts containing drugs and biologicals, including narcotics, were securely locked and attended as required by facility policy and professional standards. On two separate occasions, a medication cart on the 100-hall and a respiratory therapy medication cart on the 200-hall were observed left unattended, unsupervised, and unlocked in the hallways. The 100-hall cart was left unlocked for 10 minutes while residents and CNAs walked by, and the 200-hall cart was left unlocked for 5 minutes with similar hallway traffic. In both cases, the responsible staff members were not present, and the carts were accessible to unauthorized individuals. Interviews with facility staff, including the ADON, LVN, and RT, confirmed that the carts were left unlocked due to human error and lack of awareness of the assigned nurse's whereabouts. The facility's policy requires medication carts to be locked when not in use or out of the nurse's view, and to be parked securely when unattended. The DON acknowledged that the expectation is for all medication carts to be locked when not attended by nursing staff.
Incomplete Documentation of Wound Care in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with multiple complex diagnoses, including Guillain-Barre disease, respiratory failure, and a tracheostomy. Specifically, the resident was prescribed daily wound care for a sacral pressure injury, but the November treatment administration record (TAR) lacked documentation of wound care on several specified dates. The care plan and physician's orders indicated the need for daily and PRN wound care, yet the TAR showed blanks for the prescribed treatment on multiple days. Interviews with facility staff confirmed the expectation that all care should be documented as soon as it is provided, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the missing documentation in the resident's record. The resident's representative reported that the facility neglected general care and wound care, stating that the resident did not consistently receive the prescribed wound care and that the representative had to provide dressings personally. The DON stated that the wound was improving according to the wound care physician's documentation but was unaware of the missing entries in the TAR. The facility's policy requires accurate maintenance of medical records, but the lack of documentation for wound care on the specified dates resulted in incomplete and unorganized records for the resident.
Failure to Support Resident's Right to Refuse Care Without Coercion
Penalty
Summary
Staff failed to promote and facilitate a resident's right to self-determination and choice, specifically regarding the right to refuse care. The resident, an adult male with diagnoses including hypertension, chronic kidney disease, and coronary artery disease, and with intact cognition as evidenced by a BIMS score of 15, was subjected to staff telling him that his family member would be called if he refused to change his clothes. This approach was used as a means to gain compliance with care, as confirmed by both the DON and a CNA, and was described as a threat by the resident himself. The care plan included a directive to call the family member upon refusal of care, per the family member's request. The resident reported feeling sad and infantilized by this practice, expressing concern that his family member would be angry and stop visiting if called. The DON acknowledged that staff had become accustomed to using the threat of calling the family member to compel the resident to comply with care, and recognized this as a violation of the resident's rights. The administrator also confirmed that such actions were not permitted, even if requested by the family, as they infringed upon the resident's right to refuse care and could cause psychosocial harm.
Failure to Prevent Diversion of Pain Medication
Penalty
Summary
The facility failed to protect the rights of two residents to be free from misappropriation of property, specifically regarding the diversion of pain medications. Both residents had orders for Norco, with one resident rarely taking the medication and the other receiving it on a scheduled basis for pain management. The medications were administered and refilled exclusively by one LVN, who was also the only person to receive the medications from the pharmacy. This allowed the LVN to divert medications when they were delivered, as she was responsible for calling in refills and receiving the deliveries without adequate oversight. The deficiency was identified after an audit revealed several cards of Norco were unaccounted for, prompting further investigation. The audit involved both the in-house and hospice pharmacies, and it was discovered that the LVN had diverted the medications upon delivery. The process in place at the time did not ensure that medications were properly secured or that there was a reliable verification system involving multiple staff members when narcotics were received from the pharmacy. Interviews with staff indicated that the standard procedure required two nurses to verify and sign for narcotics upon delivery, but this process was not consistently followed in the cases involving the two residents. The lack of adherence to established protocols for receiving and securing medications enabled the LVN to divert the narcotics without detection for an extended period.
Failure to Notify State Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of a resident's discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman prior to the resident's discharge, as required. Record review and interviews confirmed that a resident with diagnoses including Guillain-Barre disease, respiratory failure, and a tracheostomy was admitted for LTC and later discharged to a hospital for elevated care, with no expectation of return. There was no evidence in the medical record that a discharge notice was sent to the state ombudsman. Interviews with the state ombudsman, social worker (SW), director of nursing (DON), and administrator revealed that none were aware of a notification being made to the ombudsman regarding the resident's discharge. The SW stated she had been directed not to coordinate with the ombudsman and had no evidence of a report for the discharge. The facility's policy indicated that for resident-initiated discharges, notification to the ombudsman was not required, but the discharge in question was not clearly documented as resident-initiated.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% due to two errors out of 26 opportunities. These errors involved a resident who was administered medications late. Specifically, RN A administered a 10 gram carafate tablet and 30 milliliters of 10 gm/15mL enulose solution to the resident at 5:29 p.m., which was one hour and twenty-nine minutes past the scheduled time of 4:00 p.m. The resident involved had a medical history of biliary cirrhosis, fibromyalgia, and gastro-esophageal reflux disease (GERD) with esophagitis. The resident's care plan included interventions to manage GERD and constipation, with specific medication orders for carafate and enulose to be administered at designated times to optimize therapeutic effects. The late administration of these medications could potentially affect their effectiveness, particularly the carafate, which was intended to be given before meals. RN A, who was new to the facility and unfamiliar with the residents and their medications, attributed the delay to his lack of familiarity with the medication administration procedures. The Director of Nursing (DON) confirmed that RN A was a new staff member and suggested that the late administration was due to his inexperience. The facility's policy requires medications to be administered within one hour of their prescribed time, emphasizing the importance of timely administration for optimal therapeutic effect.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. The first issue identified was the improper storage of plastic storage containers in the dish room. Three opaque plastic containers were stacked on top of each other without any separation to allow for air circulation, resulting in visible moisture between the containers. This practice contradicts the facility's policy and the U.S. FDA Food Code, which require equipment and utensils to be air-dried before being stacked or stored to prevent bacterial growth. The second deficiency involved the improper labeling and dating of a container of chopped beef brisket in the walk-in cooler. The container, which was partially full, was labeled with the date it was received, but not with the date it was opened or a use-by date. This oversight could lead to the proliferation of bacteria, as the facility's policy mandates that all opened food items be labeled with both the date opened and the use-by date to ensure food safety. The third issue was the improper storage and labeling of French fries in the reach-in freezer. A package of food wrapped in brown paper and loosely covered with plastic wrap was found without a label indicating its contents. The package was dated but not properly sealed, which could result in freezer burn and deterioration of food quality. The facility's policy requires all frozen foods to be covered, labeled, and dated to ensure they are consumed by their use-by dates or discarded if necessary.
Failure to Ensure Resident Privacy During Catheter Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during catheter care, as observed by surveyors. Two CNAs did not completely close the privacy curtain while providing catheter care, leaving the resident exposed and visible from the room's door. This incident occurred while other staff members were present in the room providing care for the resident's roommate. The CNAs acknowledged during an interview that the privacy curtain was not fully closed, although it should have been. The resident involved had a history of severe cognitive impairment and was dependent on staff for activities of daily living. The resident's medical conditions included dysphagia, type 2 diabetes mellitus, cerebral palsy, and spina bifida, and they had an indwelling catheter due to a neurogenic bladder. The facility's Director of Nursing confirmed that privacy should have been maintained during care and that staff had received training on resident rights within the year. The facility's policy on dignity emphasized the importance of maintaining resident privacy during personal care and treatment procedures.
Incomplete Care Plan for Resident with Communication Deficit
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a requirement to ensure that all residents' needs are met. Specifically, the care plan for a resident with a cognitive communication deficit was incomplete, as it did not address the resident's communication needs. This oversight was identified during a review of the resident's records, which showed that the resident had a history of hemiplegia, hemiparesis, major depressive disorder, and aphasia following a cerebral infarction. Despite these conditions being documented, the care plan lacked a focus section on the resident's communication deficit, which is crucial for staff to provide appropriate care. Observations and interviews with staff revealed that the resident used a communication card to express needs, but this method was not included in the care plan. The MDS LVN responsible for care plans acknowledged the omission and could not explain why the communication deficit was not included. The Director of Nursing also confirmed that the communication impairment should have been reflected in the care plan to ensure the resident's needs were met. The facility's policy requires that care plans include measurable objectives and timeframes to address residents' physical, psychosocial, and functional needs, which was not adhered to in this case.
Hazardous Materials Found in Resident's Bathroom
Penalty
Summary
The facility failed to maintain a safe environment for a resident with severe cognitive impairment and legal blindness. During an observation, it was found that the resident's bathroom contained several cleaning supplies with hazardous warnings, such as disinfecting sprays, isopropyl alcohol, bleach, multipurpose cleaner, and germicidal alcohol wipes. These items were stored behind a shower curtain, making them accessible to the resident, who was diagnosed with unspecified dementia with psychotic symptoms, legal blindness, and anxiety disorder. The presence of these hazardous materials in the resident's bathroom posed a risk of contact with potentially dangerous substances. Interviews with facility staff, including an RN and the DON, confirmed the presence of these cleaning supplies in the resident's bathroom. The RN acknowledged that the supplies should not have been there, given the resident's legal blindness and dementia diagnosis. The DON stated that cleaning supplies should not be present in resident rooms to prevent contact with hazardous materials. It was noted that a family member of the resident might have brought the supplies into the room, which was against the facility's policy of providing a safe and homelike environment.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The resident, who was admitted with diagnoses including malignant neoplasm of the lung, type 2 diabetes mellitus, and unspecified dementia, displayed signs and symptoms of depression. Despite these symptoms being documented in multiple progress notes over several months, the resident was not offered mental health services. The resident's quarterly MDS indicated moderate cognitive impairment, and the resident consistently reported feelings of depression, isolation, and loneliness. Interviews and record reviews revealed that the resident expressed feelings of being a prisoner and not understanding why they were residing at the facility. The Director of Nursing (DON) acknowledged being unaware of the lack of referral to mental health services and confirmed that the resident had expressed feelings of depression and isolation. The facility's policy on Behavioral Health Services, revised in February 2019, stated that the facility would provide necessary behavioral health services to maintain residents' well-being, which was not adhered to in this case.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During a medication administration round, RN C left the Hall 200 Medication Cart unlocked while entering a resident's room and closing the door, leaving the cart out of sight. The unlocked cart contained blister packs, bottles, and vials of medications intended for residents, which could lead to misappropriation or accidental ingestion. In an interview, RN C acknowledged leaving the cart unlocked and admitted to forgetting the requirement to keep it locked. The Director of Nursing (DON) confirmed that the medication cart should have been locked and that nursing staff had been trained on drug diversion prevention, including keeping carts locked when not in use. The facility's policy on medication cart security also mandates that carts be securely locked when out of the nurse's view. Despite RN C having passed a proficiency checklist for medication administration, this oversight occurred.
Infection Control Deficiencies in Equipment Sanitization and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving improper care practices. In the first incident, a registered nurse (RN) did not sanitize a blood pressure cuff between using it on two different residents. The RN acknowledged the oversight and recognized the potential risk for cross-contamination. The Director of Nursing (DON) confirmed that the RN should have sanitized the equipment between uses, as per the facility's policy on cleaning and disinfection of resident-care equipment. In the second incident, two certified nursing assistants (CNAs) failed to wear gowns while providing care to a resident who was on enhanced barrier precautions. Despite signage indicating the need for such precautions, the CNAs were unaware of the requirement. The DON confirmed that gowns should have been worn to prevent cross-contamination, in accordance with the facility's policy on enhanced barrier precautions. Both the RN and the CNAs had received infection control training within the year, and the facility conducted regular skills checks.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically with Dumpster #1. Observations revealed that the dumpster was overflowing with trash, preventing the lid from closing completely, which left an 18-inch gap. Additionally, the dumpster was missing a drainage plug on the right side, and there was trash and debris scattered around the area, including plastic bags, an empty cardboard case of soda, a plastic glove, an empty water bottle, and a cigarette butt. Interviews with the Food Service Director (FSD) and the Maintenance Director confirmed that trash was typically picked up twice a week, and the dumpster had been recently replaced. The Maintenance Director acknowledged the missing drain plug and its importance in preventing animals from accessing the dumpster. The facility's waste disposal policy and the U.S. Public Health Service Food Code require that waste containers be emptied regularly, sealed, and covered with tight-fitting lids, and that drain plugs be in place, which were not adhered to in this instance.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident who suffered a fracture to her left tibia. The resident, who had moderate intellectual disabilities, autistic disorder, and severe cognitive impairment, was unable to communicate how the injury occurred. Despite the presence of a significant bruise and swelling on her leg, the facility did not report the incident to the state reporting agency (HHSC) within the required two-hour timeframe. The resident was wheelchair and bedbound, requiring maximum assistance for activities of daily living and was dependent on staff for transfers. The injury was discovered after the resident returned from an Adult Day Care program, where she traveled via a public bus service without staff supervision. The facility's Director of Nursing (DON) and other staff members were aware of the injury but did not classify it as an injury of unknown origin, as the resident reportedly mentioned the bus in relation to the injury, despite her severe cognitive impairment. Interviews with facility staff revealed that there was confusion and a lack of clarity regarding the origin of the injury. The DON and Administrator did not report the injury to the state agency, as they did not suspect abuse or neglect, relying instead on the resident's limited communication about the bus. The facility's policy required reporting injuries of unknown origin, but the staff did not adhere to this policy, resulting in a failure to report the incident as required.
Deficient Care Plan for Resident with Intellectual Disabilities
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with moderate intellectual disabilities, autistic disorder, and type 2 diabetes mellitus with diabetic polyneuropathy. The care plan did not include essential details such as the name and contact information of the LIDDA representative, the next scheduled IDT meeting, or specifics about the Adult Day Care services the resident attended three times a week. Additionally, the care plan lacked information on the community bus service used for transportation to the Adult Day Care, including the schedule, interventions for transport, and contact information. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's care plan. RN B described the process of preparing the resident for Adult Day Care but noted that there was no daily or written communication with the Adult Day Care facility. The receptionist and LVN A confirmed that the care plan did not include necessary transportation and contact information. The MDS Coordinator, who was responsible for care plans, was unavailable for interviews, and the DON acknowledged that the care plan should have included the missing information. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs. However, the DON admitted that the care plan for the resident's Adult Day Care and transportation was not updated when the activity was initiated. The Administrator and LIDDA also provided insights into the lack of communication and coordination between the facility and the Adult Day Care, highlighting the deficiency in ensuring continuity of care for the resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
