Mullican Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Savoy, Texas.
- Location
- 105 N Main St, Savoy, Texas 75479
- CMS Provider Number
- 675439
- Inspections on file
- 34
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mullican Care Center during CMS and state inspections, most recent first.
A resident with dementia and other comorbidities was facility-initiated for discharge to an inpatient psychiatric hospital, but the facility failed to complete the ombudsman notification section of its discharge protocol and did not send the required written notice to the State LTC Ombudsman. Although documentation on an eTransfer form indicated that the physician and resident representative were notified, the local ombudsman and the resident’s responsible party both reported they were not informed of the actual discharge. Interviews with the Administrator, DON, ADON, Social Worker, and an RN showed unclear roles and missed communication, and the Social Worker was unaware of the requirement to notify the ombudsman, despite facility policy requiring written notice to the resident, representative, and ombudsman for facility-initiated transfers and discharges.
Surveyors found that the facility failed to properly label, date, and dispose of expired food items, and did not maintain safe holding temperatures for food on the steam table. Multiple expired and unlabeled items were observed in the kitchen, and several foods were held below the required temperature. Both the Dietary Manager and Administrator were unaware of these issues until informed by surveyors.
Surveyors found that the facility failed to provide palatable, attractive, and properly heated food during a lunch meal, with food temperatures below recommended levels and bland taste reported. Two residents expressed dissatisfaction with the food's appearance and texture. Additionally, the cook did not follow the prescribed puree recipe, using water instead of recommended liquids, and did not consult the recipe book. The Dietary Manager and Administrator were unaware of these deviations and lacked oversight regarding recipe adherence and staff training.
The facility did not serve meals at the posted times, with observations confirming that lunch service was delayed and a resident reporting consistent lateness for breakfast and lunch. Staff interviews acknowledged the issue and attributed delays to staff performance, despite prior in-services on timely meal service.
A resident with a history of schizoaffective disorder and major depressive disorder did not receive quarterly PASRR IDT meetings as required, due to a lapse in Medicaid coverage and lack of coordination by facility staff. Documentation showed only two IDT meetings over more than a year, despite the resident's need for specialized services. Staff interviews confirmed the missed meetings and a lack of awareness regarding the requirement.
A resident with an indwelling Foley catheter was found to have the catheter unsecured for several days, despite physician orders and care plan interventions requiring securement. The resident reported the issue to staff, but it was not addressed, and interviews with nursing staff and leadership confirmed the responsibility to ensure securement was not met.
A nurse failed to properly reconcile and dispose of a controlled medication for a resident with severe cognitive impairment and a feeding tube. The nurse disposed of a clonazepam tablet without a witness and did not follow facility policy, resulting in a discrepancy in the narcotic log and incomplete accountability for the controlled drug.
A resident with a seizure disorder and on Keppra therapy did not have the required Keppra level lab drawn as ordered, due to a miscommunication between facility staff and the lab company. The lab requisition to discontinue routine labs did not specify that the Keppra level should continue, resulting in the cancellation of all labs. The DON and lab staff confirmed the omission and lack of follow-up, and there was no facility policy in place for laboratory services.
Staff failed to follow enhanced barrier precautions during wound care for a resident with dementia and peripheral vascular disease, as both an LVN and a CNA wore gloves but did not don gowns as required by the care plan and facility policy. Both staff members acknowledged forgetting to use the gowns, despite the PPE being available and the resident's care plan specifying the need for these precautions.
A resident reported missing $250 from her room, but the facility did not file a grievance form or keep the resident informed about the resolution process. Although the resident was cognitively intact and able to communicate, staff did not follow the required grievance procedures, resulting in a lack of documentation and communication about the incident.
The facility failed to accurately code the use of restraints for three residents in their MDS assessments. The residents were noted to use bed rails as restraints, but observations and care plans indicated the use of grab bars for repositioning and transfers. Interviews revealed that the coding errors were due to a misunderstanding of the meaning of restraints.
The facility failed to maintain a safe environment on the C hall, where the flooring was raised and split, creating a trip hazard. The ADON, DON, Maintenance Director, and Administrator were unaware of the severity of the issue until it was pointed out, and the facility lacked a policy for maintaining a safe and homelike environment.
The facility failed to refer a resident with serious mental disorder for a PASARR evaluation. The resident, with diagnoses including bipolar disorder and schizophrenia, was admitted without a proper PASARR Level II screening. The MDS nurse lacked knowledge about PASARR requirements, leading to the oversight.
The facility failed to include a resident's PTSD diagnosis in her care plan, despite her severe cognitive impairment and the importance of addressing PTSD triggers. Staff members, including an LVN, ADON, DON, and the Administrator, acknowledged the oversight and its potential impact on the resident's care.
The facility failed to update care plans for three residents, leading to discrepancies between their current conditions and documented care plans. One resident frequently removed his Foley catheter leg strap, another no longer needed a wander guard, and a third was inaccurately listed as a smoker. These oversights could result in inappropriate care and potential harm.
The facility failed to ensure proper respiratory care for two residents. One resident did not have documented oxygen orders despite using oxygen, and another resident's oxygen concentrator filter was not cleaned as required. These deficiencies were confirmed through staff interviews and observations.
The facility failed to maintain accurate documentation in the MAR for a resident, leading to incomplete and inaccurate medical records. Despite being at high risk for elopement, the resident did not have a wander guard bracelet, and staff signed the MAR without verifying its presence. Interviews revealed systemic issues in monitoring and documentation processes for wander guards.
A CNA failed to follow proper hand hygiene protocols while providing peri care to a resident with multiple diagnoses, including diabetes and epilepsy. The CNA did not use hand sanitizer between glove changes, which was observed and confirmed through interviews with facility staff. The resident required substantial assistance with daily activities and had moderate cognitive impairment.
The facility failed to report a resident's allegations of abuse within the required timeframe. The resident, who has multiple medical conditions, made repeated allegations against the DON and ADON. Interviews revealed a lack of clarity and communication regarding the reporting process, leading to the incident not being reported to the state agency as mandated.
The facility failed to report a resident's allegations of abuse to the state agency within the required timeframe. Despite the resident's repeated allegations against the ADON, the incident was not reported as mandated by law. Interviews revealed a lack of clarity and adherence to the facility's policy on reporting abuse.
The facility failed to notify the Office of the State LTC Ombudsman of a resident's discharge to a psychiatric hospital, violating regulatory requirements. The resident, who was cognitively intact and had multiple diagnoses, was not allowed to return to the facility, and the necessary paperwork was not properly managed.
The facility failed to re-admit a resident after psychiatric hospitalization and did not issue the required 30-day discharge notice, violating their own policy. The resident, with multiple diagnoses, was left feeling emotionally drained and homeless.
Failure to Provide Required Transfer/Discharge Notices to Representative and Ombudsman
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer or discharge to a resident, the resident’s representative, and the State LTC Ombudsman, and to send a copy of the notice to the Ombudsman. The resident involved was an elderly male with dementia, diabetes mellitus, hypertension, and depression, who had a BIMS score of 2 indicating severe cognitive impairment and required supervision for ADLs. Record review showed a facility-initiated discharge protocol dated 01/09/2026 for this resident, with the ombudsman notification portion left incomplete. The discharge MDS dated 01/16/2026 documented that the resident was discharged to an inpatient psychiatric facility. Further record review of an eTransfer form dated 01/16/2026 at 3:00 PM, completed by the ADON, indicated the resident was transferred to an inpatient psychiatric hospital in a non-emergent transfer, and that the facility physician and resident representative were documented as notified at 9:00 AM the same day. However, the local facility ombudsman stated in interview that she was never notified of the resident’s discharge and only learned of it several days later. The resident’s responsible party reported receiving a 30‑day discharge notice on 01/09/2026 but stated that no one from the facility notified her when the resident was actually discharged on 01/16/2026, and that even during a conversation with the Administrator on the day of discharge, she was not informed that the resident had been discharged. Multiple staff interviews revealed inconsistent involvement and a lack of clarity regarding who was responsible for notifications. The ADON stated the resident received a 30‑day notice but did not know when, was not involved in the discharge to the behavioral health unit, and did not verify that the family had been contacted, though she acknowledged the family should be notified prior to discharge. The Administrator stated he had discussed the facility’s inability to meet the resident’s needs with the family and believed he had provided a 30‑day notice, but he acknowledged that he forgot to notify the family when the resident was sent to the behavioral hospital and that he did not complete the ombudsman notification section of the facility-initiated discharge protocol. The DON and Social Worker each reported limited or no direct involvement in the actual discharge notifications on the day of transfer, with the Social Worker stating she was unaware of the requirement to notify the ombudsman. RN A reported that, to his knowledge, the discharge process had been completed before his shift and that he was not involved in notifying the responsible party or physician. The facility’s own undated policy stated that for facility-initiated transfers and discharges, including emergent transfers and discharges decided while a resident is hospitalized, notices must be provided to the resident and resident representative and copies sent to the State LTC Ombudsman, which did not occur in this case.
Deficiencies in Food Storage, Labeling, and Temperature Control
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, specifically related to the storage, labeling, dating, and disposal of food items. During observations in the kitchen's refrigerators and freezers, several food items were found to be expired, including BBQ beef, celery seed seasoning, ground red pepper seasoning, and sugar seasoning. Additionally, some items such as jelly, ketchup, diced tomatoes, and hamburger meat were either missing expiration dates or were not labeled and dated as required. These issues were observed in the presence of the Dietary Manager, who stated that all items should be labeled, dated, and discarded if expired, but was unaware of the expired items found during the survey. Further observations revealed that the facility failed to maintain safe holding temperatures for food on the steam table. Several food items, including regular chicken parmesan, spaghetti sauce, and various pureed foods, were recorded at temperatures below the required 135°F for hot holding, with some items as low as 54.3°F. These findings were documented during meal service observations and confirmed by staff present at the time. Interviews with the Dietary Manager and Administrator indicated that both were unaware of the expired food items and improper labeling until informed by surveyors. The Dietary Manager reported conducting daily walk-throughs and stated that staff had recently completed in-services on labeling and dating food items. The Administrator also reported conducting daily walk-throughs but was not aware of the deficiencies until notified. Review of facility policy and FDA guidelines confirmed the requirements for proper food labeling, dating, and temperature control, which were not met during the survey.
Deficient Food Palatability, Temperature, and Recipe Adherence
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for one of three meals observed during a survey. During the lunch meal, food temperatures were recorded as being below recommended levels, with the regular chicken parmesan measured at 87°F and the puree chicken parmesan at 109°F, both of which are below the standard for hot food service. Observations and interviews revealed that the green beans were bland and cool, and the chicken parmesan was described as warm but not hot by both the Dietary Manager and surveyors. Residents interviewed expressed dissatisfaction with the food, noting issues such as tough meat, unappetizing appearance, and insufficient quantity. Further investigation found that the facility did not follow the prescribed puree recipe for the lunch meal. The cook was observed adding water and food thickener to green beans instead of using the recommended liquids such as broth, juice, milk, gravy, or sauce, as specified in the recipe book. The cook admitted to not consulting the recipe book prior to preparing the meal and stated that he relied on his own experience. The Dietary Manager was unaware that staff were not following the recipe book and confirmed that the last in-service training on following the menu was completed a month prior. Interviews with the Dietary Manager and Administrator indicated a lack of oversight and communication regarding adherence to recipes and food preparation standards. The Dietary Manager stated he was responsible for ensuring staff followed the recipe book but was not informed of deviations. The Administrator, who oversees the Dietary Manager, was also unaware of staff not following recipes and was unsure about the completion of in-service training. Both acknowledged the importance of providing palatable and appetizing food but did not identify recent complaints or issues prior to the survey findings.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve meals at the specific times posted in the main dining room, resulting in residents not receiving meals at regular times comparable to normal mealtimes in the community. The posted meal service times were 7:00 AM for breakfast, 12:00 PM for lunch, and 5:00 PM for dinner. Observations showed that lunch service had not begun by 12:42 PM, and a resident reported that both breakfast and lunch were always served late. Record review indicated that the last staff in-service on time management was completed on 4/29/25. Interviews with the Dietary Manager and Administrator confirmed awareness of the late meal service, with the Dietary Manager attributing the delay to the cook's inability to handle pressure. Both the Dietary Manager and Administrator acknowledged the importance of serving meals on time to maintain residents' routines and support their nutritional needs. Despite previous in-services on timely meal service, the deficiency persisted, as evidenced by the late lunch service and resident complaints.
Failure to Coordinate Quarterly PASRR IDT Meetings for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program to the maximum extent practicable, resulting in missed quarterly PASRR Interdisciplinary Team (IDT) meetings for a resident with a serious mental illness. Record review showed that the resident, who had diagnoses including schizoaffective disorder and major depressive disorder, was identified as PASRR positive and required specialized services. Although the care plan indicated that the local authority would be invited annually to care plan meetings, documentation revealed that quarterly IDT meetings were not consistently conducted as required. The resident's PASRR Level 1 Screening and evaluation confirmed the need for specialized services, but recommended services were not listed, and only two IDT meetings were documented over a period exceeding one year. Interviews with facility staff, including the MDS Coordinator and PASRR Coordinator, revealed that the missed meetings were attributed to a lapse in the resident's Medicaid coverage. Staff stated that when Medicaid lapsed, IDT meetings were not scheduled, and there was a lack of awareness regarding the missed quarterly meetings. The facility's policy did not specify the required frequency for PASRR IDT meetings. The administrator confirmed the expectation for quarterly meetings and identified the MDS Coordinator as responsible for coordination, but acknowledged the deficiency in meeting this requirement.
Failure to Secure Foley Catheter as Ordered
Penalty
Summary
A deficiency was identified when a male resident with a history of prostate cancer and benign prostatic hyperplasia, who had an indwelling Foley catheter, was found to have his catheter unsecured to his leg. The resident reported that the catheter had been unsecured for several days and that he had informed staff, but the issue was not addressed. The resident's care plan and physician orders required the catheter to be secured to prevent trauma and infection, and the facility's policy instructed staff to minimize friction or movement at the insertion site, although it did not specifically address securement. Interviews with nursing staff and facility leadership confirmed that the responsibility for ensuring the catheter was secured rested with the nurses and other care providers. Despite this, the catheter remained unsecured, and staff were unable to provide a reason for the lapse. The deficiency was observed during a survey, and documentation supported that the required interventions to secure the catheter were not followed as ordered.
Failure to Accurately Reconcile and Dispose of Controlled Medication
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically for one resident who was prescribed clonazepam for anxiety. On the observed date, a registered nurse (RN) removed a tablet of clonazepam from the medication card, crushed it, and prepared it for administration via the resident's gastrostomy tube. The RN then signed off the administration in the narcotic log. However, the narcotic record indicated there should have been two tablets remaining, but only one was present. The RN explained that she had disposed of a tablet after recalling that a state surveyor wanted to observe the administration, but did so without obtaining a witness, as required by facility policy. The RN admitted she was unfamiliar with the facility's policy, having only recently started working there, and did not secure a witness during the disposal process. The resident involved was a female with severe cognitive impairment, dependent on staff for all activities of daily living, and received medications via a feeding tube. Facility policy and interviews with the Director of Nursing (DON) and Administrator confirmed that a witness is required when disposing of controlled medications, and failure to do so could lead to discrepancies in drug accountability. The lack of a witness and improper reconciliation of the narcotic log resulted in an inability to accurately account for all controlled drugs, as required by federal and state regulations.
Failure to Obtain Ordered Keppra Level for Resident on Anticonvulsant Therapy
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered for a resident with a seizure disorder who was receiving Keppra, an anticonvulsant medication. The resident's care plan and hospice admission orders specified that routine labs were to be discontinued except for the Keppra level, which was to be monitored every three months. Despite these orders, the Keppra level was not obtained for the month of May. Record review showed that the last Keppra level was within therapeutic range in February, and the resident continued to receive Keppra as prescribed. However, a lab requisition to discontinue routine labs did not specify that the Keppra level should continue, leading to the cancellation of all labs, including the required Keppra level. Interviews with facility staff and the lab company revealed a miscommunication regarding which labs were to be discontinued, resulting in the Keppra level not being drawn as ordered. The Director of Nursing (DON) acknowledged that the omission occurred when the lab requisition was filled out and that nursing staff were responsible for ensuring labs were obtained as ordered. The lab company also indicated that both the facility and the lab were responsible for ensuring the correct labs were drawn, and the failure to do so was due to a lack of clarification and follow-up. There was no policy in place at the facility regarding laboratory services.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that staff followed enhanced barrier precautions (EBP) during wound care for a resident with significant medical needs. Specifically, during an observed wound care procedure, an LVN and a CNA donned gloves but did not wear gowns as required by the resident's care plan and facility policy. Both staff members acknowledged in interviews that they were aware of the EBP requirements, which included wearing both gloves and gowns for wound care, but stated they forgot to put on gowns during the procedure. The necessary personal protective equipment (PPE) was available, but not utilized as directed. The resident involved had a history of dementia and peripheral vascular disease, with a severely impaired cognitive status and ongoing pressure ulcer care. The care plan for this resident specifically indicated the need for EBP, including the use of gloves and gowns during high-contact care activities such as wound care. Facility policy also required EBP for residents with wounds, regardless of known infection status. Despite these documented requirements, staff did not adhere to the established precautions during the observed care event.
Failure to Promptly Resolve and Document Resident Grievance Regarding Missing Money
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance for one resident who reported missing $250 from her room. The resident, who was cognitively intact and able to communicate her needs, informed the Administrator about the missing money. Despite this report, no grievance form was filed, and the resident was not appropriately apprised of the progress toward a resolution. The facility's grievance log did not contain any entry for this incident, and staff interviews confirmed that the required grievance process was not followed. The resident had a history of making negative statements and allegations, but the facility's policy required that all grievances be documented and investigated. The Social Worker and DON both acknowledged that a grievance form should have been completed, and the Administrator admitted that the usual process was not followed in this case. The failure to document and address the grievance as per policy meant that other staff were not made aware of the incident, and there was no formal record of the steps taken to resolve the resident's concern.
Inaccurate MDS Assessment Coding for Restraints
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident status for three residents reviewed for MDS assessment accuracy. Specifically, the facility did not accurately code the use of restraints for these residents. Resident #17, a male with diagnoses including seizures, bipolar disorder, schizophrenia, and generalized anxiety, was noted to use bed rails daily as a restraint in his MDS assessment. However, his physician's orders and care plan indicated the use of a U-shaped grab bar for repositioning and transfers, not as a restraint. Observations confirmed the use of grab bars for transfers, not restraints. Resident #4, a male with diagnoses including epilepsy, dementia, high blood pressure, and heart failure, was also inaccurately coded as using bed rails daily as a restraint in his MDS assessment. However, his order summary and care plan did not indicate the use of side rails, and observations confirmed that he did not have side rails on his bed. Similarly, Resident #11, a male with diagnoses including complete traumatic amputation, muscle wasting, and abnormal posture, was coded as using bed rails in his MDS assessment. His care plan and order summary indicated the use of a grab bar for repositioning, and observations confirmed the use of the grab bar for transfers. Interviews with the MDS nurse, ADON, DON, and Administrator revealed that the coding errors were due to a misunderstanding of the meaning of restraints. The MDS nurse acknowledged the incorrect coding and the importance of accurate MDS assessments for reflecting resident care. The ADON, DON, and Administrator emphasized that the facility is restraint-free and that the grab bars were not used as restraints. They also highlighted the need for accurate MDS coding to ensure proper care and billing.
Unsafe Flooring on C Hall
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on the C hall. The flooring on the C hall was observed to be raised and split across the hallway, creating a trip hazard. This issue was identified during an observation on 04/09/24 and confirmed through subsequent observations and interviews with the ADON, DON, Maintenance Director, and Administrator on 04/10/24. The ADON and DON acknowledged the potential risk for falls but were not previously aware of the severity of the floor's condition. The Maintenance Director admitted that the floor had been shaved three times since 2009 and had deteriorated significantly, posing a risk for falls. He stated that regional maintenance would be responsible for fixing the floor due to an upcoming remodeling project. The Administrator was also unaware of the raised floor until notified on 04/10/24. He recognized the fall risk and planned to prioritize the issue by marking the area with yellow tape to alert residents and staff. The facility did not have a policy for maintaining a safe and homelike environment, which contributed to the oversight. The lack of immediate corrective action and awareness among the staff and administration led to the deficiency, placing residents at risk of falls and injuries due to the unsafe environment.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with possible serious mental disorder for a PASARR evaluation. The resident, a male with diagnoses including seizures, bipolar disorder, schizophrenia, and generalized anxiety, was admitted to the facility without a proper PASARR Level II screening. The resident's records indicated he was cognitively intact and required extensive assistance with daily activities. Despite having a diagnosis of schizoaffective disorder and being prescribed Quetiapine Fumarate, the initial PASARR Level I screening did not reflect his mental illness diagnosis, leading to a failure in triggering a necessary Level II evaluation. During interviews, the MDS nurse admitted to lacking knowledge about PASARR requirements and only sought guidance from the regional nurse after the deficiency was identified. The MDS nurse then filled out the necessary 1012 form for a mental illness/dementia resident review and planned to submit it for review to the local authority. The facility's administrator and DON confirmed that the MDS nurse was responsible for completing the PASARR evaluations and acknowledged the oversight in Resident #17's case. The facility's policy on PASARR screenings mandates obtaining a PL1 screening form from the referring entity before or on the day of admission. The policy emphasizes the importance of accurate and timely submission of these forms to ensure residents receive appropriate services. However, in this case, the facility did not adhere to its policy, resulting in a delay in identifying and addressing the resident's mental health needs through the PASARR process.
Failure to Include PTSD in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had severe cognitive impairment and a BIMS score of 0 out of 15, did not have her PTSD diagnosis included in her care plan. This omission was discovered during a record review and confirmed through interviews with various staff members, including an LVN, the ADON, the DON, and the Administrator. The staff members acknowledged the importance of including PTSD in the care plan to prevent potential triggers and provide appropriate care, but it was missed during the care planning process. The deficiency was highlighted by the fact that the resident's PTSD diagnosis was not communicated to the staff, as evidenced by the LVN's lack of awareness. The ADON and DON both admitted that the care plan should have included the PTSD diagnosis and that the failure to do so could result in the resident not receiving the necessary care. The Administrator also confirmed that the interdisciplinary team meeting should have ensured the inclusion of all relevant diagnoses in the care plan. The facility's policy on comprehensive care planning mandates the inclusion of measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Update Care Plans for Three Residents
Penalty
Summary
The facility failed to review and revise the person-centered care plan to reflect the current condition for three residents. For Resident #17, the care plan did not include his removal of the Foley catheter leg strap, despite multiple observations and interviews indicating that he frequently removed it. The nursing staff was aware of his behavior, but it was not documented in his care plan, and the MDS nurse and ADON were not informed. This oversight could lead to inappropriate care and potential harm to the resident. Resident #15's care plan was not updated to remove her wander guard, even though her MDS assessment indicated no wandering behavior. The medication administration record still showed checks for the wander guard, which were being signed off by the nurse. This discrepancy between the resident's current condition and the care plan could result in unnecessary interventions and a lack of appropriate care. Resident #25's care plan still listed him as a smoker, although he had not smoked in a long time. The MDS assessment did not indicate that he was a smoker, and interviews with staff confirmed that his smoking status had changed. The failure to update his care plan could lead to inappropriate interventions and a lack of accurate care. The facility's policy on comprehensive care plans emphasizes the importance of ongoing discussions and updates to reflect changes in residents' preferences and goals, which was not adhered to in these cases.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that Resident #8 had proper oxygen orders. Despite the resident being observed with oxygen set at 4.5 liters per mask, there were no corresponding physician orders documented. Interviews with staff revealed that the resident had been using oxygen for almost two weeks due to an upper respiratory infection, but the necessary orders were not written or communicated properly. This oversight was acknowledged by the CNA, LVN, ADON, DON, and the Administrator, all of whom confirmed the importance of having documented orders to ensure correct oxygen administration and prevent potential respiratory issues. The facility also failed to maintain the oxygen concentrator filters for Resident #31. Observations showed that the resident's oxygen concentrator filter had a thick grey, fuzzy material, indicating it had not been cleaned. Interviews with staff, including an LVN, ADON, DON, and the Administrator, confirmed that the filters were supposed to be cleaned weekly and as needed, but this had not been done. The staff acknowledged the importance of clean filters for proper ventilation and preventing respiratory complications. Both deficiencies highlight a lack of adherence to professional standards of practice for respiratory care. The failure to document oxygen orders for Resident #8 and to clean the oxygen concentrator filters for Resident #31 could lead to significant respiratory complications and a decreased quality of care for the residents involved.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate documentation in the Medication Administration Record (MAR) for a resident, leading to incomplete and inaccurate medical records. Specifically, the MAR for April 2024 indicated that the resident had a wander guard in place, which was not the case. Interviews with staff revealed that the resident did not have a wander guard bracelet on his chair or body, despite the MAR being signed off as if it were in place. This discrepancy was confirmed by multiple staff members, including CNAs and LVNs, who admitted to signing the MAR without verifying the presence of the wander guard bracelet. The resident in question was a male with a history of seizures, bipolar disorder, schizophrenia, and generalized anxiety. His quarterly MDS assessment indicated that he was cognitively intact but required extensive assistance with daily activities. The resident was also identified as being at high risk for elopement, with an elopement risk assessment score of 15. Despite this high risk, the resident's care plan did not include any interventions related to a wander guard, and staff failed to monitor and document the presence of the wander guard as required. Interviews with the ADON, DON, and Maintenance Supervisor revealed systemic issues in the monitoring and documentation processes for wander guards. The ADON and DON acknowledged that the nurses were responsible for checking the wander guards but failed to do so. The Maintenance Supervisor confirmed that he did not handle the wander guard system, focusing instead on door alarms. The Administrator admitted that it was an oversight on the part of the nurses to sign the MAR without verifying the presence of the wander guard bracelet. The facility's policies on wandering and elopement prevention were not adequately followed, leading to the deficiency in maintaining accurate medical records for the resident.
Failure to Maintain Infection Control During Peri Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of a CNA who did not follow proper hand hygiene protocols while providing peri care to a resident. The CNA did not use hand sanitizer between glove changes during the procedure, which involved cleaning the resident's peri area and buttocks. This lapse in protocol was observed during an inspection and confirmed through interviews with the CNA, ADON, DON, and the Administrator. The CNA admitted to not having hand sanitizer in her pocket and being in a hurry, which led to the oversight. The resident involved was a male with multiple diagnoses, including diabetes mellitus type 2, epilepsy, high blood pressure, urine retention, and mood disorder. He had moderate cognitive impairment and required substantial assistance with daily activities. The facility's policy for perineal care clearly stated the need for hand hygiene before and after glove use, but this was not adhered to during the observed procedure. The ADON, DON, and Administrator all acknowledged the importance of hand hygiene and the risk posed by the failure to follow proper procedures.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit abuse and neglect for one resident. Specifically, the facility did not report allegations of abuse made by a resident within the required timeframe. The resident, a male with Parkinson's disease, Type 2 Diabetes Mellitus, cognitive communication issues, and Schizoaffective Disorder, Bipolar Type, made repeated allegations of abuse against the DON and ADON. Despite these allegations, the incident was not reported to the state agency within the mandated 2-hour window, as required by the facility's policy. Interviews with the ADON, DON, and former Administrator revealed a lack of clarity and communication regarding the reporting of abuse allegations. The ADON documented the resident's allegations but did not report them to the state, believing the incident did not constitute abuse. The DON was unaware of the written witness statement and did not consider the incident reportable. The former Administrator could not recall instructing the ADON to document the incident and was uncertain whether it should have been reported. This failure to report the allegations as required could place residents at risk of unreported abuse, neglect, and exploitation.
Failure to Report Allegations of Abuse Timely
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation was made. Specifically, the facility did not report Resident #1's allegations of abuse to the state agency within the required timeframe. Resident #1, a male with diagnoses including Parkinson's disease, Type 2 Diabetes Mellitus, Cognitive communication, and Schizoaffective Disorder, Bipolar Type, made repeated allegations of abuse against the ADON. Despite these allegations, the incident was not reported to the state agency as required by law. Interviews with the ADON, DON, and former Administrator revealed a lack of clarity and adherence to the facility's policy on reporting abuse. The ADON documented the incident but did not report it, following the Administrator's instructions. The DON was unaware of the written witness statement and did not consider the incident reportable. The former Administrator could not recall the specifics of the incident but emphasized that all abuse allegations should be reported to the state. The facility's policy mandates that any person with reasonable cause to believe that an elderly or incapacitated adult is suffering from abuse must report it to the DON, Administrator, state, and/or adult protective services immediately.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge of a resident and the reasons for the transfer or discharge in writing. The resident, a male with diagnoses including Parkinson's disease, Type 2 Diabetes Mellitus, cognitive communication issues, and Schizoaffective Disorder, Bipolar Type, was discharged to a psychiatric hospital for evaluation and treatment. Despite the resident being cognitively intact and able to understand and communicate effectively, the facility did not provide the required notification to the Ombudsman, which is a violation of the facility's policy and regulatory requirements. The Social Worker responsible for issuing 30-day notices and assisting with discharges stated that the resident was sent to a psychiatric unit at his request and never returned. The Administrator at the time confirmed that the facility did not allow the resident to return after the psychiatric evaluation, citing the facility's inability to meet the resident's needs. However, the Administrator admitted to being unsure of the proper discharge procedures and policies, and the necessary paperwork was not properly managed or located. The Ombudsman confirmed that she was not notified of the resident's discharge. The facility's policy requires that the Ombudsman be notified of all discharges, including emergency transfers, to ensure proper follow-up and assistance with placement if needed. The failure to notify the Ombudsman and properly manage the discharge process placed the resident at risk of not having other placement options and violated regulatory requirements for resident transfers and discharges.
Failure to Re-Admit Resident After Psychiatric Hospitalization
Penalty
Summary
The facility failed to admit a resident back after he was sent to a psychiatric hospital, violating their own policy on permitting residents to return after hospitalization. The resident, who had diagnoses including Parkinson's disease, Type 2 Diabetes Mellitus, and Schizoaffective Disorder, was sent to a psychiatric hospital at his request. Despite a physician's discharge summary indicating that the resident was to return to the facility after evaluation and treatment, the facility did not allow him to return, citing an inability to meet his needs without providing specific reasons. Additionally, the facility did not issue the required 30-day discharge notice to the resident, leaving him feeling emotionally drained and homeless. Interviews with the Social Worker and the former Administrator revealed that the facility did not follow its policy and procedure for discharges. The Social Worker confirmed that the resident was sent out and never returned, while the former Administrator admitted that the facility refused to accept the resident back and failed to issue a 30-day discharge notice. The facility's policy clearly states that residents should be allowed to return after hospitalization unless specific exemptions apply, and that proper documentation and notification procedures must be followed, which were not adhered to in this case.
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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