North Star Ranch Rehabilitation And Health Care Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Bonham, Texas.
- Location
- 709 W Fifth St, Bonham, Texas 75418
- CMS Provider Number
- 675471
- Inspections on file
- 29
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at North Star Ranch Rehabilitation And Health Care Ce during CMS and state inspections, most recent first.
A resident with multiple complex conditions, including post-stroke hemiplegia, dysphagia, psychiatric disorders, and existing skin impairment, was discharged to another nursing facility without a physician discharge order, IDT discharge plan, or completed discharge summary in the EMR. Despite staff describing a process that should include a face sheet, med list, pertinent labs, recent MD documentation, and a discharge assessment or transfer form with a nurse-to-nurse report, the DON confirmed that no transfer form, discharge assessment, or discharge summary was completed, and there was no documentation that current orders, care plan, psychiatric notes, or H&P were sent. This conflicted with facility policy requiring transmission of practitioner contact information, advance directive details, special instructions or precautions, comprehensive care plan goals, and all necessary clinical information to the receiving provider.
The facility failed to implement RD nutrition recommendations for four residents, including those with celiac disease, COPD, diabetes, heart failure, protein‑calorie malnutrition, chronic foot ulcer, dysphagia, and tube feeding. The RD documented recommendations such as ice cream twice daily, a sugar‑free health shake between meals, Prostat 30 cc BID, and Med Pass 2.0 120 cc BID, but these were not entered as physician orders in the EMR, and there was no documentation that the MD was notified to accept or decline them. Residents reported not receiving the recommended supplements, and meal observations confirmed items like ice cream were not provided or listed on diet tickets. The Food Service Supervisor stated she had not received the January recommendations, the RD reported she expected recommendations to be acted upon within 72 hours, and the MD confirmed he had not been notified. The DON and ADON acknowledged that follow‑up on these recommendations had not been completed, contrary to facility policy requiring timely follow‑up and documentation when recommendations are not adopted.
The facility did not maintain adequate nursing staff levels to meet resident care needs, resulting in delayed or missed medication administration for a resident with Parkinson's disease, missed scheduled showers for another resident requiring assistance, and a third resident not being able to get out of bed as requested. Staff and management interviews, along with staffing records, confirmed that staffing levels frequently fell below the facility's own assessment requirements, especially on weekends and night shifts.
A resident with Parkinson's disease did not receive prescribed medications within the scheduled time frames on multiple occasions. Staff administered doses late, failed to give some doses, and documented medications as given without actual administration. The physician and DON were not notified of these deviations, and facility policy requiring timely and accurate medication administration was not followed.
A resident requiring substantial assistance with bathing did not consistently receive scheduled showers, particularly on Saturdays, due to frequent staffing shortages. Although records indicated showers were provided, both the resident and multiple staff confirmed that showers were missed, and nursing leadership was aware of the issue. Facility policy required assistance with hygiene for residents unable to perform these tasks independently.
A dietary aide continued to work in the kitchen with an expired Food Handler Certificate due to lack of monitoring by the Dietary Manager and absence of a facility policy. The aide was aware of the expiration but did not renew the certificate because of financial reasons, and the Interim Administrator was unaware of the lapse or its risks.
A resident with significant mobility and self-care deficits did not receive physician-ordered PT and OT services for seven days due to confusion and oversight following an appeal process. The lapse occurred when the DOR failed to add the resident back to the therapy schedule, and facility leadership was unaware of the missed sessions until after the fact.
Several residents were found to have heating and cooling vents in their rooms covered in a black mold-like substance, with some also present on nearby ceiling tiles. Staff interviews revealed confusion over who was responsible for cleaning the vents, and the maintenance director admitted the vents had not all been cleaned. None of the affected residents had respiratory diagnoses or symptoms, and their care plans did not address environmental cleanliness.
A medication aide failed to ensure a resident received their prescribed morning dose of Protonix, leaving the unlabeled pill unsecured on the bedside table for several hours after the resident declined it. Nursing staff confirmed that medications should not be left at the bedside and should be discarded if refused, but this was not done in this instance.
Multiple residents were not adequately supervised, resulting in incidents such as a resident sustaining a cigarette burn, residents assessed as unsafe smokers accessing smoking materials and smoking in unsafe areas without supervision, and a resident with cognitive impairment having unsecured disposable razors left in his room. Staff interviews revealed confusion and lack of awareness regarding supervision requirements and facility policy.
A resident was found with medications and shaving cream left unsecured in their room, without a physician order or assessment for self-administration. Staff interviews confirmed that these items should have been stored in locked compartments or designated storage areas, in accordance with facility policy.
The facility did not ensure that saline eyewash solutions in the kitchen, laundry, medication room, and shower room were within expiration dates, as all reviewed eyewash stations contained expired solutions. Staff interviews revealed confusion about responsibility for monitoring and replacing the solutions, and the facility's policy requiring removal of outdated biologicals was not followed.
Four residents requiring oxygen therapy did not have proper physician orders or documentation, with some receiving oxygen without an order and others not receiving oxygen as ordered. Staff were unaware of missing or incorrect orders, and required signage for oxygen use was not consistently present, resulting in care that did not meet professional standards.
Several residents reported receiving cold, bland, or unappetizing food, and surveyors observed meal service delays and improperly prepared food, with staff citing recipe restrictions and equipment limitations as contributing factors.
A resident with schizoaffective and bipolar disorder was administered Seroquel 25 mg without valid written consent on the required HHSC form, as only a consent for a different dosage was on file. The ADON and Administrator confirmed the oversight, and the facility did not provide a policy on psychotropic medications when requested.
A resident with COPD who required continuous oxygen therapy was unable to leave his room for several days due to the facility's lack of portable oxygen. Despite notifying staff and the Administrator, the resident was not provided with an alternative, resulting in missed activities and restricted mobility.
A resident with Parkinson's disease and intact cognition had an incomplete OOH-DNR form, missing the MPOA's printed name, signature date, and notary signature. Staff interviews revealed confusion over responsibility for DNR documentation, and facility policy required proper inquiry and respect for advance directives.
A resident with moderate cognitive impairment and acute kidney failure was not given a SNF ABN when discharged from Medicare Part A skilled services before covered days were exhausted. Staff interviews confirmed the required notice was not provided, and the facility lacked a policy for issuing SNF ABNs.
A CNA witnessed a resident strike another resident and reported the incident to an LVN, who found no injuries and informed the ADON and Administrator. The incident was not reported to authorities within the required timeframe, and no incident or skin assessment was completed. Facility leadership did not interview the involved residents or ensure proper documentation, resulting in a failure to follow abuse reporting protocols.
A CNA witnessed a resident with behavioral issues physically contact another resident with dementia, but the incident was not thoroughly investigated or reported as required. Although an LVN assessed the alleged victim and found no injuries, no incident report or skin assessment was completed, and the event was not reported to the state agency. Interviews revealed that the Administrator and ADON did not interview the involved parties or ensure proper documentation, contrary to facility policy.
Two residents were affected by inaccurate MDS assessments: one was incorrectly documented as having a feeding tube, and another was mistakenly coded as using a restraint when she actually used a transfer assist bar for mobility. Staff interviews and record reviews confirmed these errors, which were attributed to mistakes in coding and documentation.
Two residents with cognitive impairments and medical needs were observed using oxygen, but their care plans and physician orders did not reflect this intervention. Staff interviews revealed confusion over care plan responsibilities, and facility policy requiring comprehensive, updated care plans was not followed.
A resident receiving Eliquis for atrial fibrillation and a knee prosthesis infection was not monitored for side effects of anticoagulant therapy, despite care plan requirements. Nursing staff and leadership confirmed that monitoring was not documented or entered into the electronic record, and there was no facility policy in place for anticoagulant monitoring.
A resident with a history of seizures and other medical conditions did not receive required routine laboratory tests, including a Comprehensive Metabolic Panel and anti-seizure medication levels, as ordered by the physician. Staff interviews revealed a lack of awareness and an ineffective lab monitoring system, resulting in missed labs and non-compliance with facility policy.
A resident with a seizure disorder had laboratory results indicating subtherapeutic levels of Dilantin and Phenobarbital, but the physician was not notified of these abnormal results until 20 days later, after a surveyor intervened. The delay occurred due to assumptions about physician access to electronic records and a lack of clear responsibility for physician notification, despite facility policy requiring prompt communication of abnormal labs.
A resident with severe cognitive impairment and a mechanically altered diet order was served a ground beef patty instead of the prescribed ground chicken fried chicken. Dietary staff substituted the entree to reserve enough chicken for other residents, and the error was not identified by the charge nurse or dietary manager until after the meal was served, contrary to facility policy requiring adherence to resident menu choices.
The facility did not adhere to professional food safety standards, as evidenced by an unclean ice scoop holder with visible sediment and the failure to dispose of expired boiled eggs in the refrigerator. Staff and administration confirmed that cleaning and food disposal procedures were not followed according to facility policy.
A trash can in the designated smoking area was found to contain a smoked cigarette, rather than only trash. A laundry aide and the administrator both confirmed that staff supervising residents during smoking should ensure cigarettes are extinguished in the proper receptacle, as outlined in the facility's smoking policy.
The facility did not post daily nurse staffing data at the beginning of each shift for two days, displaying outdated information instead. The ADON, responsible for this task in the absence of a DON, missed completing and posting the required forms due to being busy and was unaware of the potential risks to residents. The Administrator confirmed the expectation for daily posting and acknowledged that the failure could prevent residents and families from knowing the staffing levels.
A resident with multiple health conditions fell and sustained serious injuries shortly after being admitted to a facility. The fall occurred because the bed was not properly locked during wound care. Staff believed the bed was secure, but it moved, causing the resident to fall. The facility's fall prevention policy was not fully implemented due to the resident's brief stay.
A resident with multiple health conditions fell from her bed shortly after admission, sustaining serious injuries, including a fractured orbital floor and cervical spine fractures. The facility failed to report the incident to the state agency as required, due to communication breakdowns and a lack of understanding of reporting responsibilities among staff.
The facility failed to maintain a clean and homelike environment in two halls. Hall 200 had a persistent urine odor due to a shortage of cleaning supplies and staff, while several room floors on hall 100 remained dirty despite cleaning efforts. Additionally, a resident's room had peeling wallpaper that was not reported for maintenance. The facility lacked a housekeeping supervisor and a deep cleaning schedule.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. One resident's fall and use of Xanax, another's use of Eliquis, and a third's use of a [NAME] button for enteral feedings were not included in their care plans until after state surveyor intervention.
The facility failed to ensure that a resident requiring respiratory care had physician orders for her Bipap machine, leading to potential risks due to unknown settings. This was confirmed through observations, interviews, and record reviews, highlighting a significant oversight in maintaining proper respiratory care standards.
The facility failed to ensure that nurses were trained on the use of a Bipap machine for a resident with respiratory conditions, leading to a lack of proper care and potential respiratory issues. Interviews and record reviews revealed that nurses were not adequately trained, and competency checks were not performed as required by facility policy.
The facility failed to ensure that a resident's quarterly MDS assessment was electronically completed and transmitted to the CMS System within 14 days after completion. The MDS nurse admitted to accidentally checking the section not to transmit the assessment, leading to the delay.
The facility failed to maintain a safe environment in Hall 100 due to cracked and uneven flooring and did not secure an oxygen cylinder in the storage area, posing safety risks. Staff and administration were aware of these issues but had not yet implemented specific plans to address them.
The facility failed to establish a system for the receipt and disposition of controlled drugs, leading to unaccounted medications. The DON was responsible for the discontinued medications but was unable to find the current log, indicating a lapse in documentation. The Administrator confirmed that narcotic medications should be logged upon receipt, but this was not done, risking missing and unaccounted-for drugs.
The facility failed to meet residents' nutritional needs by not serving hot spiced apples and not following the puree recipe for chicken fettuccine alfredo, using water instead of milk. This affected residents requiring pureed food consistency, risking inadequate nutrition.
The facility failed to maintain an infection prevention and control program, leading to improper hand hygiene during a resident's bolus feeding and inadequate separation of clean and dirty linens. These lapses placed residents at risk for infection.
Failure to Complete and Communicate Required Discharge Documentation
Penalty
Summary
Surveyors identified a failure to ensure that discharge information was documented in the medical record and appropriately communicated to the receiving provider for one resident. The resident was an older female with multiple significant diagnoses, including cerebral infarction with right-sided hemiplegia, dysphagia, hyperlipidemia, Buerger's disease, psychotic disorder, and major depressive disorder. Her MDS showed short- and long-term memory deficits, modified independence in decision-making, inattention, disorganized thinking, verbal behaviors, and dependence in most ADLs with a mechanically altered diet. Her care plan included DNR status, behavior issues such as yelling and cursing at staff, refusal of psychiatric treatment and incontinent care, use of bedside loops, anticoagulant use, contractures, foot drop, and an existing skin impairment. Record review showed that, despite this complex clinical profile, the resident’s EMR contained no physician’s order to discharge, no Interdisciplinary Team discharge plan, and no completed discharge summary. The care plan had a closing date, but there was no documentation of the required discharge elements such as the practitioner’s contact information, advance directive information, special instructions or precautions for ongoing care, or comprehensive care plan goals being included in the discharge documentation. The DON reported that the discharge nurse only completed a progress note indicating the resident was transferred via ambulance with medications and personal belongings, without documenting the receiving location or whether a report was called and clinical records were sent. Interviews with LVNs and the DON revealed that staff understood, in general terms, that discharges should include a face sheet, medication list, pertinent labs, recent physician documentation, and a discharge assessment or transfer form, and that a nurse-to-nurse report should be called to the receiving facility. However, for this resident, the DON confirmed that neither a transfer form nor a discharge assessment and discharge summary were completed, and there was no documentation that current physician’s orders, care plan, psychiatric notes, or a history and physical were sent to the accepting facility. The facility’s own policy required that specific information, including practitioner contact information, resident representation and advance directive information, special instructions or precautions, comprehensive care plan goals, and all necessary clinical information, be conveyed to the receiving provider, but this was not documented for the resident’s discharge to another nursing facility of her choice.
Failure to Implement RD Nutrition Recommendations for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents maintained acceptable nutritional status by not implementing or acting upon registered dietician (RD) recommendations for four residents. For the first resident, who had celiac disease and cystic fibrosis with intestinal manifestations, the RD documented a recommendation for ice cream twice daily with lunch and dinner to address nutritional needs. The electronic medical record (EMR) contained no corresponding physician order, and there was no documentation that the physician had been notified to accept or decline the recommendation. The resident’s care plan referenced RD evaluation and diet change recommendations as needed, but the diet order remained unchanged since its original entry, and the resident reported never receiving ice cream with meals. Observation of a lunch meal confirmed that ice cream was not provided and was not listed on the tray ticket. For the second resident, who had COPD, hypertension, diabetes type II, heart failure, and obesity, the RD recommended a sugar-free health shake once daily between meals. The EMR showed no order for the health shake and no documentation that the physician had been contacted regarding the recommendation. The resident’s care plan included interventions for providing diet as ordered and RD evaluation as needed, but the diet order had not been updated since its original date. The resident stated he had not received a health shake between meals and did not recall ever receiving one. Weight records showed a significant weight loss over a one‑month period, and there was no evidence that the RD’s recommendation had been translated into an active order or implemented. For the third resident, who had peripheral vascular disease, a chronic left foot ulcer, protein‑calorie malnutrition, anemia, and hypertension, the RD recommended ice cream with lunch and Prostat 30 cc twice daily for low albumin. The physician’s orders did not include ice cream with lunch or Prostat, and there was no documentation that the physician had been notified to accept or decline these recommendations. The care plan referenced a regular diet with house shake once daily, med pass twice daily, fortified cereal, and providing supplements as recommended or ordered, but the new RD recommendations were not reflected in the orders. The resident reported not receiving ice cream with lunch or a protein drink twice daily, and observation of a lunch meal confirmed that ice cream was not provided and not listed on the diet ticket. For the fourth resident, who had metabolic encephalopathy, cerebral infarction, Parkinsonism, dysphagia, and a feeding tube, the RD recommended Med Pass 2.0, 120 cc twice daily, to prevent further weight loss. The physician’s orders did not include Med Pass 2.0 twice daily, and the care plan focused on tube feeding with Jevity 1.5 and pleasure feedings, along with RD evaluation and monitoring of caloric intake. Nursing staff confirmed there was no order for Med Pass 2.0 twice daily. Interviews with the Food Service Supervisor indicated that dietary recommendations were to be provided to the DON for physician review and that nursing was responsible for entering orders into the EMR and notifying dietary so changes could be added to tray tickets; the supervisor reported not receiving any January recommendations for these four residents. The RD stated she provided recommendations within 24 hours of her visit and expected them to be acted upon with the physician within 72 hours, consistent with facility policy, but the physician later confirmed he had not been notified of the RD’s recommendations for these residents. The DON and ADON acknowledged that the recommendations had been assigned for follow‑up but were not completed, and the DON stated it was her responsibility to ensure timely physician notification, in accordance with the facility’s policy requiring consultant recommendations to be followed up within 72 hours and non‑accepted recommendations to be documented in the nurse’s notes and on the recommendation sheet.
Failure to Provide Sufficient Nursing Staff and Timely Care
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on a 24-hour basis to meet the care needs of all residents, as required by resident care plans and the facility assessment. On multiple occasions, medication administration for a resident with Parkinson's disease and other conditions was delayed beyond the scheduled time window, and in some cases, doses were not administered as ordered. Staff interviews revealed that these delays and omissions were due to short staffing, with medication aides and nurses reporting being the only staff available to administer medications during certain shifts. Documentation showed that staff did not always notify the physician or DON when medications were given late or missed, and some staff admitted to marking medications as given in the MAR without actually administering them. Another resident, who required substantial assistance with bathing due to impaired balance and other health issues, reported not receiving scheduled showers on Saturdays. Staff interviews confirmed that showers were sometimes missed due to short staffing, particularly on weekends. Staff described working across multiple areas of the building and being unable to complete all required care tasks. The facility's own assessment indicated a need for a specific number of CNAs per shift, but staffing records showed that these levels were not consistently met, especially on weekends and night shifts. A third resident, who was cognitively intact but required total assistance with mobility and ADLs, reported not being able to get out of bed as requested, particularly on weekends when staffing was low. Staff confirmed that there were times when only one or two aides were available for the entire building, making it difficult to provide timely care. Management interviews revealed a lack of awareness of the facility's staffing requirements and no policy for staffing, despite the facility assessment specifying minimum staffing levels. Review of staffing records over several months showed repeated instances where the number of CNAs and medication aides fell below the assessed requirements.
Failure to Administer Medications as Scheduled and Document Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident with Parkinson's disease and dyskinesia. The resident was prescribed Carbidopa-Levodopa and Buspirone to be administered three times daily. Record reviews showed that on multiple occasions, these medications were not administered within the scheduled time window, and in some cases, doses were either missed or documented as given without actual administration. Medication administration records indicated that staff administered the resident's morning medications late, outside the scheduled 7:00 a.m. to 10:00 a.m. window, and the noon doses were either not given or were documented as given close to the previous dose. Staff interviews revealed that the late administration was due to short staffing, and in some instances, staff marked medications as given on the Medication Administration Record (MAR) without actually administering them. Staff did not notify the physician or the Director of Nursing (DON) about the late or missed doses, nor about the documentation discrepancies. Further interviews with the Assistant Director of Nursing (ADON), DON, and the attending physician confirmed that medications should be administered within a specific time frame and that deviations should be reported. The facility's policy required medications to be administered safely, timely, and as prescribed, with staffing arranged to prevent interruptions. However, the facility did not ensure adherence to these procedures, resulting in the resident not receiving medications as scheduled.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
A deficiency occurred when a female resident with diagnoses including congestive heart failure and schizoaffective disorder, who required substantial assistance with bathing, did not consistently receive scheduled showers on Saturdays. The resident was cognitively intact and her care plan specified that staff were to assist with bathing, particularly washing her back areas. Although the facility's records indicated that all scheduled showers were provided, the resident reported missing showers on Saturdays, attributing this to staff shortages. Multiple staff interviews confirmed that there were frequent staffing shortages, especially on weekends, which led to missed showers for several residents, including this resident. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) acknowledged that when short-staffed, it was not always possible to provide all required care, including showers. One CNA stated she provided a shower to the resident after the resident reported missing her scheduled shower. Another staff member admitted to not giving any showers on a specific Saturday due to being assigned throughout the building and being short-staffed. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were aware of the missed showers, with the ADON stating she had completed charting under the impression that showers had been given, though they had not. The DON and Interim Administrator both acknowledged being informed by the resident about missed showers and confirmed that staff were responsible for ensuring showers were provided. The facility's policy required that residents unable to perform activities of daily living independently receive necessary assistance, including with hygiene and bathing.
Failure to Ensure Dietary Staff Maintained Current Food Handler Certification
Penalty
Summary
The facility failed to ensure that dietary staff maintained current Food Handler Certificates, specifically for one dietary aide. Record review showed that the dietary aide's Food Handler Certificate had expired prior to her continued service in the kitchen. The Dietary Manager acknowledged awareness of the expiration but did not monitor or ensure timely renewal of the certificate. The aide herself was aware of the expiration but did not renew due to financial constraints. The Dietary Manager and the human resources department were identified as responsible for tracking and maintaining these certifications, but neither took action to prevent the lapse. Interviews revealed that the Interim Administrator was unaware of the expired certificate and did not know the associated risks. Additionally, the facility did not have a policy in place regarding the maintenance of food handler certificates. The lack of oversight and absence of a formal policy contributed to the deficiency, resulting in dietary staff working without the required certification.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
A deficiency occurred when a resident did not receive physician-ordered physical therapy (PT) and occupational therapy (OT) services for a total of seven days in June. The resident, who was cognitively intact and had significant mobility and self-care deficits, was admitted with diagnoses including atrial fibrillation, muscle weakness, unsteadiness, and a cognitive communication deficit. Orders were in place for both PT and OT to be provided multiple times per week, but therapy was not delivered from 06/16/25 through 06/20/25 and again from 06/23/25 through 06/24/25, as confirmed by therapy logs and progress notes. The lapse in therapy services was linked to confusion surrounding the appeal process after a Notice of Medicare Non-Coverage (NOMNC) was issued. The responsible party (RP) communicated that the appeal was won, but therapy was not resumed promptly due to an oversight by the Director of Rehabilitation (DOR), who admitted to forgetting to add the resident back to the therapy schedule. During this period, the resident remained in bed and did not receive the ordered therapy, which was corroborated by both the resident and the RP during interviews. Interviews with facility staff, including the DOR, Assistant Director of Nursing (ADON), Director of Nursing (DON), and interim Administrator, revealed a lack of awareness regarding the missed therapy sessions. The DOR acknowledged responsibility for ensuring therapy was provided as ordered and attributed the failure to an oversight. The ADON and DON were not aware of the missed sessions, and the DON stated there was no policy in place regarding therapy provision. The interim Administrator also confirmed that the DOR was responsible for ensuring therapy orders were followed.
Failure to Maintain Clean and Sanitary Resident Room Vents
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for four residents by not ensuring that the heating and cooling vents in their rooms were free from a black mold-like substance. Observations on the specified date revealed that the vents in the rooms of these residents were visibly covered in this substance, with some also present on adjacent ceiling tiles. Multiple residents reported that the vents had appeared this way for several months, and at least one resident stated he had complained about the issue but could not recall to whom. None of the residents involved had documented pulmonary diagnoses or reported current respiratory symptoms. Interviews with staff, including a nurse, CNA, housekeeper, and the maintenance director, revealed a lack of clarity regarding responsibility for cleaning the vents. The nurse and CNA, both regularly assigned to the affected hall, had not noticed the black substance and were unsure whether housekeeping or maintenance was responsible for vent cleaning. The housekeeper stated that vent cleaning was not part of housekeeping duties and believed it was handled by maintenance. The maintenance director acknowledged that he had noticed the issue during the winter months and was in the process of cleaning the vents but had not completed the task. The facility's policy on providing a homelike environment requires a clean, sanitary, and orderly setting for residents. However, care plan reviews for the affected residents did not address the need for a clean environment or any respiratory issues. The ADON confirmed that maintenance was responsible for vent cleanliness and emphasized the importance of clean vents to prevent respiratory issues, particularly for residents with chronic pulmonary conditions.
Unsecured Medication Left at Bedside After Administration Refusal
Penalty
Summary
A deficiency occurred when a medication aide failed to ensure that a resident received their prescribed morning dose of Protonix, a medication used to treat GERD. The medication was left in an unlabeled, unsecured cup on the resident's bedside table for several hours after the resident declined to take it during the morning medication pass. The resident, who had diagnoses including Parkinson's disease, type II diabetes, a history of fracture, GERD, and chronic pulmonary embolism, was cognitively intact and able to make himself understood. Facility records indicated that the resident required supervision or moderate assistance with most activities of daily living, but could independently reposition and transfer except for tub/shower transfers. Interviews with nursing staff confirmed that medications should not be left at the bedside and that any refused medication should be properly discarded. The medication aide responsible for the morning pass acknowledged not ensuring the resident took all medications and not removing the refused pill. The facility's policy required medications to be administered as ordered and within one hour of the prescribed time, and specified that only residents with physician approval could self-administer medications. However, the policy did not address leaving unlabeled medications at the bedside.
Failure to Prevent Accident Hazards and Inadequate Supervision of Smoking and Sharp Objects
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident, who had a history of seizures and required assistance with daily activities, sustained a cigarette burn on his thigh after dropping a cigarette while smoking. Documentation showed that he was assessed as an unsafe smoker and required supervision and a smoking apron, but on observation, he was not wearing the apron while smoking under supervision. There was no evidence that the incident was reported to the state, and staff interviews revealed a lack of awareness and follow-up regarding the incident and required interventions. Another resident, diagnosed with multiple sclerosis and assessed as an unsafe smoker, was allowed to sign out and smoke in an unsafe area without supervision and kept cigarettes, a vape, and a lighter in his possession. Staff interviews indicated confusion about the resident's supervision requirements and the facility's smoking policy, with some staff believing the resident could make his own decisions despite being deemed unsafe. Observations confirmed that the resident was unsupervised while smoking and vaping, and staff were unaware of the full extent of his access to smoking materials. Additional deficiencies included a resident assessed as a safe smoker who was observed smoking on the side of a residential street after signing out, and another resident with severe cognitive impairment who also signed herself out to smoke in an unsafe area. Furthermore, a resident with moderate cognitive impairment and dependence on staff for personal hygiene was found to have seven disposable razors stored insecurely in his room, accessible on top of his mini refrigerator. Staff acknowledged that razors should not be left in resident rooms and should be disposed of in sharps containers after use, but the razors remained accessible for an extended period.
Removal Plan
- Residents #22, #48, and #32 will be supervised when in an unsafe area. The physician was notified of both the smoking and residents leaving safe supervised area.
- All smoking assessments were audited for accuracy and care plan updated as indicated. Residents #22, #48, and #32 were reassessed and evaluation determined they are safe smokers and able to vape safely. Resident #25 was reassessed and evaluation determined he is an unsafe smoker.
- All smokers were reassessed, and changes made to safe or unsafe smoking, including vaping as indicated.
- Assessments completed by Corporate Clinical Specialist and Corporate Case Mix. Residents assessed to be unsafe will be supervised and smoking supplies will be held at the nurse's station. Residents assessed to be a safe smoker will be able to smoke unsupervised at their leisure in the designated smoking area.
- An emergency care plan meeting was conducted with residents (#22, #48, #32, and #25) regarding safe supervision and smoking policy, to include vaping. Residents #22, #48 and #32 were informed they can smoke only in the smoking area of the facility. Resident #25 was informed that he remains an unsafe smoker and must be supervised. All smoking residents were educated in regards to the smoking area of the facility and informed that location is the only place they can smoke. Care plans updated as indicated to include education regarding safety plan and pedestrian safety.
- Ombudsman notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn.
- Medical Director notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn.
- Corporate Clinical Specialist in-serviced Administrator and ADON regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, smoking assessment accuracy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz.
- Facility Administrator and ADON in-serviced all staff regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz. Staff will not be allowed to work until completion.
- Corporate Clinical Specialist in-serviced staff on residents that are safe smokers and those that are not, and how to find that information.
- Corporate Clinical Specialist, or designee, in-serviced licensed nurses on completing smoking risk assessment accurately as related to current health concerns/conditions, resident capabilities, and resident smoking material preference (cigarettes and/or electronic cigarettes). In-service included that Licensed Nurses are responsible for completing the smoking assessments upon admission, change of condition, and quarterly.
- The above training regarding Accident/Hazard Supervision, specifically in regard to safe smoking and safe supervision will be implemented into new hire orientation.
- To monitor compliance, residents will be monitored by the DON/designee through observations and communication with staff daily and monthly.
- DON/designee will review smoking assessments weekly and monthly.
- The QA committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, the facility will continue to be monitored as per the routine facility QA committee.
Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments accessible only by authorized personnel, as required by policy. During observations, a resident was found with a bottle of fluticasone propionate nasal spray and biotene dry mouth moisturizing spray on his bedside table, and a can of barbasol shaving cream on his windowsill. Record review showed that there were no physician orders addressing the use of these items, and the resident had not been assessed for self-administration of medications. The baseline care plan indicated the resident required assistance with personal hygiene and oral care. Interviews with staff revealed that the resident's family member often brought in medications and other items, and that the resident had not been evaluated for self-administration. Staff confirmed that medications should be stored on the medication cart and shaving cream in the storage closet or shower room, not left at bedside. Facility policy required all drugs and biologicals to be stored securely in locked compartments, but this was not followed in the case of this resident.
Expired Saline Eyewash Solutions at Multiple Facility Locations
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment by not ensuring that saline eyewash solutions at four locations—the kitchen, laundry, east wing medication room, and east wing shower room—were within their expiration dates. Observations revealed that all reviewed eyewash stations contained expired saline solutions, with specific expiration dates noted on the bottles. Staff interviews confirmed that the expired solutions had not been replaced, and there was confusion among staff regarding responsibility for monitoring and replacing the eyewash solutions. The maintenance staff member acknowledged responsibility for checking the eyewash stations but admitted to missing the scheduled checks, and the dietary supervisor indicated that replacements had not been available when needed. Further interviews with staff, including a registered nurse, a certified nursing assistant, the assistant director of nursing, and the administrator, revealed a lack of clarity regarding the monitoring process and policy adherence for eyewash solution expiration. The facility's policy on the storage of drugs and biologicals requires that outdated or deteriorated items be returned or destroyed, but this was not followed for the eyewash solutions. No information about residents' medical history or condition was provided in relation to this deficiency.
Failure to Ensure Proper Orders and Documentation for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care consistent with professional standards for four residents who required oxygen therapy. For one male resident with metabolic encephalopathy, oxygen was administered via nasal cannula at 2 liters per minute, but there was no physician's order for oxygen in his chart. The resident reported using oxygen continuously due to shortness of breath, and both the charge nurse and ADON were unaware of the missing order until notified by the surveyor. The ADON stated that orders were entered based on hospital discharge paperwork, and if oxygen was not listed, it was not entered. The administrator confirmed that nursing management was responsible for ensuring orders were documented and placed in the electronic medical record. Another female resident with dementia, shortness of breath, diabetes, and hypertension had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, during observation, she was found in bed without oxygen, and there was no oxygen concentrator in her room. The resident was unable to confirm if she used oxygen, and her MDS assessment did not indicate oxygen use during the look-back period, despite the care plan requiring it. A third female resident with a history of UTI, stroke, diabetes, and hypertension was observed receiving oxygen at 3 liters per minute via nasal cannula, but there was no physician's order for oxygen until after surveyor intervention. Additionally, there was no oxygen sign on her door as required by facility policy. A fourth female resident with apraxia, shortness of breath, hypertension, dementia, and depression was also found to be using oxygen without a corresponding physician's order in the record until after surveyor intervention. Staff interviews revealed a lack of awareness regarding the need for written orders and proper documentation for oxygen therapy, and the facility's policy required verification of a physician's order prior to administration.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
Surveyors found that the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for several residents and during one observed meal. Multiple residents reported receiving cold, bland, or unappetizing food, with one resident specifically noting a burned roll that was inedible. Observations during meal service revealed issues with tray delivery, as staff had difficulty locating and serving trays efficiently, resulting in delays. During a sampled lunch, surveyors and the Dietary Manager noted that some food items were not fully cooked, bland, or not warm. Interviews with staff, including the Dietary Manager, ADON, and Executive Director, confirmed awareness of the issues, with explanations citing recipe adherence, lack of seasoning due to dietary restrictions, and logistical challenges such as insufficient food carts. The Dietary Manager acknowledged being in training and expressed concerns about the ability to serve hot food due to equipment limitations. Staff agreed that residents should receive hot and palatable meals, and recognized that the current practices were not meeting this expectation.
Failure to Obtain Written Consent for Psychoactive Medication Administration
Penalty
Summary
The facility failed to obtain valid written consent for the administration of a psychoactive medication, Seroquel 25 mg, for a resident with schizoaffective disorder and bipolar disorder. Although there was a signed consent form for Seroquel 50 mg, there was no written consent on the required HHSC Form 3713 for the 25 mg dosage that was actively being administered. The resident had a moderately impaired cognition, as indicated by a BIMS score of 10, and was taking antipsychotic medication daily during the review period. The care plan documented the use of psychotropic medication for schizophrenia and psychotic disorder, with interventions to administer medications as ordered and consult with pharmacy. Interviews with the ADON and Administrator revealed that responsibility for obtaining the correct psychotropic medication consents rested with the ADON and DON. The ADON acknowledged that the consent for the correct medication and form was present, but the dosage did not match the current order, and this discrepancy was missed during recent audits. The facility did not provide a policy regarding psychotropic medications when requested by surveyors.
Failure to Provide Portable Oxygen Restricted Resident's Mobility
Penalty
Summary
The facility failed to ensure that a resident with COPD who required continuous oxygen therapy had access to portable oxygen, which prevented him from leaving his room. The resident reported being confined to his room for several days due to the unavailability of portable oxygen, missing facility activities as a result. He stated that he had informed several staff members and the Administrator about the issue, but no alternative options were provided, and the portable oxygen was still not delivered. Record reviews confirmed the resident's diagnosis of COPD and the physician's order for continuous oxygen via nasal cannula. The care plan included monitoring for respiratory compromise. The Administrator acknowledged being informed about the shortage of portable oxygen and stated that he contacted the DME company to order more but did not seek alternative sources to bridge the gap. The facility's policy requires residents to receive adequate and appropriate care and services, including a physical environment that ensures their well-being.
Incomplete OOH-DNR Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was completed in accordance with requirements. Specifically, the OOH-DNR for a male resident with Parkinson's disease, who was cognitively intact and aware of his DNR status, was missing the Medical Power of Attorney's (MPOA) printed name, the date the document was signed by the MPOA, and the notary's signature. The resident's care plan indicated he was a DNR and that his advanced directive options and rights were to be reviewed with him and his family. Interviews with facility staff revealed confusion regarding responsibility for ensuring DNR forms were properly completed. The Regional Social Worker acknowledged the missing information on the resident's OOH-DNR and stated that the Administrator and Director of Nursing (DON) were responsible for overseeing DNR accuracy. The Administrator confirmed the expectation that DNRs be fully completed, including all required signatures and dates, and identified the Regional Social Worker as responsible for monitoring DNRs. Facility policy required inquiry about advance directives upon admission and respect for such directives in accordance with state law.
Failure to Provide SNF ABN Notification for Medicare Coverage Change
Penalty
Summary
The facility failed to inform a resident of changes in Medicare coverage and potential financial liability for services not covered, as required. Specifically, a male resident with acute kidney failure and moderate cognitive impairment, who was receiving occupational and physical therapy, was not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when he was discharged from Medicare Part A skilled services before his covered days were exhausted. This notice would have informed him of his option to continue services at his own expense. Interviews with facility staff, including the Regional Financial Specialist and the Administrator, confirmed that the Business Office Manager (BOM) was responsible for issuing the SNF ABN but failed to do so. The staff acknowledged the importance of providing the form to ensure the resident was aware of his financial responsibilities. Additionally, it was revealed that the facility did not have a policy regarding the issuance of SNF ABNs.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of resident-to-resident abuse was reported to the appropriate authorities within the required timeframe. Specifically, a CNA witnessed one resident strike another on the right arm and immediately reported the incident to an LVN. The LVN assessed the resident for injuries, found none, and reported the incident to the ADON and Administrator. Despite this, the incident was not reported to the state agency within two hours as required by regulation. The Administrator did not report the incident, stating that there was no injury and that the resident who was allegedly struck denied being hit. The Administrator also did not interview either resident involved in the incident. The ADON was under the impression that another resident had witnessed the event and did not speak to the involved residents or instruct the LVN to complete an incident report or skin assessment. The Executive Director stated that reporting was not necessary due to the cognitive status of the resident who allegedly struck the other. Record review showed that no incident or skin assessment was completed for either resident. The facility's own Abuse Prohibition Policy requires all allegations of abuse to be reported immediately or within two hours. The failure to report the witnessed incident of potential abuse in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate and Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and respond to an alleged incident of abuse involving two residents. According to the report, a CNA witnessed one resident, who has a history of behavioral issues and severely impaired cognition, physically contact another resident on the right arm. The CNA immediately reported the incident to an LVN, who assessed the alleged victim for injuries and found none. The LVN then reported the incident to the ADON and Administrator. Despite this, no incident report or skin assessment was completed, and the event was not reported to the state agency as required by facility policy. The resident who was allegedly struck has a diagnosis of dementia/Alzheimer's and impaired cognitive function, but was documented as able to make herself understood and understand others. The resident who allegedly struck her has paranoid schizophrenia, a BIMS score indicating severe cognitive impairment, and a documented history of behavioral symptoms directed toward others. The care plans for both residents included interventions for their respective cognitive and behavioral issues, but there is no documentation that these interventions were reviewed or updated in response to the incident. Interviews with facility staff revealed confusion and lack of follow-through regarding the reporting and investigation process. The Administrator and ADON did not interview the residents involved or the CNA who witnessed the incident, and the Administrator stated he did not report the incident to the state agency because there was no injury. The ADON stated she expected an incident report and skin assessment to be completed, but this was not done. The facility's Abuse Prohibition Policy requires thorough investigation and timely reporting of all allegations, which was not followed in this case.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one male resident with a history of paranoid schizophrenia and severe cognitive impairment, the quarterly MDS assessment incorrectly indicated the presence of a feeding tube, despite documentation and staff interviews confirming that he had not had a feeding tube for several years. The resident's care plan did not address a feeding tube, and both the MDS Coordinator and ADON acknowledged the error, attributing it to a mistake in coding. For a female resident with multiple sclerosis and intact cognition, the quarterly MDS assessment inaccurately documented the use of a restraint. In reality, the resident used a transfer assist bar to aid with movement, which was not considered a restraint according to facility staff and regional case mix personnel. The resident's care plan described the use of hand hoops and transfer bars for positioning and self-care, but not as restraints. Staff interviews confirmed the coding error and emphasized the importance of accurate assessments for proper care planning.
Failure to Care Plan Oxygen Use for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all the needs of two residents, specifically regarding their use of oxygen. For one resident, documentation showed she was severely cognitively impaired and required extensive assistance with daily activities. Although she was observed using oxygen and reported needing it for two years, her care plan and physician orders did not reflect this intervention. The omission was confirmed through record review and direct observation. Another resident, who was moderately cognitively impaired and had diagnoses including apraxia, dyspnea, and dementia, was also observed using oxygen. However, her care plan did not include oxygen use, and physician orders for oxygen were only updated after surveyor intervention. Prior to this, the only related order was for changing oxygen tubing as needed for infection control, with no standing order for oxygen administration documented in her records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, particularly for acute changes such as new oxygen orders. The MDS nurse, ADON, and other staff acknowledged that care plans should have included oxygen use for these residents but cited gaps in communication and documentation as reasons for the oversight. Facility policy requires comprehensive care plans to be developed and updated to reflect residents' current needs, but this was not followed in these cases.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for side effects of the anticoagulant medication Eliquis. The resident, a cognitively intact female with diagnoses including atrial fibrillation and atherosclerotic heart disease, was prescribed Eliquis for atrial fibrillation and for an infection and inflammatory reaction due to a knee prosthesis. The care plan required staff to monitor and document any adverse reactions to anticoagulant therapy, such as bleeding, bruising, or changes in mental status. However, review of the medication administration record showed no evidence that monitoring for side effects was performed during the specified period. Interviews with nursing staff and facility leadership revealed that the responsibility for entering and ensuring monitoring for anticoagulant side effects was not fulfilled. The nurse assigned to the resident did not see any monitoring listed in the electronic record, and the ADON acknowledged that the monitoring was overlooked and not added to the computer system. The facility did not have a policy on anticoagulant monitoring or medication administration, and the lack of monitoring was attributed to an oversight by the admitting nurse and a lack of backup checks by other staff.
Failure to Ensure Timely Laboratory Services for Resident
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered for one resident, resulting in missed routine laboratory tests. Specifically, a male resident with a history of seizures, anemia, glaucoma, and high blood pressure did not have his Comprehensive Metabolic Panel (CMP) drawn every six months as ordered, nor were his Phenobarbital and Dilantin levels checked every three months as required by physician orders. Review of the resident's electronic health record showed that the last CMP was drawn in July, and the last Phenobarbital and Dilantin levels were drawn in November, with no subsequent labs documented. Interviews with facility staff revealed that nurses were responsible for entering lab orders into the electronic system, which was accessible to the outside lab company. However, the ADON admitted to being unaware of the missed labs until questioned by the surveyor and acknowledged the absence of an effective lab monitoring system. The facility's policy required that laboratory services meet residents' needs and that results be reported promptly, but these procedures were not followed in this case, leading to the deficiency.
Failure to Promptly Notify Physician of Abnormal Anticonvulsant Lab Results
Penalty
Summary
The facility failed to promptly notify and follow up with the ordering physician regarding laboratory results that were outside of the clinical reference range for one resident with a seizure disorder. Specifically, the resident had active orders for Phenytoin (Dilantin) and Phenobarbital to manage seizures, and laboratory results collected and approved showed both medication levels were low. Despite this, the physician was not notified of the abnormal results until 20 days later, after a state surveyor brought the issue to the attention of the Assistant Director of Nursing (ADON). The physician subsequently gave orders to adjust the medication dosages and recheck levels. Interviews revealed that the ADON expected charge nurses to notify the physician of abnormal labs but assumed the physician was reviewing results in the electronic medical record system, which the physician was unable to access due to technical issues. The facility's policy required prompt notification of abnormal lab results to the ordering provider, but this was not followed. The ADON and Director of Nursing (DON) were identified as responsible for monitoring and overseeing labs, but the process failed in this instance, resulting in a significant delay in physician notification.
Failure to Follow Prescribed Menu for Mechanically Altered Diet
Penalty
Summary
The facility failed to follow the prescribed menu for a resident requiring a mechanically altered diet. Specifically, the resident, who had a history of myocardial infarction and severe cognitive impairment, was ordered to receive a ground chicken fried chicken entree for lunch. Instead, the resident was served a ground beef patty. The resident's care plan and physician orders specified a mechanically altered diet, and the lunch meal ticket indicated ground chicken fried chicken as the correct entree. Staff interviews confirmed that the resident did not receive the correct meal, and the dietary staff member responsible admitted to substituting ground beef for ground chicken to ensure enough chicken was available for residents on regular diets who requested seconds. The dietary manager was unaware of the substitution until after the meal was served and stated that the menu should have been followed for all diet textures. The charge nurse responsible for checking the resident's tray did not recognize the substitution and only became aware of the issue after it was pointed out by a state surveyor. The facility's policy required that menus be developed and prepared to meet resident choices, but this was not followed in this instance, resulting in the resident not receiving the ordered meal.
Failure to Maintain Food Safety Standards in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the ice scoop holder in the main dining room was observed to have orangish-brown sediment in the bottom, and records indicated it had not been cleaned since the last documented date. The Dietary Manager confirmed that kitchen staff were responsible for cleaning the ice scoop holder and acknowledged the presence of sediment when shown. The daily cleaning list provided showed the last cleaning date, with no evidence of more recent cleaning. Additionally, a bag of boiled eggs in the refrigerator was found with only one date and was not disposed of within the required timeframe. The Dietary Manager stated that eggs should be discarded within seven days of opening, and that all kitchen staff were responsible for timely removal of expired food. Interviews with the Dietary Manager, ADON, and Administrator confirmed expectations that kitchen staff should regularly check expiration dates, dispose of outdated foods, and clean the ice scoop holder and ice machine according to facility policy. Facility policies reviewed indicated that food storage areas should be kept clean, all foods in the refrigerator should be labeled and dated, and all equipment and food contact surfaces should be cleaned and sanitized per policy and manufacturer instructions. The failure to follow these procedures was acknowledged by staff and administration during interviews.
Failure to Enforce Smoking Safety Policies in Designated Area
Penalty
Summary
The facility failed to establish and enforce policies regarding designated smoking areas and smoking safety. During an observation, a trash can in the designated smoking area was found to contain a smoked cigarette, rather than only trash. A laundry aide confirmed that staff responsible for supervising residents during smoking should check the trash can to ensure cigarettes are not discarded there, as this could pose a fire risk. The administrator acknowledged that cigarettes should be extinguished in the proper receptacle and that staff supervising residents should monitor this process. Review of the facility's smoking policy indicated the facility is responsible for providing a safe and hazard-free environment for residents assessed as safe for smoking privileges.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information at the beginning of each shift for two days during the review period in April 2025. Specifically, on April 22 and April 23, the staffing sheets displayed were dated April 21, and the current staffing data, including the total number of hours worked by licensed nurses and certified nurse aides as well as the daily census, was not posted as required. Observations confirmed that the outdated staffing sheets were hung on the employee bulletin board by the time clock in the hallway leading to the smoking area. During interviews, the ADON, who was responsible for daily staffing in the absence of a DON, acknowledged missing the completion and posting of the staffing forms for the two days, citing being busy as the reason. The ADON also indicated a lack of awareness regarding the risks to residents from not posting the staffing information, stating she understood it as a regulatory requirement. The Administrator confirmed that the expectation was for the ADON to complete and post the staffing data daily and recognized that the failure could result in residents and families not being aware of the staffing numbers.
Resident Fall Due to Unlocked Bed
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that adequate supervision was provided to prevent accidents, resulting in a fall for one resident. The incident involved a resident who was admitted to the facility with multiple diagnoses, including heart failure, hypertension, diabetes, anxiety, and COPD. The resident was admitted from a short-term general hospital and had been in the facility for only about an hour before the incident occurred. During the admission process, the resident was being assessed and wound care was being provided by a registered nurse and a certified nursing assistant. The bed was not properly locked, which led to the bed moving and the resident falling to the floor. The fall resulted in significant injuries, including fractures to the orbital floor and cervical spine, as well as a laceration and hematoma to the head and eye. The resident was subsequently sent to the emergency room for evaluation and treatment. Interviews with the staff involved revealed that both the registered nurse and the certified nursing assistant believed the bed was locked, but it was not. The facility's Fall Prevention Program policy requires that all residents be assessed for fall risk at admission and that specific interventions be implemented to minimize falls. However, due to the resident's short time in the facility, a baseline care plan had not been completed, and the necessary precautions were not in place, leading to the accident.
Failure to Report Resident's Serious Injuries After Fall
Penalty
Summary
The facility failed to report an incident involving a resident who sustained serious injuries after falling out of bed shortly after being admitted. The resident, a female with a history of heart failure, hypertension, diabetes, anxiety, and COPD, was admitted to the facility from a hospital. Within approximately an hour of her arrival, she fell from her bed, resulting in a fractured orbital floor and cervical spine fractures. Despite the severity of the injuries, the facility did not report the incident to the state agency as required by regulations. Interviews with facility staff revealed a lack of communication and understanding of reporting responsibilities. The MDS Coordinator/ADON was aware of the fall and communicated with the resident's family but did not receive information about the extent of the injuries. The Marketer was informed of the injuries by the hospital but did not report them to the facility's Administrator, as there was no administrator at the time. The Regional Nurse was informed of the fall but did not consider it reportable due to it being a witnessed event, and was unaware of the full extent of the injuries until notified by a surveyor. The facility's policy on abuse prohibition requires reporting of serious bodily injuries within two hours, but this protocol was not followed. The failure to report the incident in a timely manner could place residents at risk of injuries, abuse, and/or neglect. The facility's lack of a clear reporting process and communication breakdown among staff contributed to the deficiency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in two halls, specifically hall 100 and hall 200. Hall 200 was observed to have a strong urine odor on multiple occasions, and the housekeeping aide confirmed that the facility was short on cleaning supplies and lacked a housekeeping supervisor. The Administrator acknowledged the issue but did not smell the urine odor himself. The facility did not have a housekeeping cleaning and deep cleaning checklist, and the deep cleaning was not performed due to staff shortages and lack of supplies. Several room floors on hall 100 were observed to be unclean with light and dark spots. Housekeeper G, who started working at the facility recently, confirmed that the floors remained dirty despite cleaning efforts and that the facility had run out of the correct cleaning chemicals. The Administrator, who also served as the housekeeping supervisor, acknowledged the issue and mentioned a Performance Improvement Project (PIP) for deep cleaning, but no schedule for deep cleaning was produced. Resident #45's room had peeling wallpaper, which the resident and staff were aware of but had not reported in the maintenance book. The Maintenance Supervisor planned to replace the wallpaper with textured paint but had no written plans. The Administrator was unaware of the issue but stated that all staff should report maintenance needs in the maintenance book. The facility policy emphasized providing a safe, clean, and homelike environment, which was not upheld in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident #9, a [AGE] year-old female with anxiety, high blood pressure, heart failure, and diabetes, experienced a fall in the shower room that was not included in her care plan. Additionally, her use of Xanax for anxiety was not care planned until after state surveyor intervention. The MDS nurse and DON acknowledged the oversight, emphasizing the importance of care plans for continuity of care and best possible outcomes for residents. Resident #16, a [AGE] year-old female with anxiety, sleep apnea, COPD, and pulmonary hypertension, was on anticoagulant therapy with Eliquis. However, her care plan did not include any interventions or monitoring related to the use of Eliquis until after state surveyor intervention. The MDS nurse and DON admitted that the omission was an oversight and stressed that care plans should reflect residents' care and needs to ensure they receive appropriate care. Resident #43, a [AGE] year-old female with cerebral palsy, high blood pressure, dysphasia, and epilepsy, required a feeding tube and the use of a [NAME] button for enteral feedings. Her care plan did not include the use of the [NAME] button or the schedule for changing the extension tubing every 14 days. The DON and Administrator acknowledged that the omission placed the resident at risk for improper care and potential infection. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs, which were not met in these cases.
Failure to Ensure Proper Respiratory Care Orders
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care was provided such care consistent with professional standards of practice. Specifically, the facility did not have physician orders for the resident's Bipap machine, which is essential for managing her conditions, including sleep apnea, COPD, and pulmonary hypertension. The resident's comprehensive care plan indicated the use of a Bipap machine at night, but there were no corresponding physician orders in the electronic medical records. This oversight was confirmed through observations, interviews, and record reviews, revealing that the nurses were unaware of the correct Bipap settings, which are crucial for proper respiratory care. During interviews, the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged the absence of the necessary orders and the potential risks associated with not having the correct settings for the Bipap machine. The Administrator also confirmed that all residents should have orders to ensure proper care. The facility's policy on medication orders emphasized the importance of maintaining a current list of orders in each resident's clinical record, including specific details for oxygen orders. The failure to adhere to this policy could lead to respiratory complications for residents requiring such care.
Failure to Ensure Nurse Competency in Bipap Machine Usage
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for a resident requiring respiratory care. Specifically, the facility did not ensure that nurses were trained on the use of a Bipap machine for a resident with multiple respiratory conditions, including sleep apnea, COPD, and pulmonary hypertension. This deficiency was identified through observations, interviews, and record reviews, which revealed that the resident's care plan required the use of a Bipap machine at night, but there were no physician orders for the Bipap, and nurses were not adequately trained on its settings and operation. During interviews, several nurses, including the night nurse and weekend nurse, were either unavailable or admitted to not knowing the Bipap settings or having received proper training. The Director of Nursing (DON) acknowledged that while Bipap training had been conducted, there was no documentation or clear recollection of when the training occurred or who conducted it. The DON also admitted that competencies should be checked on hire, yearly, and as needed, but this had not been done for the Bipap machine. The facility's policy on staffing and competency indicated that nursing staff should be trained and demonstrate competency in identifying, documenting, and reporting resident changes of condition, but this was not adhered to in this case. The facility's policy on CPAP/Bipap support stated that only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask and that the manufacturer's instructions should be followed for setup. However, the record review of competency skills did not show that the involved nurse had been checked off on Bipap assessments or settings. This lack of proper training and competency checks placed the resident at risk of respiratory issues due to incorrect Bipap settings and operation.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for one resident. Specifically, the quarterly MDS assessment for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, heart disease, anxiety, and diabetes mellitus, was not transmitted as required. The MDS nurse admitted to accidentally checking the section not to transmit the assessment to CMS, which led to the delay in transmission. Interviews with the MDS nurse, Director of Nursing (DON), and Administrator revealed that the MDS nurse was responsible for creating, completing, and transmitting all MDSs in the facility. The DON and Administrator both acknowledged that the MDS should have been transmitted in a timely manner and that the failure to do so could result in a delay in payment. The facility's policy on MDS completion and submission timeframes, revised in September 2010, mandates that quarterly MDS assessments be transmitted within 14 calendar days of completion, a guideline that was not followed in this instance.
Failure to Maintain Safe Environment and Proper Oxygen Storage
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically in Hall 100 and the oxygen storage area. Observations revealed that the flooring on Hall 100 was cracked and uneven, posing a potential trip hazard. Staff interviews indicated that the issue had been present for an unknown amount of time, with some cracks appearing 2-3 weeks prior. The Maintenance Supervisor acknowledged the problem but had no set schedule for routine checks and was awaiting corporate approval for major repairs. The Director of Nursing (DON) and the Administrator were aware of the issue but had not yet implemented a specific plan to address it. Additionally, the facility failed to secure an oxygen cylinder in the designated storage area, leaving it freestanding and posing a safety risk. Observations and staff interviews confirmed that the oxygen cylinder was not stored in the appropriate rack or holder. The DON and the Administrator both acknowledged that all staff were responsible for ensuring proper storage of oxygen cylinders but admitted that the current practices were not being followed. Facility policies reviewed indicated that oxygen cylinders should never be left freestanding and that the environment should be safe, clean, and orderly.
Failure to Maintain Accurate Records for Controlled Medications
Penalty
Summary
The facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation. During an observation and interview, it was found that the facility did not keep a record of receipt of controlled medications awaiting disposition, which could lead to unaccounted medications. Specifically, the Director of Nursing (DON) was responsible for the discontinued medications and was the only one with the key to the storage cabinet. However, the DON was unable to find the current log of the medications to be disposed of, indicating a lapse in proper documentation and reconciliation procedures. The last recorded medication destruction was completed several months prior, further highlighting the deficiency in maintaining accurate records for controlled substances awaiting disposal. The Administrator confirmed that narcotic medications should be logged as they are received by the DON. The failure to reconcile these medications could result in missing and unaccounted-for drugs. The facility's policy on medication storage and disposal requires that all controlled substances be subject to special handling, storage, disposal, and recordkeeping in accordance with federal and state laws. However, the facility did not adhere to these guidelines, as evidenced by the missing log and the lack of periodic reconciliation of controlled substances. This deficiency could place residents at risk for loss of prescribed medications, safety issues, and potential drug diversion.
Failure to Follow Menu and Recipe Guidelines
Penalty
Summary
The facility failed to ensure the meals served met the nutritional needs of residents, as evidenced by the failure to serve hot spiced apples as part of the noon-time meal and the failure to follow the puree recipe for chicken fettuccine alfredo. On the specified date, residents were served sherbet ice cream instead of hot spiced apples, and the puree recipe for chicken fettuccine alfredo was not followed, with water being used instead of milk. This failure could affect all residents in the facility who required pureed food consistency by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. During an interview, a resident stated that the facility served the same foods and that the food had no flavor, indicating dissatisfaction with the meals provided. Observations revealed that the dietary aide did not follow the recipe book for the puree chicken alfredo, adding water instead of milk. The dietary aide mentioned that the dietician had told her she could use water, although this was not in accordance with the recipe. The dietary manager, who was responsible for overseeing the dietary staff, was observed yelling at the dietary aide about the proper consistency for puree foods. Further interviews with the dietary staff and the dietitian revealed inconsistencies in following the menu and recipe book. The dietary manager admitted to not having received much training and acknowledged that not all dietary staff had been in-serviced on how to puree foods. The dietitian stated that any substitutions should be approved beforehand, which was not done in this case. The administrator was unaware of the dietary staff not following the menu or recipes, emphasizing the importance of adherence to ensure residents received a complete diet and good quality food.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. One resident, a female with severe cognitive impairment and multiple medical conditions, was observed receiving a bolus feeding from an LVN who did not follow proper hand hygiene protocols. The LVN did not change gloves or sanitize hands after handling a dirty dressing, and the resident's feeding tube extension was not bagged and dated as required. This failure was acknowledged by both the LVN and the Director of Nursing (DON), who confirmed that the resident was at risk for infection due to these lapses in protocol. Additionally, the facility did not properly store clean and dirty linens separately. Observations revealed that clean laundry and dirty barrels were stored next to each other in a shower room. A CNA acknowledged the improper storage and moved the items apart, but the DON and the Administrator both confirmed that staff should be aware of the need to keep clean and dirty items separate to prevent cross-contamination. The facility's policies on laundry and linen handling, as well as hand hygiene, were not followed, contributing to the risk of infection. Interviews with the DON and the Administrator highlighted that the facility's infection prevention and control program was not adequately implemented. The DON and the Administrator both stated that handwashing proficiency check-offs were performed upon hire and quarterly, but these measures were not effectively enforced. The facility's policies clearly outlined the need for proper hand hygiene and the separation of clean and dirty linens, but these guidelines were not adhered to, placing residents at risk for infection.
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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