Oak Park Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 7302 Oak Manor Dr, San Antonio, Texas 78229
- CMS Provider Number
- 455789
- Inspections on file
- 50
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Oak Park Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents' physician progress notes were not updated to reflect discontinued medications, resulting in discrepancies between the notes and current physician orders. Nursing staff and the DON confirmed that the progress notes still listed medications that had been stopped, while the care plans and orders did not. This lack of alignment was acknowledged by both nursing and medical staff, who cited missed updates and insufficient oversight of documentation accuracy.
Surveyors found that the facility failed to maintain a safe, functional, and sanitary environment, with unresolved maintenance issues such as stained and damaged bathroom fixtures, broken lighting, and water-damaged ceilings in multiple resident rooms and hallways. These deficiencies were known to facility leadership and listed on pending work orders but had not been addressed.
A resident with severe cognitive impairment and respiratory failure was ordered oxygen therapy on an as-needed basis, but the care plan was not updated to reflect this intervention. Staff interviews revealed a misunderstanding about care planning requirements for PRN oxygen use, and the omission was confirmed by both the ADON and DON, despite facility policy mandating care plan revisions when a resident's condition changes.
In a dining room, CNAs were observed using personal cell phones while sitting with residents, contrary to facility policy. A resident with intact cognition reported frequent phone use by staff, indicating a lack of care. The facility's policy emphasizes treating residents with dignity and respect.
A facility failed to comply with physician orders for three residents, leading to deficiencies in care. A resident did not receive prescribed insulin due to an LPN's judgment, another missed a scheduled HgA1c lab test, and a third received Midodrine HCl outside prescribed parameters without physician approval. These actions were not documented or communicated to the physician, contrary to facility policy.
A long-term care facility failed to manage medications properly for three residents. An expired insulin pen was found in a nurse's cart, insulin was not administered per physician order for a resident on hospice, and Midodrine HCl was given outside prescribed parameters for a dialysis patient. The DON acknowledged these issues, emphasizing the need for adherence to physician orders and proper medication management.
The facility failed to properly label and store medications in two medication carts. In one instance, three opened Lispro insulin Kwik Pens for a resident were found, but only one had an open date, making it impossible to determine the expiration of the others. Additionally, two loose pills without proper labeling were found in another cart. The DON confirmed that all medications should be labeled correctly, and insulin pens should have open dates to ensure efficacy.
The facility's kitchen failed to meet food safety standards, with unlabeled and expired food, improper hygiene practices by staff, and inadequate temperature control and cleanliness. These issues were observed during a survey, posing a risk of food-borne illness to residents.
The facility failed to maintain accurate medical records and obtain necessary consents for medications. An LPN incorrectly documented the administration of Losartan Potassium for a resident with hypertension, and several residents received antipsychotic medications without the required written consents. These deficiencies were confirmed through interviews and record reviews, highlighting lapses in following facility policies.
A LTC facility failed to maintain an effective infection control program, with staff not adhering to proper hygiene practices. A CNA did not change gloves after touching a privacy curtain before catheter care, another CNA failed to change gloves after colostomy care, and an LVN did not sanitize hands after picking up a pen from the floor before medication administration. Additionally, an LVN did not follow Enhanced Barrier Precautions while administering G-tube medications due to lack of training.
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents upon their discharge from Medicare Part A skilled nursing services, despite having benefits remaining. This oversight was attributed to human error, and the administration confirmed the necessity of following Medicare guidelines for financial liability protections.
Two residents' MDS assessments inaccurately reflected their smoking status, with one resident smoking 5-10 cigarettes daily and another 2-5 cigarettes daily, despite being coded as non-smokers. The errors were attributed to an inexperienced MDS nurse who did not review necessary documentation. Despite the inaccuracies, both residents had care plans with appropriate smoking interventions, and staff believed these errors did not impact their care.
A facility failed to complete a baseline care plan within 48 hours for a newly admitted resident with multiple complex medical conditions, including chronic kidney disease and dementia. The plan was completed nine days after admission, contrary to the facility's policy. MDS nurses cited recent turnover as a reason for the delay, acknowledging that it could impact the staff's ability to provide proper care.
A resident with quadriplegia and other conditions was not seen by a physician within the required 30 days after admission, as per Texas Administrative Code. The first documented physician visit occurred 60 days post-admission, although the resident received care from a nurse practitioner. Communication issues between the resident and the physician team were noted.
A facility failed to implement a pharmacist's medication regimen review recommendations for a resident with moderate cognitive impairment and chronic conditions. Despite approval from the physician, necessary orders for BMP and HgbA1c tests were not added to the resident's chart, highlighting an oversight in following established procedures.
A resident with type 1 diabetes did not receive a scheduled HgA1c test every three months as ordered by the physician. The last test was conducted in July, and the subsequent test due in October was missed. The DON confirmed the oversight and acknowledged the importance of following physician orders to monitor the resident's diabetic status.
The facility did not follow the prescribed menu for residents on pureed diets, substituting instant mashed potatoes for pureed tater tots and adding flavoring to vegetables without maintaining a substitution log. The CDM and RD acknowledged these deviations, and the ADON highlighted the importance of adhering to recipes for resident health.
A facility failed to coordinate hospice care and maintain required documentation for a resident receiving hospice services. Despite the resident's satisfaction with care, the facility lacked a current hospice plan of care, and staff interviews revealed unclear responsibilities for maintaining hospice documentation. This deficiency could risk inadequate end-of-life care.
A resident with a history of alcohol abuse was not properly monitored, leading to a non-consensual sexual act with another resident who was unable to consent due to cognitive impairment. The facility failed to implement adequate monitoring and assessment measures, resulting in a deficiency.
A facility failed to update a care plan for a resident with a history of alcohol use and abuse, despite multiple documented episodes of intoxication. The resident's care plan lacked measurable goals and interventions related to alcohol use, and staff interviews revealed that the care plan should have been updated to address the resident's behavior and potential risks. The facility's policy requires care plans to be revised as residents' conditions change, but this was not done in this case.
A resident with multiple health conditions, including diabetes and dementia, did not have complete wound care documentation in their medical records. The facility's TAR showed missing entries for wound care treatments on several dates. Interviews with an LVN and a Treatment Nurse revealed they forgot to document the treatments, despite acknowledging its importance. The DON confirmed the lack of documentation, which was against the facility's policy requiring detailed records of all care provided.
Physician Progress Notes Not Updated to Reflect Discontinued Medications
Penalty
Summary
The facility failed to ensure that physicians' progress notes accurately reflected the current medication regimen for two residents. For one resident with polyneuropathy, the Lidocaine patch was discontinued in the physician's orders and medication administration record, but the most recent physician progress note still indicated the patch should be continued at bedtime. The care plan did not mention the medication, and nursing staff were unaware of the last administration, leading to confusion about the resident's current treatment. For another resident with a history of tremors, Benztropine Mesylate had been discontinued months prior, and there were no active orders for the medication. However, the physician's progress notes continued to state that Benztropine should be continued. The care plan did not reference the medication, and nursing staff confirmed the discrepancy between the progress notes and the actual orders, acknowledging the importance of consistency for resident care. Interviews with staff, including LVNs and the DON, revealed a lack of oversight in ensuring that physician progress notes were updated to match current orders. The DON stated that she did not review the quality or accuracy of the physician's notes, and the physician acknowledged that updates to progress notes may be missed when medication changes occur. Facility policy and OBRA regulations require that clinical records, including physician progress notes, accurately reflect the resident's current plan of care.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, functional, sanitary, and comfortable environment across three of four resident hallways. Observations revealed unresolved maintenance issues in several resident rooms, including a yellow stain with missing caulking around a toilet bowl, a large black stain on a bathroom door, a chipped bathroom tile, broken floor molding, a missing section of a bathroom door jamb, a door penetration near a bathroom door handle, and a broken bathroom ceiling light. Additionally, a significant water stain and peeling paint were noted on a hallway ceiling adjacent to a resident room. Interviews with the Maintenance Director and Administrator confirmed that these areas requiring repair were known to the facility and were listed on a posted work order log. The facility's policy requires the Maintenance Director to review, prioritize, and ensure completion of work orders, but the observed deficiencies had not yet been addressed at the time of the survey. No information was provided regarding the medical history or condition of specific residents affected by these environmental deficiencies.
Failure to Update Care Plan for Oxygen Use
Penalty
Summary
The facility failed to review and revise the care plan for a resident after a comprehensive assessment, specifically neglecting to update the care plan to reflect the resident's use of oxygen. The resident, a 74-year-old male with diagnoses including unspecified dementia, respiratory failure with hypoxia, and general anxiety disorder, had a physician's order for oxygen to be used as needed. Despite this order, the care plan dated several months after the oxygen order did not include any mention of oxygen use. Observations confirmed that the resident was using an oxygen concentrator, and interviews with staff revealed that the omission was due to a misunderstanding that only full-time oxygen use required care planning. Both the ADON and DON acknowledged that the resident's as-needed oxygen use was not included in the care plan, contrary to facility policy, which requires care plans to be revised as residents' conditions change.
Failure to Maintain Resident Dignity in Dining Room
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity in the Station 4 dining room, as observed on 12/18/24. Certified Nursing Assistants (CNAs) W and X were seen using their personal cell phones while sitting at a dining table with two unidentified residents. This behavior was contrary to the facility's policy, which prohibits CNAs from using phones in the dining room to ensure they are available to assist residents as needed. During an interview, CNA X acknowledged that she was not supposed to be on her phone, and the Director of Nursing (DON) confirmed that CNAs were not allowed to use phones in the dining room. Resident #62, who was diagnosed with mononeuropathy and had intact cognition as per the Annual MDS assessment, reported that nursing staff frequently used their phones in the dining room. Although he had not observed them using phones while feeding residents, he noted that they made calls while waiting for meal trays, which made him feel that the staff did not care. The facility's policy on Quality of Life-Dignity, revised in August 2009, emphasizes that residents should be treated with dignity and respect at all times, which includes maintaining and enhancing their self-esteem and self-worth.
Medication and Lab Order Non-Compliance
Penalty
Summary
The facility failed to administer medications and conduct necessary lab tests according to physician orders for three residents, leading to deficiencies in care. Resident #22, who was on hospice care and had severe cognitive impairment, did not receive her prescribed Humalog KwikPen insulin as per the sliding scale order. Despite her blood sugar levels indicating the need for insulin, the LPN decided not to administer it, believing it was unnecessary. This decision was made without consulting the physician or documenting the rationale, contrary to the facility's policy. Resident #31, who had moderate cognitive impairment and a history of diabetes, did not have her HgA1c lab drawn every three months as ordered by her physician. The last lab was conducted in July, and the subsequent test due in October was missed. The DON confirmed the oversight and acknowledged the importance of these tests in monitoring the resident's diabetic status, although the reason for the missed lab was not identified. Resident #53, who was cognitively intact and had multiple health issues including end-stage renal disease, received Midodrine HCl outside the prescribed parameters. The medication was administered despite the resident's systolic blood pressure being above the threshold set by the physician. The LPN used personal judgment to administer the medication, anticipating a drop in blood pressure during dialysis, but did not seek physician approval for this deviation. The DON was unaware of this breach in protocol, which was not documented in the resident's progress notes.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and management of medications, as evidenced by the presence of an expired Glargine Kwik Pen in the Hall 100 Nurse's cart for a resident. The pen was marked with an open date that exceeded the 28-day usage period, indicating it was expired. Both the LVN and the DON acknowledged the oversight, with the LVN admitting responsibility for removing expired medications and marking open dates. The facility's policy requires that expired medications be returned or destroyed, but this was not adhered to, potentially compromising the efficacy of the insulin administered to the resident. Another deficiency involved the administration of insulin for a resident on hospice care. The resident's blood sugar levels were recorded at 150 on two occasions, yet the insulin was not administered as per the physician's sliding scale order. The LPN responsible for the administration chose not to give the insulin, believing the resident's blood sugar was within range, despite the physician's order. The DON stated that the nurse should have followed the physician's order or obtained a hold order if the insulin was not to be administered. A third issue was identified with the administration of Midodrine HCl for a resident undergoing dialysis. The medication was administered despite the resident's systolic blood pressure being above the physician-ordered threshold. The LPN used personal judgment to administer the medication, anticipating a drop in blood pressure during dialysis. However, the DON indicated that the medication should have been held according to the physician's order, and any deviation should have been communicated to the physician for approval.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles, specifically concerning the labeling and storage of medications in two medication carts. In the Hall 100 Nurse's cart, three opened Lispro insulin Kwik Pens for a resident were found, but only one had an open date marked. This lack of labeling made it impossible to determine how long the other two pens had been opened, raising concerns about their expiration. The resident involved was an elderly woman with a history of metabolic encephalopathy and type 2 diabetes mellitus, and her medication order required precise administration of insulin Lispro. The absence of open dates on the insulin pens could lead to the administration of expired medication, which may not be effective. Additionally, the Hall 100 Medication Aide's cart contained two loose pills in separate blister packs without any pharmacy labels indicating the resident's name or cautionary information. These pills were identified as Diltiazem 120mg and Metoprolol 100mg. The medication aide acknowledged that the pills should not have been left loose in the cart without proper labeling. The Director of Nursing confirmed that all medications should be properly labeled and that insulin pens should be marked with open dates to ensure they are used within their effective period. The facility's policy requires that improperly labeled drug containers be returned to the pharmacy for correct labeling before storage.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas. During an inspection, it was observed that prepared salads in a refrigerator were not labeled with discard dates, and drinks were incorrectly labeled with only initials. Additionally, in the walk-in refrigerator, food items such as ham salad and cheese were found past their use-by dates, which were subsequently discarded by the Certified Dietary Manager (CDM). These labeling and storage issues indicate a lack of compliance with food safety protocols. Further observations revealed that Dietary Aides were not following proper hygiene practices. Dietary Aide T and another staff member, [NAME] U, were seen wearing nose rings while handling food, which contradicts the U.S. Food and Drug Administration's guidelines that prohibit jewelry, except for a plain ring, during food preparation. Additionally, personal beverages and outside food were found in the food preparation area, which the CDM acknowledged should not be present, although they deemed the beverages acceptable. The facility also failed to maintain proper temperature control and cleanliness in the kitchen. A refrigerator temperature was recorded at 42°F, above the recommended 41°F, without further investigation or documentation of corrective measures. Dusty debris was found on the apparatus holding kitchen utensils, indicating a lapse in cleanliness. These deficiencies collectively pose a risk of food-borne illness to residents consuming meals prepared in the facility.
Deficiencies in Medical Record Accuracy and Consent for Medications
Penalty
Summary
The facility failed to maintain accurate and complete medical records for its residents, as evidenced by several deficiencies identified during a survey. One significant issue involved the incorrect documentation of medication administration for a resident with hypertension. The resident's Medication Administration Record (MAR) indicated that Losartan Potassium, a blood pressure medication, was administered despite the resident's blood pressure being outside the prescribed parameters. The LPN responsible for administering the medication acknowledged the error, stating that she likely clicked the wrong button in the system, marking the medication as administered when it should have been held. This error was not documented in the resident's progress notes, and the physician was not notified of the deviation from the prescribed parameters. Additionally, the facility failed to obtain the necessary signed consents for administering antipsychotic medications to several residents. One resident was given Risperdal for bipolar disorder without the required written consent on Form 3713. Another resident received Quetiapine for schizoaffective disorder, and yet another was administered both Risperdal and Paroxetine without the appropriate consents. The facility's policy requires that consents be obtained and documented before administering such medications, but this was not adhered to, as confirmed by interviews with nursing staff and the Director of Nursing (DON). The lack of proper documentation and consent for medication administration could potentially place residents at risk of receiving inappropriate care. The facility's policies on medication administration and behavioral assessment were not followed, leading to these deficiencies. The DON confirmed that the facility did not obtain the necessary consents and acknowledged the potential adverse effects on residents if medications were administered without proper authorization.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several lapses in proper hygiene and protective measures by staff members. One incident involved a CNA who did not change gloves or sanitize hands after touching a privacy curtain before proceeding with catheter and peri-care for a resident with severe cognitive impairment and an indwelling catheter. This oversight was acknowledged by the CNA, who admitted to being focused on the task and not realizing the potential for spreading germs from the curtain to the resident. Another deficiency was observed when a CNA failed to change gloves after emptying a colostomy bag and before touching various surfaces in the bathroom. The CNA admitted to not knowing where to place the basin to change gloves, which led to potential contamination of the bathroom door and shower handles. Despite having received training and competency checks in colostomy care, the CNA used a basin due to the liquid nature of the colostomy contents, which was not part of her usual practice. Additionally, an LVN did not wash or sanitize her hands after picking up a pen from the floor before administering medication to a resident. The LVN acknowledged forgetting to perform hand hygiene, despite being trained in infection control and medication administration. Furthermore, another LVN did not follow Enhanced Barrier Precautions while administering medications via a G-tube, as she was not wearing a gown and was unaware of the requirement due to a lack of training. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not adhered to, contributing to these deficiencies.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to provide necessary notifications to two residents regarding changes in their Medicare Part A coverage. Specifically, the facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNF ABN) to these residents when they were discharged from Medicare Part A skilled nursing services, despite having benefits remaining. This notice is crucial as it informs residents that Medicare will no longer cover skilled services, ensuring they are aware of their financial responsibilities. The absence of this notification was identified for two residents who completed their Medicare Part A stays within the six months prior to the survey. Interviews with the facility's administration confirmed that the failure to provide the SNF ABN was due to human error. The administration acknowledged that the facility is required to follow Medicare Part A rules and the Medicare Claims Processing Manual for financial liability protections. Despite the oversight, it was noted that the residents were not placed in harm or at risk for denial of future Medicare Part A participation. The facility's guidelines, as per the Medicare Claims Processing Manual, necessitate issuing an ABN when a Medicare service is deemed not reasonable and necessary, or when providing custodial care.
Inaccurate MDS Assessments for Smoking Status
Penalty
Summary
The facility failed to ensure the comprehensive assessments accurately reflected the smoking status of two residents, leading to discrepancies in their Modified Significant Change MDS assessments. Resident #26's assessment inaccurately indicated that he was not a current tobacco user, despite documentation showing he smoked 5-10 cigarettes per day. Similarly, Resident #49's assessment also incorrectly stated he was not a current tobacco user, although records showed he smoked 2-5 cigarettes per day. These inaccuracies were found in the MDS assessments completed by MDS H, who was inexperienced and did not review the necessary documentation, such as the residents' smoking safety screen assessments. Interviews with facility staff revealed that the responsibility for ensuring the accuracy of the MDS assessments lay with the RN signing off on the assessments, as well as the corporate MDS nurse overseeing them. The MDS F, who started working at the facility in October 2024, stated that the errors were likely due to MDS H's inexperience and lack of access to the necessary documentation. Despite the incorrect coding, both residents had care plans with appropriate smoking interventions, and the staff believed these errors did not impact the residents' care. The facility's policy required all individuals completing any portion of the MDS Resident Assessment Form to sign the document, attesting to the accuracy of the information. However, MDS H, who was still in training and working for another facility, did not know to request additional documentation to accurately complete the assessments. The Director of Nursing confirmed the inaccuracies but noted that the residents' care plans included current smoking interventions, suggesting that the incorrect coding did not affect the residents' care.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a woman with multiple diagnoses including chronic kidney disease, type 2 diabetes, dementia, schizophrenia, bipolar disorder, and anxiety disorder, was admitted to the facility. Despite her complex medical needs, her baseline care plan was not completed until nine days after her admission, which was a deviation from the facility's policy that mandates the creation of such a plan within 48 hours to ensure immediate care needs are met. Interviews with the facility's MDS nurses revealed that the responsibility for completing baseline care plans lies with them. However, due to recent turnover in the MDS nurse position, the baseline care plan for this resident was not completed on time. The MDS nurse acknowledged that the delay in completing the baseline care plan could result in staff not having the necessary information to provide appropriate care to the resident. The facility's policy, revised in 2016, clearly states the requirement for a baseline care plan to be developed within 48 hours of admission to address the resident's immediate care needs.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least once every 30 days for the first 90 days after admission, as required by the Texas Administrative Code. Specifically, a resident diagnosed with quadriplegia, polyneuropathy, and hypertensive heart disease was not seen by a physician until 60 days after admission. This oversight was identified during a review of the resident's Physician Progress Notes, which revealed that the first comprehensive note by the physician was dated two months post-admission. Interviews conducted with the resident and the physician highlighted communication issues between the resident and the physician team. The resident expressed concerns about the lack of response to his medication issues and felt that communication with the physician team was problematic. The physician, MD D, acknowledged that while he often saw the resident informally, he did not document these interactions, and the first formal documentation occurred 60 days after admission. Despite the delay in physician visits, the physician noted that the resident received care from a nurse practitioner, which he believed mitigated the impact of the late physician visit.
Failure to Implement Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's medication regimen review recommendations for a resident were reviewed and acted upon by the attending physician. Specifically, after a medication review conducted on 11/18/24, the facility did not update the doctor's orders for a resident as recommended by the pharmacist and approved by the physician. This oversight involved the omission of orders for BMP and HgbA1c tests, which were suggested to monitor the resident's health conditions, including type 2 diabetes, hypertension, and chronic kidney disease. The resident in question had a moderate cognitive impairment, as indicated by a BIMS score of 9 out of 15. Despite the pharmacist's recommendation and the physician's approval, the necessary orders were not added to the resident's medical chart. Interviews with facility staff revealed that this was an oversight, and the facility did not provide requested policies for pharmacy reviews or following doctor's orders, indicating a lack of adherence to established procedures.
Failure to Conduct Scheduled HgA1c Test for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for a resident, specifically neglecting to perform a scheduled HgA1c test every three months as ordered by the physician. The resident, an elderly woman with a history of cerebral infarction, quadriplegia, and type 1 diabetes mellitus, was supposed to have her HgA1c levels monitored to manage her diabetes effectively. However, the last recorded HgA1c test was conducted in late July, and the subsequent test due in October was not performed. During an interview, the Director of Nursing (DON) confirmed the oversight, acknowledging that the test was not conducted as per the physician's orders. The DON was unaware of the reason for the lapse but recognized the importance of adhering to the physician's orders to monitor the resident's diabetic status. This failure to conduct the necessary lab test could potentially compromise the resident's health management.
Failure to Follow Prescribed Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets during the dinner meal on December 18, 2024. The menu for that day included pureed substitutes such as Pureed Sloppy [NAME], Pureed Tater Tots, and Pureed Soft Cooked Vegetables. However, during the preparation of the meal, the staff member responsible for pureeing the food decided to use instant mashed potatoes instead of pureed tater tots, citing difficulty in achieving the correct consistency for the tater tots. Additionally, the staff member pureed cabbage for the vegetable portion and added chicken base and lemon pepper to the pureed vegetables for flavor enhancement. The Certified Dietary Manager (CDM) confirmed the substitution of instant mashed potatoes for pureed tater tots and the addition of flavoring to the vegetables, explaining that these changes were made to ensure resident safety and palatability. However, there was no substitution log maintained to document these changes, which is a requirement when deviations from the menu occur. The Registered Dietitian (RD) acknowledged the absence of a substitution log and noted that such logs should be maintained and signed. The Assistant Director of Nursing (ADON) emphasized the importance of following recipes to maintain residents' health, stabilize weights, and control sodium intake. The facility's policy on standardized recipes, revised in April 2007, mandates the use of standardized recipes in food preparation.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified during a review of the records and interviews with staff, revealing that the facility did not maintain the required hospice forms and documentation, including the current hospice plan of care. This lack of documentation and coordination could potentially place residents receiving hospice services at risk of inadequate end-of-life care. The resident in question, who was on hospice services, had a terminal prognosis related to senile degeneration of the brain and severe cognitive impairment. Despite the resident expressing satisfaction with the communication between the facility and hospice, the facility's records did not contain evidence of the current hospice plan of care. Interviews with staff, including the LPN, ADON, and social worker, indicated a lack of clarity and responsibility regarding the maintenance and verification of hospice documentation. The facility's contract with the hospice and its internal policy outlined the responsibilities for coordinating care and maintaining documentation. However, interviews with the DON and other staff members revealed inconsistencies in understanding and executing these responsibilities. The DON stated that the social worker was responsible for the hospice binders, while the social worker indicated that nursing staff were responsible for verifying the current plan of care. This miscommunication and lack of clear responsibility contributed to the deficiency identified by the surveyors.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. On the night of the incident, a resident who was intoxicated and aggressive was not properly monitored and was left unsupervised in his room for 15 minutes. During this time, he left his room and was found by a CNA engaging in a non-consensual sexual act with another resident who was unable to consent due to severe cognitive impairment. The resident who committed the act had a history of alcohol abuse and was known to the facility staff. Despite this, his care plan did not include any interventions for alcohol use, and there were no orders to stop medications when the resident was actively drinking. The facility's staff failed to conduct a proper assessment or implement adequate monitoring measures when the resident returned to the facility intoxicated. The incident was not immediately reported to the appropriate authorities, and there was a lack of documentation regarding the monitoring of the intoxicated resident. The facility's policies on abuse and neglect were not effectively implemented, leading to a failure to protect the vulnerable resident from harm.
Failure to Update Care Plan for Resident with Alcohol Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of alcohol use and abuse. The resident, who was cognitively intact and had diagnoses including alcohol abuse with alcohol-induced anxiety disorder and major depressive disorder, had five documented episodes of alcohol intoxication or smelling of alcohol. Despite these incidents, the resident's care plan did not include measurable goals, objectives, or interventions related to alcohol use and abuse. Interviews with facility staff, including the MDS Nurse, ADON, and DON, revealed that the care plan should have been updated based on the resident's repeated alcohol use and intoxication. The staff acknowledged that the care plan is a tool to coordinate care and communicate necessary interventions, and it should have been revised to address the resident's alcohol use and potential risks, such as holding medications with MD approval when the resident was actively drinking. The facility's policy on comprehensive person-centered care plans requires that they include measurable objectives and timetables to meet residents' needs and be revised as residents' conditions change. However, the care plan for this resident was not updated despite multiple incidents of alcohol use, and the interdisciplinary team did not address the resident's drinking behavior during their meetings.
Incomplete Wound Care Documentation for a Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding wound care documentation. The resident, a male with a history of cerebral vascular accident, diabetes mellitus type 2, hyperlipidemia, anxiety, dementia, and arterial sclerotic heart disease, had a diabetic ulcer on the right foot and a stage 4 decubitus ulcer on the left heel. The facility's treatment administration record (TAR) for October 2024 showed blank spaces for the resident's wound care treatments on four specific dates, indicating a lack of documentation. Interviews with the staff, including an LVN and a Treatment Nurse, revealed that they forgot to sign the TAR after performing the treatments on the resident's feet on the specified dates. Both staff members acknowledged the importance of documenting treatments to ensure accurate medical records. The facility's Director of Nursing confirmed the lack of documentation and stated that it was expected for staff to document treatments in the electronic medical record. The facility's policy on charting and documentation emphasized the need for detailed documentation of all services provided to residents, including the date, time, and name of the individual providing care.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
